Every finding on record at Mountain Valley of Cascadia

Based on observations, record review, and staff and resident interviews, it was determined that the facility failed to ensure self-administration of medications was evaluated and implemented properly for 1 of 1 resident (Resident #32) who were reviewed for self-administration. This deficiency allowed for Resident #32 to have unrestricted access to medications and created the potential for medication errors to occur. Findings include:Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), chronic respiratory failure, and chronic obstructive pulmonary disease (COPD-a progressive long-term lung condition that makes it hard to breathe).On 8/17/26 at 2:41 PM, one grey and white inhaler was observed on Resident #32's side table. The inhaler had a label on it that read, albuterol sulfate HFA (Hydrofluoroalkane) mcg (micrograms) and a last fill date of 7/14/26. An active physician's order for Proventil HFA Inhalation Aerosol Solution (albuterol sulfate HFA) 108 (90 Base) MCG/ACT (micrograms per actuation) with a start date of 7/14/26, documented for staff to administer 2 puffs orally every 6 hours as needed for shortness of breath and to thoroughly rinse mouth after the treatment.There was no documentation of an interdisciplinary team self-administration evaluation within Resident #32's medical record.On 8/17/26 at 3:10 PM, RN #1 and the Surveyor observed Resident #32's side table. RN #1 stated Resident #32 kept the inhaler at bedside and that he was allowed to self-administer the medication as needed. On 8/17/26 at 3:36 PM, RN #1 stated that for a resident to self-administer medications an evaluation would need to be done. RN #1 stated if the resident was assessed as an appropriate candidate then the care plan would be updated and a physician's order would be obtained. RN #1 then reviewed Resident #32's medical chart and stated she could not find an evaluation, order, or care plan for self-administration of an albuterol inhaler.

Based on record review and staff interview, it was determined the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) evaluations were accurate. This was true for 1 of 2 residents (Resident #8) whose PASRR records were reviewed. This failure placed Resident #8 at risk for their mental health needs to go unmet, creating the potential for harm. Findings include:Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including COPD, dementia, a history of substance and alcohol use disorder, and post-traumatic stress disorder (PTSD). Resident #8's medical record documented they were diagnosed with depression on 4/15/25 and began taking a medication for their depression. Resident #8's most recent PASRR, dated 3/28/25, did not reflect their current mental health status or medication prescribed. On 8/21/26 at 8:59 AM, the Resident Support Service Manager stated, due to the new mental health diagnosis and addition of a mental health medication, an updated PASRR should have been submitted.

Based on record review, staff interview and review of the National Library of Medicine, PubMed Central, it was determined the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 15 residents (Resident #3) whose care plan was reviewed for dementia care and oxygen therapy. This deficient practice placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include: The National Library of Medicine, PubMed Central, review of the article titled, Comprehensive Care Plan Development Using Resident Assessment Instrument Framework: Past, Present and Future Practices, accessed 8/26/26, documented, Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed be within the context of the comprehensive interdisciplinary assessment framework- the Resident Assessment Instrument. Resident #3 was admitted [DATE] and readmitted [DATE] with multiple diagnoses including, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients), respiratory failure (a serious medical condition that happens when your lungs cannot get enough oxygen into your blood or remove enough carbon dioxide from your body), and shortness of breath. Resident #3's medical records documented, Oxygen (O2) 1-2 lpm (Liters Per Minute) to maintain saturations above 90% as needed for hypoxia, start date 3/1/26. Resident #3's medical records documented vascular dementia was diagnosed on [DATE]. On 8/20/26 at 6:44 AM, a review of the comprehensive care plan found that Resident #3's comprehensive care plan did not address her vascular dementia or her oxygen therapy. On 8/20/26 at 11:22 AM, the CNO stated Resident #3 did not have a comprehensive care plan for vascular dementia or for her oxygen therapy and she should have a comprehensive care plan for both.

Based on observations, record review, policy review and staff interviews, it was determined that the facility failed to ensure services provided met professional standards of nursing practice for 1 of 25 residents (Resident #32) when staff administered an incorrect dosage of medication, which deviated from the physician's order. This failure to give the correct dose of a medication created the potential for adverse health outcomes when the medication was not given at the ordered dose. Findings include:The facility's policy titled, Medication Administration, revised 9/10/25, documented, A medication error refers to any observed or identified mistake in the preparation or administration of medications or biologicals that does not follow- the prescriber's written order. It further documented, Staff responsible for medication administration should follow the ten (10) rights to medication administration- a. Right Medication, b. Right Resident, c. Right Dose, d. Right Route, e. Right Time and Frequency, f. Right Documentation, g. Right Assessment, h. Right to Refuse, i. Right Evaluation, j. Right Education. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included acute respiratory failure with hypoxia, chronic respiratory failure, and COPD.A review of the physician's order documented, Thiamine HCl oral tablet 250mg, give 1 tablet by mouth one time a day for supplement, dated 7/14/26.On 8/19/26 at 9:34 AM, observed LPN #1 give 1 tablet of 100mg of thiamine to Resident #32 in his room. When LPN #1 returned to the medication cart, surveyor asked her what dosage she gave Resident #32, she checked the bottle and confirmed it was a 100 mg tablet of thiamine and she had only given 1 tablet. LPN #1 stated she gave Resident #32 100 mg of thiamine, but he gets it again later and she would have caught the mistake and corrected it then. On 8/19/26 at 10:40 AM, the CNO reviewed the physician's order and stated the confusion was because the thiamine 250 mg said to give one tablet. She stated she needed to get the order clarified.

Based on observations, record reviews, and staff interviews, it was determined the facility failed to ensure respiratory treatment equipment was stored properly. This was true for 1 of 4 residents (Resident #26) who were reviewed for respiratory care. This deficiency created the potential for Resident #26 to develop respiratory related infections. Findings include:The American Lung Association's, 'Patient Care Articles,' updated 5/29/26, documented, In a skilled nursing facility, proper storage of a nebulizer following American Lung Association guidelines requires disassembling the device, allowing all washed reusable parts to completely air-dry on a clean surface in a cool, dry place, and storing them in a clean enclosed container or bag to prevent bacterial growth and contamination.Review of the facility BiPAP/CPAP Administration policy, dated 9/12/25, documented face masks and tubing are to be stored in a plastic bag when not in use to prevent contamination.Review of the facility Oxygen Administration, Safety, Storage & Maintenance, dated 10/10/25, documented to store oxygen and respiratory supplies in a plastic bag when not in use.Review of the facility Inhalant (Nebulizer) Medication Administration policy, dated 9/16/25, documented that, nebulizer equipment may be stored in the resident's room without a labeled container, provided it is placed in a clean, dry location that does not pose a contamination risk (e.g., not on the floor or near a sink).Resident #26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (a long-standing, chronic lung impairment that suddenly worsens, leaving the lungs unable to move enough oxygen into the blood), diabetes, and an acute exacerbation of COPD (a sudden flare-up of breathing problems like severe shortness of breath, increased cough, and changes in mucus color).Review of Resident #26's order summary documented the following physician orders:- Formoterol Fumarate Inhalation Nebulization Solution (bronchodilator) 20 micrograms per 2 milliliters (MCG/2ML), give 2 ml inhale orally via nebulizer two times a day for Respiratory Failure, for a start date of 6/15/26;- Oxygen at 2-5 liters per minute (LPM) continuously per nasal cannula with humidification, for a start date of 6/22/26;- Non-Invasive Positive Pressure Ventilation (NIPPV): To wear at night or while sleeping, for a start date of 7/29/26;A 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] documented Resident #26 to be assessed with a moderate cognitive impairment.On 8/17/26 at 1:33 PM, the following was observed in Resident #26's room:- A blue oxygen concentrator machine next to Resident #26's bed, not in use with the oxygen tubing and cannula with no protective barriers observed, on the bed and left on and running;- A grey nebulizer machine with tubing and mouthpiece in a grey plastic bin sitting on a small pile of personal belongings with the mouthpiece hanging over the edge of the bin, exposed to the elements;- A white NIPPV machine on Resident #26's bedside table with tubing and face mask components laying directly on the table with no protective barrier observed.On 8/19/26 at 3:29 PM, the following was observed in Resident #26's room:- A blue oxygen concentrator machine next to Resident #26's bed, not in use with the oxygen tubing and cannula with no protective barriers observed, on the bed and left on and running;- A white NIPPV machine on Resident #26's bedside table with tubing and face mask components laying directly on the table with no protective barrier observed.On 8/21/26 at 9:13 AM, the CNO stated that respiratory equipment such as nebulizer masks and tubing, CPAP/BiPAP masks and tubing, and oxygen therapy tubing and cannula should be stored in a bag when not in use to keep them clean. The CNO further stated that although there is no risk, oxygen concentrators should be turned off when not in use.

Based on observation, staff interview, policy review and record review, it was determined the facility failed to ensure that expired medications were removed from the medication storage area and discarded in accordance with professional standards and facility policy. This was true for 1 of 2 medication carts reviewed for medication storage and cart review. This deficient practice had the potential to affect the strength, quality and purity of the medication. Findings include:The facility's policy titled Medication Storage and Labeling, released 10/13/25 documented The facility will ensure that medications are stored and labeled in accordance with CMS regulations, state law and acceptable professional principles to ensure safety, efficacy, and compliance. It further stated, Expired or discontinued medications must be removed promptly and disposed of per facility policy and DEA [Drug Enforcement Agency] guidelines to prevent diversion. On 8/19/26 at 12:33 PM, during medication storage and cart review, the surveyor in the presence of LPN #1, found Zofran 4mg tabs for Resident #55, expired 5/9/26 on the medication cart.On 8/19/26 at 12:33 PM LPN #1 acknowledged the Zofran was expired. LPN #1 stated, the medication should be removed from the cart and discarded.

Based on observations, policy review, Food and Drug Administration Food Code 2022 review, and staff interviews, it was determined that the facility failed to ensure resident's personal food was stored appropriately for 1 of 1 residents personal refrigerator/freezers reviewed for safe food handling and storage. This deficiency created the potential for food-borne illnesses to occur. Findings include:Review of the facility Personal Food Storage, Handling & Resident Access policy, dated 9/12/25, documented that any food not consumed immediately should be sealed in a container or resealable bag and labeled with, the resident's name (unless stored in a personal refrigerator), the date received (if bagged leftovers without manufacturer packaging), and a use-by date based on whichever of the following applies:-The manufacturer's expiration or best by date, if that date applies after opening-The manufacturer's recommended use after date timeframe-If no manufacturer guidance exists, a default of three days from received dateThe FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 8/20/26 at 2:44 PM, a tour of the resident personal food refrigerator/freezer was conducted with the CEO and Dietary Manager. The following was observed:- In the refrigerator, one plastic container holding a store-brand, half-eaten, pre-prepared red enchilada meal, with a printed date of 8/14/26, without any dates or labels;- In the freezer, one opened plastic bag of 'Nathan's' brand frozen onion rings, without any dates or labels and exposed to the elements.On 8/20/26 at 2:52 PM, The CEO and Dietary Manager both stated that they did not know how foods in the resident personal food refrigerator were supposed to be stored and would have to follow up on that.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure the facility staff followed proper infection control practices and glove change protocols. This was true for 1 of 1 residents (Resident #1), when staff failed to perform hand hygiene when going from a dirty environment to a clean environment. This deficient practice placed residents at risk for cross-contamination, and the spread of healthcare associated infections. Findings Include:The facility's policy titled, Hand Hygiene, revised 09/15/25, documented, Hand hygiene is recognized as a cornerstone of effective infection control and is essential in preventing the transmission of healthcare-associated infections (HAIs). This facility is committed to maintaining the highest standards of infection prevention and control to ensure the safety and well-being of our residents, staff, and visitors. In alignment with the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommendations, this policy outlines the expectations and procedures for hand hygiene practices among healthcare personnel.All healthcare workers should perform hand hygiene at critical moments during resident care, according to CDC guidelines. These moments include but are not limited to:Immediately before and after touching a resident.Before performing a procedure such as an aseptic task (e.g. placing an indwelling device such as a urinary catheter, dressing care and/or manipulation of a central venous catheter).Before moving from work on a soiled body site to a clean body site on the same resident. Resident #1 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including, sepsis (a life-threatening medical emergency that occurs when the body has an extreme, toxic response to an infection), pneumonia (a lung infection that inflames the tiny air sacs in one or both lungs, causing them to fill with fluid or pus), and myocardial infarction (occurs when blood flow to a part of the heart muscle abruptly decreases or stops, causing tissue death).On 8/18/26 at 4:04 PM, CNA #1 entered Resident #1's room to perform incontinence care. Surveyor observed incontinence care with Resident #1's permission. CNA #1 put on enhanced barrier precaution (EBP) gown and gloves and performed incontinence care. CNA #1 finished Resident #1's incontinence care. CNA #1, while still wearing the same gloves, touched items on the bedside table, the feeding tube when bringing Resident #1's clothes back down and the bedside table.On 8/18/26 at 4:10 PM, Surveyor asked CNA #1 when she should change gloves and wash hands after incontinence care and CNA #1stated, she did not remove her gloves and wash her hands prior to touching items in the room.On 8/19/26 at 10:40 AM,CNO stated gloves should be removed after immediately after performing incontinence care and hands should be washed.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents' representatives were immediately notified when residents fell or had a change in condition. This was true for 1 of 3 residents (Resident #116) whose records were reviewed for changes in condition. This deficient practice placed residents at risk of harm due to lack of advocacy and support from their representatives when they were unable to make decisions for themselves due to decreased health status and level of consciousness. Findings include:The facility's Fall Response & Management policy, revision date 8/21/25, documented Procedure 4. If a Resident sustains a fall, a physical assessment will be completed, and the provider and Resident Representative are notified. The facility's Event Management & Reporting policy, dated 9/16/25, documented Procedure 1. Initial Response and Documentation c. The nurse's documentation of the event will include, but not limited to: iv. Notifications to representative and/or resident contact, physician, outside agencies and any new orders received. The facility's Resident Change of Condition policy, revision date 8/31/25, documented Procedure 1. Notify the Resident, physician/provider, and, if applicable, Resident representative when any of the following occurs:a. Accident with injury and potential need for physician intervention b. Significant change in physical, mental, or psychosocial statusc. Need to alter treatment significantly d. Transfer or discharge decision5. Notify the resident's family or responsible party of the change in conditions as listed above. Resident #116 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including heart failure, dementia, and depression. On 7/7/26 at 1:17 PM, review of Resident #116's medical record had documented a progress note dated, 5/31/26 at 10:43 PM, Post Fall Review: Date and Time of Fall: 5/31/26 8:50 PM. Resident #116 found lying on her stomach. Head turned to the left side, and resting on the floor. Bilateral lower extremities (BLE) extended below her with bilateral feet proximal to wheelchair. Bilateral upper extremities (BUE) at her sides at rest. Injury noted: Yes Bruising-discoloration caused by impact. She had a bloody nose r/t fall, and a large bruise forming on her forehead just above her eyebrows. Resident Statement: No response. CNA alerted nurse. VS assessed, and neuro-checks started. She was repositioned to her bottom and assisted back into her wheelchair. She was brought out to the nurse station and transferred to a recliner.A cold cloth and pressure was applied to bloody nose. Provider was notified. Resident #116's medical record had not documented her representative was notified of her fall at the time of the event on 5/31/26.On 7/7/26 at 1:45 PM, review of Resident #116's medical record had documented a progress note, dated 5/31/26 at 10:43 PM, the Provider ordered to continue neuro checks and any s/s of concussion. Continue to apply ice pack to forehead, prn.On 7/7/26 at 3:11 PM, review of Resident #116's medical record documented a progress note, dated 6/1/26 at 9:15 AM, Resident #116's family notified of her 5/31/26 fall. On 7/7/26 at 4:09 PM, review of Resident #116's medical record had documented a progress note, dated 6/1/26 at 5:53 PM, Resident #116 with increase in overall general pain to facial region, increased nonverbal s/s of pain and discomfort. Bruising noted throughout the forehead, left and right eyes, and nose. Not wanting to get out of bed d/t increase in pain.Resident #116's medical record did not include documentation her representative was notified of her increased pain.On 7/7/26 at 4:20 PM, review of Resident #116's medical record had documented a progress note, dated 6/2/26 at 3:59 AM, nurse spoke with resident's POA's here at facility. Resident #116's representative requested resident be sent to hospital for medical evaluation and imaging related to the 5/31/26 fall. Resident #116 transported via facility van to the local emergency department. At 3:00 AM, facility nurse called the emergency department and was notified Resident #116 diagnosed with Ondontoid fracture - C2. On 7/8/26 at 9:02 AM, review of the facility's Incident & Accident (I&A) report, dated 5/31/26, documented Resident #116 had a fall from her wheelchair. She sustained bruising to the forehead and a bloody nose. Resident #116's medical record documented Provider was notified. No documentation resident representative was notified of the fall at the time of the event. On 7/8/26 at 3:10 PM, the Director of Nursing stated at the time of the fall it was thought the event did not need to be reported to the resident representative as the Provider had been notified.On 7/8/26 at 3:17 PM, the CEO stated the resident representative should have been notified at the time of the event and had not been.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:The State Operation Manual, Appendix PP revised on 7/23/25, documented S483.35 (i) (1) Nurse Staffing Information. Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.The facility's Daily Staffing sheets were missing scheduled nurse staffing and hours on the following dates:- 8/31/25- 5/31/26- 6/5/26- 6/12/26- 6/13/26- 6/14/26- 6/20/26- 6/27/26On 7/8/26 at 3:30 PM, the CEO stated the daily staffing sheets should have been completed correctly and were not.

Based on observation, FDA Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned. These deficiencies had the potential to affect the 57 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include: The FDA Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 4/30/25 at 3:05 PM, during a kitchen inspection, pots and pans located on the clean dish drying rack were observed with the following: -A stainless steel pot had a red ring around the middle interior of the pot. On 4/30/25 at 3:26 PM, the Registered Dietitian (RD) stated the pot with the red ring was visibly dirty and removed it from the clean drying rack. On 5/1/25 at 7:05 AM during a follow-up kitchen inspection, a baking sheet pan, and cooking pots had a ring of dark residue around the upper areas and underside lip of the pots and pans. On 5/1/25 at 8:00 AM, Kitchen Staff: Culinary Aide #1, Culinary Aide #2, and Medical Records Manager helping as Culinary Aide #3, stated the pans and pots with the dark, encrusted residue were cleaned and sanitized as they had been washed in the high temperature dish machine. However, Kitchen Staff all agreed the dark residue should not scratch off if the pans and pots were cleaned. They were unaware the pans were not supposed to have encrusted dark residue.

Based on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined that facility failed to ensure residents were free from misappropriation of property and exploitation. This was true for 1 of 1 residents (Resident # 39) reviewed for abuse, neglect, misappropriation of resident property and exploitation. This failed practice created the potential for all facility residents to experience exploitation and misappropriation of property. Findings include: The facility's Abuse policy, revised 3/2024, stated the facility would prevent all types of abuse, neglect, misappropriation of residents' property and exploitation. The CMS SOM, Appendix PP, dated 8/8/24, defined: - Exploitation, as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. - Misappropriation of resident property, as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consents. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, infection of left artificial hip, congestive heart failure, active smoker, and atrial fibrillation (an irregular heart rate). Resident #39's Annual MDS, dated [DATE], documented Resident #39 was cognitively intact. A Facility Reported Incident, dated 9/4/24, included an investigation summary which documented on 9/3/24, resident #39 told staff he gave $1,500 to an employee for first and last month's rent for an apartment for them to share. The investigative summary documented Dietary Aide #1 admitted to taking $1500 cash from Resident #39 and paying first and last months' rent for a new apartment but could not provide any receipts or proof his name was added to the lease. The facility's investigation substantiated Resident #39 gave money to Dietary Aide #1 to rent an apartment. On 5/1/25 at 11:00 AM, the Administrator confirmed Dietary Aide #1 accepted money from Resident #39. These findings represent past non-compliance with this regulatory requirement. The facility did the following: -Resident representative was notified. -Dietary Aide #1's employment was terminated for unprofessional conduct related to accepting funds from a resident. -All staff were given an in-service training discussing gifts & gratuities, conflict of interest, employee resident relationships, and review of the Abuse and Neglect Policy. Training completed on 9/4/24. There was sufficient evidence the facility corrected the non-compliance as of 9/4/24 as there were no further exploitation and misappropriation of property reported after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on record review and staff interview, it was determined the facility failed to ensure residents' MDS documented correct assessment information. This was true for 3 of 16 residents (#12, #46, and #57) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: Appendix PP of the SOM, revised 8/8/24, documented assessments must accurately reflect the resident's status. 1. Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE] with multiple diagnoses including heart attack, chronic atrial fibrillation (irregular heart beat), and language disorder following a heart attack. The Significant Change MDS assessment, dated 1/24/25 documented Resident #12 was receiving hospice care. A review of Resident #12's record documented Resident #12 was discharged from hospice on 1/7/25. On 5/1/25 at 10:34 AM, MDS Nurse #1, with MDS Nurse #2 present, stated, When a resident goes off or on hospice we will do a Significant Change Assessment. It was an error [Resident #12] was marked on hospice on 2/7/25. 2. Resident #46 was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes, and high blood pressure. An Annual MDS Assessment, dated 2/25/25 documented Resident #46 was taking an anticoagulant medication. A review of active and discontinued physician's orders did not document any anticoagulant medications. On 5/1/25 at 10:36 AM, MDS Nurse #1, with MDS Nurse #2 present, stated, Resident #46 is taking an aspirin which is an antiplatelet, not an anticoagulant. The medication was incorrectly marked on the MDS as an anticoagulant. 3. Resident #57 was admitted to the facility on [DATE] with multiple diagnoses including heart disease, high blood pressure, and dementia. An Annual MDS Assessment, dated 3/25/25 documented Resident #57 was taking an anticoagulant. A review of active and discontinued physician's orders did not document any anticoagulant medications. On 5/1/25 at 10:38 AM, MDS Nurse #1, with MDS Nurse #2 present, stated, Resident #57 is taking aspirin, an antiplatelet medication, not an anticoagulant. The medication was incorrectly marked on the MDS as an anticoagulant.

Based on observation, record review, SOM and policy review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written for 2 of 16 residents. This was true for residents (#11 and #48) reviewed for care plans. This deficient practice placed the residents at risk for harm when their care plans did not reflect the care necessary for each resident. Findings include: The CMS SOM, Appendix PP, dated 8/8/24, documented each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs. 1. Resident #11 was initially admitted to the facility on [DATE] with multiple diagnoses including dementia, heart failure, and muscle weakness. An Annual MDS Assessment, dated 12/4/24, documented resident #11 was observed wandering daily. Resident #11's care plan, last reviewed 12/4/24, did not include directions to care for her daily wandering. Resident #11 was observed wandering into resident rooms on the following dates: - On 4/29/25 at 2:15 PM, Resident #11 was room [ROOM NUMBER], a male resident's bathroom. - On 4/30/25 at 11:00 AM, Resident #11 was observed in the doorway of room [ROOM NUMBER]. - On 5/1/25 in the morning, Resident #11 was observed at an exit doorway with her hand on the door. On 4/29/25 at 2:00 PM, the DON stated, Resident #11's care plan should have included directions to care for her wandering behavior. 36193 2. Resident #48 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease and dysphagia (difficulty swallowing). A physician's progress notes, dated 1/8/25 documented Resident #48 had significant difficulty with dysarthria (a motor speech disorder that occurs when the muscles used for speech are weak or difficult to control. It often results in slurred or slow speech that can be hard to understand). Resident #48's care plan did not document he had difficulty with speech. A document titled Communications, dated 7/27/24 documented Resident #48 was hard to understand, and he had a communication board that he was taught to use. The staff were to encourage Resident #48 to speak slower and use his board for better assistance with communicating. Resident #48's care plan did not address he had difficulty with speech and uses a communication board. On 4/30/25 at 3:26 PM, the DON reviewed Resident #48's care plan and stated she did not see Resident #48's difficulty with speech was included in his care plan. The DON stated, Yes, it should have been in the care plan.

Based on record review, policy review and staff interview, it was determined the facility failed to ensure residents' care plan were revised and updated. This was true for 1 of 16 residents (Resident #40) whose care plans were reviewed. This deficient practice created the potential for harm if cares and services were not provided due to inaccurate information on the care plan. Findings include: The facility's Care Plan policy, revised 10/15/22, documented the care plan would be reviewed and revised by the interdisciplinary team as necessary to reflect the individual's current status. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses including dementia and diabetes. A care plan, initiated 1/26/24, documented Resident #40 was on hypnotic therapy Trazodone (antidepressant) as needed related to inability to sleep. Resident #40's physician's order did not include an order for Trazodone. On 4/30/25 at 9:33 AM, the DON stated Resident #40's Trazodone was discontinued by his physician. The DON stated residents' care plans were updated quarterly and as needed, and Resident #40's care plan should have been updated when the Trazodone was discontinued, and it was not.

Based on observation, staff interview, and CDC guidance it was determined the facility failed to ensure glucometer (used to check the blood glucose levels) was cleaned/sanitized after being use. This was true for 2 of 2 residents (#32 and #47) observed for blood glucose level testing. This deficient practice created the potential for the spread of infectious organism from cross contamination which could harm Resident #32 and #47. Findings include: The CDC website https://www.cdc.gov/infection-control/hcp/environmental-control/index.html, article titled Guidelines for Environmental Infection Control in Health-Care Facilities (2003) Nursing Homes, accessed on 5/5/25, updated July 2019 documented use barrier protective coverings as appropriate for non-critical equipment surfaces that are touched frequently with gloved hands during delivery of patient care, likely to become contaminated with blood or body substances . On 4/30/25 at 11:56 AM, MAC #1 entered Resident #47's room with a glucometer, cotton balls, alcohol wipes and lancet in hand. MAC #1 placed the glucometer on top of Resident #47's overboard table with no barrier between the glucometer and the overbed table, and checked his blood glucose. After the completion of blood glucose test, MAC #1 went to the sink, placed the glucometer on top of the sink counter with no barrier between the sink and the glucometer, removed her gloves and washed her hands. MAC #1 picked up glucometer, returned to the medication cart, placed the glucometer on top of the medication cart, and recorded the blood glucose to her computer. MAC #1 then placed the glucometer inside the storage box without cleaning/sanitizing the glucometer. On 4/30/25 at 12:02 PM, MAC #1 entered Resident #31's room with a glucometer, cotton balls, alcohol wipes and lancet in hand. MAC #1 placed the glucometer on top of Resident #31's overboard table with no barrier between the glucometer and the overbed table, and checked his blood glucose. After the completion of blood glucose test, MAC #1 went to the sink, placed the glucometer on top of the sink counter with no barrier between the sink and the glucometer, removed her gloves and washed her hands. MAC #1 picked up the glucometer, returned to the medication cart, placed the glucometer on top of the medication cart, and recorded the blood glucose to her computer. MAC #1 then placed the glucometer inside the storage box without cleaning/sanitizing the glucometer. The storage container has the following inside: glucometer, cotton balls, alcohol wipes, lancet and test strips. On 4/30/25 at 12:08 PM, MAC #1 stated she did not clean/sanitize the glucometer before placing them in their individual container. MAC #1 stated she was not sure if the glucometer was needed to be clean since they have their individual container. On 4/30/25 at 2:34 PM, the IP stated there should be a barrier like a paper towel between the glucometer and surfaces such as the overbed table or sink counter. The IP stated the glucometer should be cleaned before placing them in their container.

Based on record review, policy review, CDC guidelines, and staff interview it was determined the facility failed to ensure antibiotic stewardship program was implemented and resident had appropriate clinical indications for the use of an antibiotic. This was true for 1 of 4 residents (Resident #49) whose records were reviewed for antibiotic use. This deficient practice created the potential for Resident #49 to develop resistance to antibiotics resulting ineffective or difficult treatment for infections. Findings include: The CDC website https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, article titled Core Elements of Antibiotic Stewardship for Nursing Homes, accessed on 5/5/25, documented Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic Stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use.' The article also recommended that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. The facility's Antibiotic Stewardship policy, revised 10/15/22 documented the facility focused on improving antibiotic use through an Antibiotic Stewardship program to ensure appropriate antibiotic usage practices are in place, to promote optimal therapeutic and cost-effective care for their residents, and reduce the likelihood of developing multi-drug resistant organisms. The policy also documented the facility's pharmacy consultant reviews the antibiotic therapy as part of the Medication Regimen Review and makes recommendation to improve antibiotic use as needed, which may include the review of indications, assignment of antibiotic stop dates and etc. Resident #49 was admitted to the facility on [DATE] with multiple diagnoses including Methicillin Susceptible Staphylococcus Aureus (MSSA - bacterial infection) and Intentional Self-Harm by unspecified firearm discharge. A physician's order, dated 11/7/24, documented Resident #49 was to receive Amoxicillin-Pot Clavulanate (antibiotic) Oral tablet 875-125 milligrams, one tablet by mouth two times a day related to sepsis (a serious condition that can cause extensive inflammation throughout the body and can lead to tissue damage, organ failure and even death) due to Methicillin Susceptible Staphylococcus Aureus. The physician's order documented no stop date at this time. On 4/30/25 at 2:46 PM, the IP stated Resident #49 had sepsis when he was prescribed the antibiotic in November 2024. When asked if Resident #49 still had an infection, the IP stated Resident #49 had no more infection. When asked why Resident #49 was still taking the antibiotic, the IP stated she would ask the physician for the indication of Resident #49's antibiotic. On 5/1/25 at 9:53 AM, the Pharmacist stated Resident #49's antibiotic was reviewed in November 2024 during their Antibiotic Stewardship meeting. The Pharmacist stated the Infectious Disease Physician ordered the Amoxicillin-Pot[assium] Clavulanate for Resident #49 with no stop date, and he did not include Resident #49 on his succeeding review of residents' antibiotic in the facility. When asked if the continued use of the antibiotic was needed when Resident #49 did not have an infection anymore, the Pharmacist stated, I agree they [facility] should have reviewed the indication for the antibiotic. On 5/1/25 at 10:58 AM, during the follow-up interview, the IP stated she did not ask the infectious disease physician's indication for the continued use of Resident #49's antibiotic when he was no longer had an infection. The IP stated, Yes, I should have asked the physician for the indication of the antibiotic.

Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect 58 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. FDA Food Code Section 3-303.12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. On 05/16/24 at 12:13 PM, during a kitchen tour with the facility dietitian, condensation from the cooling fans in the walk-in freezer was observed falling and accumulating on the following food items located below the cooling fans: - One yogurt container. - Multiple containers of ice cream and frozen berries inside a black bin. - One open bag of berries and two loaves of bread inside an unsealed cardboard box. The dietitian confirmed the food was not being stored appropriately. She immediately removed the contaminated foods. On 05/16/24 at 1:56 PM, during a follow-up visit with the dietitian, a pipe located on the outer left side of the ventilation unit inside the walk-in freezer was observed to be covered with a white frozen substance. An unsealed cardboard box with packaged food inside was leaning against the pipe. The dietitian confirmed that food boxes were not properly stored. 2. FDA Food Code Section 6-403.11 documented areas designated for employees to eat, drink, and use tobacco products shall be located so that food, equipment, and linens single-service and single use articles are protected from contamination. On 05/16/24, at 12:13 PM, an iced coffee, identified as a staff personal item, was observed stored in the facility's walk-in freezer. The dietitian removed the ice coffee and confirmed that personal food should not be stored in the walk-in freezer, and it should be stored in the employee break room.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure cold food storage equipment was maintained in safe operating condition. This was true for 1 of 3 cold food storage equipment (kitchen walk-in refrigerator). This placed residents at risk of contracting food borne illnesses if they consumed food that was not kept at a safe temperature. Findings include: Review of the facility's policy, General Environment Condition, revised 1/28/17, stated the physical plant and equipment are monitored through the prevention maintenance plan and work order system for potential hazards. This policy was not followed. Review of a Maintenance Work Order, dated 11/18/22, stated, walk-in freezer low on R404A [refrigerant - chemical coolant]. On 4/4/23 at 4:00 PM, the temperature in the kitchen walk-in refrigerator was observed to be 51 degrees Fahrenheit (F) per the thermometer located in the back of the unit. The walk-in refrigerator contained eggs, juices, meats, milk, dairy products, produce, and other perishables. The Dietary Manager (DM) acknowledged the temperature should not be warmer than 41 degrees F. The DM said she turned off the walk-in refrigerator about an hour ago due to it freezing up, and she just turned it back on. When asked how often this occurred, the DM said it only happened occasionally. She stated, the Maintenance Director (MD) instructed her to turn the refrigerator off for one hour when it started making a loud noise. On 4/4/23 at 4:20 PM, the temperature in the kitchen walk-in refrigerator was 48 degrees F per thermometer. At 4:30 PM, the temperature in the kitchen walk-in refrigerator continued to measure at 48 degrees F. On 4/5/23 at 2:18 PM, the RM stated, the walk-in refrigerator had a similar problem on 11/18/22, and a repair company was called in. The RM stated they could have the refrigerator repaired within one to two weeks. He said the refrigerator was currently working properly. The RM acknowledged the refrigerator could stop working in the middle of the night and staff would come in to spoiled food which should not be served. He said during the day the dietary staff would know the walk-in refrigerator wasn't working properly when the unit started making a loud noise. Up to that point, the refrigerator would be slowly getting warmer. Therefore, they would have to check the temperature frequently until it was repaired. On 4/5/23 at 4:15 PM, the MD confirmed he instructed the DM to turn off the walk-in refrigerator because it was making a loud noise due to ice build-up on the coils and causing it to stop cooling. He stated this occurred because the refrigerant was low which was also the problem in November 2022 when the repair company came out. The MD said the maintenance work order referenced the walk-in freezer, but it was the walk-in refrigerator that had low refrigerant. On 4/6/23 at 10:30 AM, the CEO provided a Culinary Inspection report, dated 3/29/23, which detailed the refrigerator/freezer walk inspection results. The inspection did not include checking the refrigerant. The facility failed to ensure the facility's walk-in refrigerator was in safe operating condition.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 15 residents (Resident #18) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information in the care plan. Findings include: The facility's Care Plans policy, revised 10/15/22, documented the facility was to develop and implement a comprehensive person-centered care plan for each resident and revised it based on changing goals, preferences and needs of the resident and in response to current interventions. This policy was not followed. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including depression, dementia, sleep disorder, and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A physician's order, dated 6/20/22, documented Resident #18 was to receive Trazodone (antidepressant) HCl (hydrochloride) 50 milligrams by mouth in the evening related to unspecified mood affective disorder. A care plan, revised 3/19/21, documented Resident #18 had sleep disorder related to dementia and Parkinson's Disease and he used Trazodone to assist him with his insomnia. The care plan directed staff to give him Trazodone as prescribed, monitor him for effectiveness and notify the physician of any worsening signs and symptoms of insomnia. On 4/5/23 at 9:04 AM, the Social Services Director (SSD) stated Resident #18 was taking Trazodone for insomnia. When asked to review the physician's order for Trazodone, the SSD stated the physician ordered Trazodone for Resident #18's unspecified mood disorder. The SSD stated she was told the Trazodone was for Resident #18's insomnia. The SSD stated Resident #18's care plan indication for use of Trazodone should have been according to the physician's order and it was not. Resident #14's care plan was not revised to reflect his Trazodone was for unspecified mood disorder as ordered by the physician.