Every finding on record at Mountain View Healthcare Center

Based on interview and record review, the facility failed to conduct fall risk assessments (FRA-an evaluation used to determine an individual's likelihood of falling) after the episodes of falls on 11/17/25 and 12/19/25 for 1 of 2 residents (Resident 1). This failure had the potential not to determine the factors that may contribute to the risk of falling that may affect the development of appropriate nursing interventions to prevent possible repeated falls for Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities),chronic kidney disease (CKD-a condition where kidneys are damaged and lose the ability to filter waste and fluid out of blood), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN- high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the sacrum (the large upside-down, triangular-shaped bone at the very base of lower back right between hips), lumbar region intervertebral disc degeneration (breakdown of the rubbery cushion (discs) between vertebrae), difficulty in walking, need assistance with personal care, and retention of urine. Review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/31/25 indicated a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, judgement status of the resident) score of 2 which means her cognition (how brain learns, remembers and make decisions) was severely impaired. She needed assistance in activity of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)), transfers from chair to bed, personal hygiene, and toileting needs. During a review of Resident 1's medical record on 7/13/26 at 11:26 a.m., indicated her initial FRA dated 10/29/25 had a score of 16 which meant she was at risk of falling. Further review indicated Resident 1 had unwitnessed falls on 11/17/25 and 12/19/25 with no major injuries. There was no evidence of documentation that FRAs were conducted by the facility after the incident of falls on 11/17/25 and 12/19/25. During a concurrent interview and Resident 1's medical record review with the Director of Nursing (DON) on 7/15/26 at 11:44 a.m., the DON confirmed there was no evidence of documentation in Resident 1's medical record that FRAs were conducted after the incident of falls on 11/17/25 and 12/19/25. The DON acknowledged that the FRAs should have been conducted by the facility for Resident 1 after the falls on 11/17/25 and 12/19/25 as per their facility's procedure and practices. Review of the revised facility's policy and procedures dated 3/2018 indicated, Upon admission, the nursing staff and physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.

Based on interview and record review, the facility failed to identify and monitor the specific target behavior for the use of olanzapine (a psychotropic medication that affects the person's mind, emotions, and behavior) for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) as manifested by agitation and labile mood for 1 of 2 residents (Resident 2). This failure had the potential for Resident 2's physician not to accurately evaluate the effectiveness of the use of olanzapine and may compromise Resident 2's psychological well-being. Findings: Review of Resident 2's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (excessive, persistent, and uncontrollable fear or worry). Review of Resident 2's physician's order dated from 6/18/26 to 6/26/26 indicated give one tablet of olanzapine 2.5 milligram (mg, unit of measurement) every 12 hours for bipolar disorder manifested by agitation and labile mood. Then from 6/26/26 to 7/2/26 indicated give tablet of olanzapine 5 mg every 12 hours for bipolar disorder manifested by agitation and labile mood. Further review of Resident 2's medical record indicated there was no evidence of documentation that the specific target behavior was identified and monitored for agitation (severe restlessness characterized by excessive motor and verbal activity) and labile mood (shifting of emotions like sudden laughter, intense sadness, or burst of angers) by the facility's licensed nurses (LNs) for Resident 2 for the use of olanzapine from 6/18/26 to 7/2/26. During an interview with the Registered Nurse A (RN A) on 7/14/26 at 1:57 p.m., she confirmed there was no evidence of documentation in Resident 2's medical record that specific target behavior was identified and monitored the use of olanzapine from 6/18/26 to 7/2/26. RN A acknowledged that per facility's policy and practice, the specific target behavior should have been identified, monitored and documented by facility's LNs for the use of olanzapine for Resident 2 from 6/18/26 to 7/2/26. Review of the undated facility's policy and procedures titled, Psychotropic Medication Use Policy indicated . 2. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication (s).

Based on interview and record review, the facility failed to inform the Responsible Party (RP, the designated person who oversees a patient's medical, personal, or legal care decisions) for 1 of 2 residents (Resident 1) when:There was no written documentation in Resident 1's medical record that Resident 1's RP was notified prior to discontinuation of 1:1 observation (sitter) on 5/1/26 andThere was no written documentation in Resident 1's medical record that Resident 1's RP was informed of room changed on 12/4/25.These failures deprived Resident 1's RP of the opportunity to advocate alternative choices/options and participate in care planning for Resident 1's welfare and safety. Findings:1.Review of Resident 1's medical record indicated he was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (a progressive state of decline in mental abilities), depression (persistent feeling of sadness, emptiness, and a loss of interest in activities), anxiety (constant feeling of worries or fear), difficulty walking, and generalized muscle weakness.Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 3/11/26 indicated he had a Brief Interview for Mental Status ( BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 5, which means his cognition (thinking and processing information) was severely impaired.Review of Resident 1's physician's orders dated 2/26/26 indicated, Resident 1 was incapable of understanding rights, responsibilities, and informed consent. Resident 1 was very high risk for fall. Ensure bed in lowest position between care. Communicate with bedside sitter throughout shift. Provide frequent safety reminders every shift.Review of Resident 1's medical record indicated the daughter was the RP for Resident 1's care.Review of Resident 1's Fall Risk Assessments (screening to determine patient's risk of falling) dated 12/10/25 indicated a score of 11; dated 3/11/26 indicated a score of 10; and 5/4/26 indicated a score of 16 (a total score of 10 or above represents high risk for falls). During an interview with Licensed Vocational Nurse A (LVN A) on 5/19/26 at 2:20 p.m., she confirmed that 1:1 observation (sitter) was discontinued on 5/1/26 for Resident 1.During an interview and staffing schedule review on 5/29/26 at 10:43 a.m. with the Director of Nursing (DON), she confirmed that one member of facility staff was assigned as a sitter in Resident 1's room from 4/25/26 through 4/30/26. Then, starting on 5/1/26, the 1:1 observation (sitter) was discontinued for Resident 1.Review of Resident 1's Interdisciplinary Team (IDT, a coordinated group of healthcare professionals within the facility who work together to plan, deliver, and evaluate patient care) dated 5/5/26 indicated, Resident 1 was provided a 1:1 observation (sitter) upon admission to the facility due to Resident 1 was a high risk for fall. The 1:1 observation was discontinued on 5/1/26 due to Resident 1 demonstrated improved stability in overall condition. Resident 1 was scheduled on regular checks for safety.During an interview and record review on 5/29/26 at 10:54 a.m. with DON, she confirmed there was no written evidence in Resident 1's medical record that Resident 1's RP was notified of the discontinuation of the 1:1 observation (sitter) for Resident 1 prior to 5/1/26. DON acknowledged the facility should have notified Resident 1's RP prior to discontinuation of 1:1 observation (sitter) on 5/1/26.Review of the facility's revised policy and procedures dated 11/2025 titled, Health, Medical Condition and Treatments Options, Informing Residents of indicated, Each resident is informed of their health status and medical condition, including diagnosis, treatment recommendations, and prognosis, in advance of treatment and on an on-going basis. If resident has an appointed representative, the representative is also informed. The resident's attending physician, the facility's medical director, or the director of nursing services is responsible for informing the resident of their medical condition. Such information includes providing the resident/representative with information about resident's: i. type of care or treatment recommended (based on the assessment and care plan) .l. treatment alternatives or options 2.Review of Resident 1's medical record indicated he was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy, dementia, depression, anxiety, difficulty walking, and generalized muscle weakness.Review of Resident 1's MDS dated [DATE] indicated that he had BIMS score of 5, which means his cognition (thinking and processing information) was severely impaired.Review of Resident 1's medical record indicated the daughter was the RP for Resident 1's care.Review of Resident 1's medical record dated 12/4/25 indicated, Resident 1 was offered a room change and agreed to room change. Resident 1 was moved to another room.During an interview and Resident 1's medical record review on 5/29/26 at 10:43 a.m. with the DON, she confirmed there was no written evidence in Resident 1's medical record that Resident 1's RP was notified of the room changed on 12/4/25. DON acknowledged Resident 1's RP should have notified of room change.Review of the undated facility's policy and procedures titled Room Change/Roommate Assignment indicated, Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents or their representatives, will be given advance notice of such a change as is possible.

Based on interview and record review, the facility failed to follow standards of practice when medications were not given as prescribed for two of three residents (Residents 1 and 2):Resident 1's lamotrigine (a medication used to prevent seizures [uncontrolled jerking, blank stares, and loss of consciousness]) order and administration time was adjusted in the electronic health record (EHR) and lamotrigine was not given to Resident 1 on 10/7/25 and 10/8/25;Resident 2's lacosamide (a medication used to prevent seizures) order was incorrectly duplicated in the EHR and nurses did not administer the correct daily dose to Resident 2 on 10/21/25, 10/22/25, and 10/23/25.These failures resulted in missed medication doses, overmedication, and had the potential to result in health complications. Findings: 1. Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including epilepsy (uncontrolled electrical disturbance in the brain which can cause seizures). Review of Resident 1's SNF (Skilled Nursing Facility) Orders from the hospital, dated 10/6/25 indicated a list of medications the resident should be taking, which included lamotrigine (a medication used to prevent seizures) 25 milligrams (mg, unit of measurement) Take 2 tablets (50 mg total) by mouth daily at bedtime for 5 days. The orders also indicated Resident 1 was Currently on Week 2 of an up-titration (gradual increase of a medication dose from a low dose to a higher dose) schedule for lamotrigine and indicated the increases to the dosage of lamotrigine over the course of 8 weeks. Review of Resident 1's Clinical Physician Orders indicated an order, dated 10/6/25 Lamotrigine 25 mg Give 2 tablet by mouth at bedtime for seizure for 5 days. The lamotrigine order was discontinued on 10/7/25. Review of Resident 1's Clinical Physician Orders indicated an order, dated 10/7/25 Lamotrigine 25 mg Give 2 tablet by mouth in the morning for seizure for 1 week, with a start date of 10/8/25 at 9 a.m. Review of Resident 1's Progress notes, dated 10/7/25 at 3:01 p.m. indicated Registered Nurse A (RN A) wrote, IFT [Interfacility Transfer] order [admission orders/orders from the hospital] and diagnosis were reviewed with the NP [Nurse Practitioner] and updated and placed as accurate. Review of Resident 1's Encounter Progress Notes written by the NP, dated 10/7/25 indicated, Continue Lamictal [lamotrigine] titrating up recommended by Neurologist . Continue all home medications as reviewed and prescribed by primary care physician and/or Discharging hospital physician as noted in Discharge or Transfer Summary. Review of Resident 1's Medication Administration Record for 10/2025 indicated Resident 1 received lamotrigine 25 mg 2 tablets (50 mg) on 10/6/25 at 9 p.m. There was no documentation that indicated Resident 1 received lamotrigine 25 mg 2 tablets (50 mg) on 10/7/25 and 10/8/25. Review of Resident 1's Physical Therapy (PT) Treatment Encounter Note(s), dated 10/8/25 indicated, The skilled therapeutic activities commenced with the patient consenting between 10:15am-10:30am to engage in therapy while lying in bed . Once in the therapy gym, the patient attempted the Omnicycle [motorized machine used in rehabilitation therapy to increase strength and mobility to arms and/or legs]; however, jerky/dystonic movements [involuntary muscle contractions] were observed getting worse, prompting the immediate cessation of the activity, and nursing staff was notified. The patient was subsequently wheeled back to the room, transferred back to bed, and placed in a side-lying position with the bed flat after a seizure was identified . Review of Resident 1's Change in Condition Evaluation, dated 10/8/25 indicated, At approximately 1000 [10 a.m.], writer went to administer [Resident 1's] morning medications; however, the [Resident 1] was not in the room. And was attending therapy in the rehab department . At approximately 1050 [10:50 a.m.] the therapist reported that [Resident 1] was experiencing a seizure during the therapy session . 911 was called and [Resident 1] was transferred to [the hospital] . Review of Resident 1's Neurology Consult Note from the hospital , dated 10/8/25 indicated recommendations included, . Facility education re: [regarding] importance of not missing anti-seizure meds and giving ALL as prescribed . During an interview on 10/21/25 at 4:25 p.m., RN A explained how Resident 1's lamotrigine administration time was changed to be given in the morning instead of at bedtime. RN A stated on 10/7/25 she went through the admission orders with the Nurse Practitioner (NP) and adjustments were made. RN A confirmed there was no lamotrigine dose given to Resident 1 on 10/7/25. RN A stated the lamotrigine order was changed on 10/7/25 and the start date was 10/8/25. RN A stated she did not know why the NP decided to change Resident 1's lamotrigine order. During an interview on 12/4/25 at 11:33 p.m., the NP stated usually the facility continues with the hospital medication and does not change it. She stated she was not sure why Resident 1's lamotrigine order was changed. The NP stated she did not put an order to change Resident 1's lamotrigine. During an interview on 12/31/25 at 12:03 p.m. the director of nursing (DON) explained why the lamotrigine dose was not given to Resident 1 on 10/7/25. The DON stated when orders are changed in the EHR, the next dose starts the next day. The DON stated Resident 1's lamotrigine order was scheduled to be given on 10/8/25 at 9 a.m., but it was not given because Resident 1 was taken to therapy. The DON stated nurses can give a medication dose one hour before to one hour after the dose is due. She stated Resident 1 should have received her morning medications on 10/8/25 between 8 a.m. and 10 a.m. During an interview 1/16/26 at 9:46 a.m., the Doctor of Medicine (MD) stated he was not sure why Resident 1's lamotrigine order was changed to be given in the morning. During an interview on 1/16/26 at 1:03 p.m., the consultant pharmacist (CP) stated she called the facility and stated they are unaware as to why the timing of Resident 1's lamotrigine order was changed. The CP stated changes in medication administration timing should be ordered by a provider. 2. Review of Resident 2's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including wedge compression fracture (a type of break in the vertebra [spine] where the broken bone collapses and forms a wedge shape) and epilepsy. Resident 2's record also indicated he was hospitalized from [DATE] to 10/20/25 and readmitted to the facility on [DATE]. Review of Resident 2's SNF Orders from the hospital, dated 10/20/25 indicated he had an order for lacosamide 150 mg tablet Take 1 tablet (150 mg total) by mouth 2 (two) times a day. The orders indicated the last time lacosamide 150 mg was given was 10/20/25 at 9:31 a.m. Review of Resident 2's physician orders indicated he had the following lacosamide orders:Lacosamide Oral Tablet 150 mg Give 1 tablet by mouth two times a day for seizure, start date on 10/21/25 at 8 a.m. Lacosamide Oral Tablet 150 mg Give 1 tablet by mouth every 12 hours for seizures, start date on 10/21/25 at 9 p.m. Review of Resident 2's MAR for October 2025 indicated one lacosamide order was scheduled for the medication to be given at 8 a.m. and 5 p.m. and another lacosmide order was scheduled for the medication to be given at 9 a.m. and 9 p.m. Review of Resident 2's Controlled Drug Record (CDR) for Lacosamide indicated the medication label Lacosamide 150 mg tablet Take 1 tablet (150 mg total) by mouth 2 times a day. Resident 2's CDR indicated Lacosamide 150 mg was given to Resident 2 twice a day from 10/11/25 to 10/16/25. The CDR also indicated Lacosamide 150 mg was given to Resident 2 once on 10/21/25, three times on 10/22/25, and four times on 10/23/25:10/21/25 at 9:04 a.m.;10/22/25 at 8:40 a.m.;10/22/25 at 5 p.m.;10/22/25 at 9 p.m.; 10/23/25 at 8 a.m.;10/23/25 at 9 a.m.;10/23/25 at 5 p.m.; and 10/23/25 at 9 p.m. Review of Resident 2's Progress Notes, dated 10/23/25 indicated at 6 p.m., Resident 2 complained of dizziness. The notes also indicated at 8 p.m., Resident 2's evening medications were given and at 9 p.m., Resident 2 complained of dizziness and requested to go to the hospital. The notes indicated 911 was called and Resident 2 was transported to the hospital. During an interview and concurrent record review on 12/31/25 at 11:27 a.m., the DON confirmed Resident 2 received Lacosamide 150 mg on 10/21/25 at 9:04 a.m.; 10/22/25 at 8:40 a.m., 5 p.m. and 9 p.m.; 10/23/25 at 8 a.m., 9 a.m., 5 p.m., and 9 p.m. During an interview on 1/16/26 at 11:49 a.m., Licensed Vocational Nurse B (LVN B) stated he does not remember giving Resident 2's lacosamide twice on 10/23/25. LVN B stated Resident 2's lacosamide was supposed to be given once on his shift. He stated he just follows what is in the MAR. During an interview on 1/21/26 at 9:42 a.m., Licensed Vocational Nurse C (LVN C) stated she does not remember giving Resident 2's lacosamide twice on 10/23/25. LVN C stated she was usure of the date, but she remembered transferring Resident 2 to the hospital due to blurry vision and stroke-like symptoms. During an interview on 1/16/26 at 1:03 p.m., the CP stated the maximum daily dose of lacosamide is 400 mg. She stated on 10/23/25 Resident 2 received 600 mg, which is more than the maximum daily dose. The CP stated administering lacosamide over the maximum daily dose predisposes the resident to side effects, including headaches, dizziness, ataxia (poor muscle control), and altered mental status. The CP stated she spoke to the DON to find out why Resident 2 had two lacosamide orders. The CP stated the DON told her the nurse who input the lacosamide order forgot to discontinue the first one. The CP stated it was definitely an error. She stated it looks like nurses can input an order without any oversight and she will recommend providing an education session for nurses to prevent this from happening again. Review of the facility's policy, Administering Medications, revised 4/2019 indicated, Medications are administered in a safe and timely manner, and as prescribed . Ensure that the six rights of medication are followed: a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation .Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time . Administer within 60 minutes prior to or after schedule time unless otherwise ordered by physician.

Based on interview and record review, the facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for one of three residents (1) procedures to discharge on e of three residents (1) when: 1. The facility did not follow their policy on, Against Medical Advice (AMA, a patient's decision to leave a healthcare facility or discontinue treatment despite the recommendations of their doctor) when Resident 1 was discharged AMA after he did not return to the facility when he went out on pass (a temporary absence for an inpatient who has received official permission to leave a hospital or care facility but is not being officially discharged ) for several hours.2. The facility did not provide Resident 1 with the discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) timely (30 days before discharge or as soon as possible).3. Resident 1 also did not have discharge care plan to include some of his discharge needs such as medication management (the process of ensuring prescription drugs and other medications are used correctly to maximize safety and effectiveness), Home Health (services provided by health care provider to resident after discharge to home) referral , DME (durable medical equipment, is medical equipment that is durable, can be reused, and is prescribed by a doctor for use in a patient's home)needed, etc.).The post-discharge plan of care did not address Resident 1's limitations and his ability to care for himself. 4. Facility did not have any interdisciplinary care team (IDT, interdisciplinary team, a group of professionals from different fields who collaborate to achieve a common goal)meeting to discuss Resident 1's discharge plan /needs, did not identify the location of his discharge, and/or complete a referral to appropriate community agency placement (is the arrangement of an individual with a community-based program or service to meet a specific need, such as for care and housing).5. Resident 1 did not have a discharge summary (is a medical document that provides a comprehensive overview of a patient's hospitalization, including their diagnosis, treatment, procedures, and follow-up care instructions to serve as an important communication tool between healthcare providers, ensuring that the patient's primary care physician or other healthcare professionals have all the necessary information to continue their care effectively) that included assistance needed for him to adjust to his new living environment.6. These failures endangered the health and safety of Resident 1 who was unexpectedly discharged from the facility without proper preparation for appropriate placement and/or home health referral, medication management, medical equipment set up, and follow-up medical appointments. Resident 1's whereabouts was unable to locate. 1. A review of iQIES (Internet Quality Improvement and Evaluation System, is used to manage provider and patient information and ensure quality healthcare for Medicare and Medicaid beneficiaries) complaint received on 10/9/2025, indicated, (Resident 1 called to report that he was discharged from the facility on 10/07/25 because the facility stated that he no longer needed that level of care. On the day (10/6/25) he left the facility to run errands. His car broke down, and he was gone for 5 - 6 hours. When he returned from auto parts store, he was discharged . The facility they did not want to provide medication. After going back and forth for over an hour with the facility some medication was provided . During a review of Resident 1's face sheet (a document that summarizes a patient's key demographic and medical information for quick access) it indicated he was admitted to the facility on [DATE] and was discharged AMA on 10/7/25. He had diagnoses including polyneuropathy (is a condition in which multiple peripheral nerves {A nerve is an organ composed of multiple nerve fibers bound together by sheaths of connective tissue throughout the body become damaged or dysfunctional {means a state of not functioning normally, or a problem that disrupts a system's normal operations}), acute on chronic systolic (congestive) heart failure (a sudden worsening of symptoms in individuals with an existing condition of chronic systolic heart failure {a lifelong condition for heart muscle weakens and difficult for the heart to pump blood effectively}) shortness of breath (SOB, is an uncomfortable feeling of not being able to breathe well enough), chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), obstructive sleep apnea (is a sleep-related breathing disorder ) and need for assistance with personal care, hypertension (HTN, high blood pressures, a condition where the force of blood against artery walls is consistently too high, making the heart work harder and increasing the risk of heart, brain, and kidney diseases ), pacemaker (is a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic cardiovascular disease (ASCVD, is a hardening of your arteries from plaque (a small, abnormal patch of tissue on a body part or an organ) building up gradually inside them to cause cardiovascular diseases ). During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 9/6/25, it indicated his brief interview for mental status (BIMS, is a quick, mandatory cognitive (is relating to or involving the processes of thinking and reasoning ) screening tool used in long-term care to assess a person's orientation, attention, and memory) was intact with score of 15 and his functional abilities (the skills and capacities a person has to perform daily tasks, ranging from basic self-care like dressing and eating to more complex activities such as financial management, communication, and professional work) for self-care (is the practice of deliberately taking actions to protect and improve one's own physical, mental, and emotional health) required setup or clean-up assistance for eating, oral hygiene, toileting, dressing, personal hygiene and putting and taking off footwear. He required supervision or touching assistance (is a level of support where a helper provides verbal cues, steadying, or light physical contact as a person completes an activity) for chair or toilet transfer, car transfer shower transfer or walk 10 feet were not attempted due to medical condition or safety concerns. During a review of Resident 1's Temporary Absence Release form indicated he went out on pass on the following dates and time: 9/11/25 at 15:40 (3:40 p.m.), 9/25/25 at 4:07 p.m., 9/26/25 at 10:22 a.m., 9/30/25 at 11 a.m., 10/2/25 at 11:30 a.m., 10/3/25 at 3:23 p.m., 10/4/25 at 11 a.m. and 10/6/25 at 1:30 p.m. During a review of Resident 1's progress notes, dated 10/6/25 at 9 p.m., it indicated, Patient went out in the morning and had not returned to the unit until late at night. Contacted patient by phone; patient stated he was on the way back. Instructed patient to obtain prior approval before going out and to notify the medical staff if they returning late. Education provided. During a review of Resident 1's progress notes, dated 10/7/25 at 1:17 a.m., it indicated, It is now 1:15 AM, patient hasn't come back yet. Called resident on his personal phone left a message. He called back after a few minutes; he said his car broke down and he was stuck at (store) waiting for it to open. He said he was trying to go to DMV (Department of Motor Vehicles, a state-level government agency responsible for managing driver's licenses, vehicle registrations, and state identification cards) but didn't make it on time. He said he would come back in the morning. Told him staff was wondering why he didn't come back? asked him if he was safe, he said Oh yes, I'm safe. Will endorse to next shift. Called emergency contact #2, left VM (voice message) to (emergency contact person) Will let supervisor know. During a review of Resident 1's progress notes, dated 10/7/25 at 10 :40 a.m., it indicated, (Resident 1) left facility to go to social security office on 10/6 at 13:30 (1:30 p.m.). Per (Resident 1) he will return within 2 (two) hours. Resident did not return as scheduled. Contact was made at approximately 2230 (10:30 p.m.) with (Resident 1) who informed him would be back at the facility by 2330 (11:30 p.m.). He did not come back to facility and did not establish contact before midnight 10/7 at approximately 1040 (10:40 a.m.) Call placed to (Resident 1) to inform that he has been discharged for AMA, and all personal belongings will be available to pick up with social services. During a review of Resident 1's progress notes, dated 10/7/25 at 2:30 p.m., it indicated, Pt (patient) asked to speak with SS (social service). Writer went outside to speak with them. Writer explained to pt that they did not come back when they said they would and that it was already explained to them (Resident 1) they would be discharged under our system under AMA, which they (Resident 1) already verbalized understanding to. Pt asked, Where am I supposed to go? Writer told pt they should reach out to the placement specialist we placed them with. Pt said, I can't afford that. Explained to pt that they could base off of previous conversations with patient, and they were only choosing not to. Pt said, What about food? Writer explained that the Room and Boards presented to them already provide food and a bed. Writer said, Their food wouldn't be enough for me; it's not enough at this facility anyways. Writer reiterated that it is their decision not to continue to the search for placement and SS has presented all they could to them. Pt said, What about my meds( medications), I can't not take my meds. Writer explained to pt that if they discharge under AMA, they don't receive their medication, and we could give them a list of what they were taking. Pt agreed to wanting the medication list. Writer printed out the list and gave it to PT (patient). Pt kept saying My phone was dead, how do you expect me to call you guys? Writer informed pt that this explanation wasn't a valid excuse due to them being able to answer the phone when our nursing staff called them in the middle of the night. Pt asked to speak with admin, this writer informed supervisor. During a review of Resident 1's AMA release form, dated 10/7/25, it indicated that Resident 1 refused to sign. During an interview on 10/10/25, at 10:40 a.m., with registered nurse A (RN A, the nurse supervisor), she stated Resident 1 had an order for out on pass for four hours and was required to complete the sign in sheet (is a document used to record the names, contact information, and arrival and departure times of individuals attending an event, entering a facility, or participating in an activity), and check in and out with a license nurse.During an interview on 10/10/25, at 12:34 p.m., with licensed vocational nurse B (LVN B), LVN B stated she was working the morning shift on 10/6/25 when Resident 1 went out on pass at 1:30 p.m. LVN B confirmed she was aware Resident 1 went out on pass at 1:30 p.m. of 10/6/25 and Resident 1 in the past always returned on time with no problems. LVN further stated Resident 1 was very independent; alert and oriented and he was short stay (is a temporary period of care, typically lasting from a few days up to several months, for individuals recovering from surgery, illness, or injury) in the facility for rehabilitation (a type of short-term therapy focused on helping a patient regain independence after an illness or injury, often through a coordinated care plan involving multiple therapists). During an interview on 10/10/25, at 1 p.m., with the social service director (SSD), the SSD stated, when Resident 1 did not return after midnight (on 10/6/25), he was already considered discharged from the facility. The SSD also stated, Resident 1 passed the time frame for out on pass; hence, he was discharged from the facility. The SSD further stated that Resident 1 was in transitioning looking for placement they (social services) offered him the placement, but he refused, because he did not want to pay any money. So, on the next day of 10/7/25 when he returned to the facility it was afternoon already and Resident 1 was informed that he had been discharged for AMA in the morning by our assistant director of nursing (ADON). Resident 1 came back to pick up his belongings; we explained to him the reason why he was discharged AMA because he did not return as scheduled. The SSD stated Resident 1's medication list had been printed out and was given to him when he came back to pick up his belongings. During an interview on 10/10/25, at 4:15 p.m., with the director of nursing (DON), the DON stated, Resident 1's remaining medications were given to him on 10/7/25 when he came back to pick up his belongings. The DON explained why the facility discharged Resident 1 AMA, it was because he did not return phone calls from facility staff when his return to the facility was delayed, he only came back in the afternoon of the next day (10/7/25). During an interview on 10/16/25, at 2:48 p.m., with the social service assistant (SSA), the SSA stated Resident 1 did not let us know that his car was broken until after midnight when the night shift nurse called him by phone and found out that his car was broken and could not return to the facility. Resident 1 informed the nurse that he would be back in the morning the next day, but he did not. That's why when Resident 1 did not return as he supposed to be before midnight then he would consider to be AMA discharged . The SSA further stated that at nighttime there was no way to arrange transportation services for Resident 1. He was very alert, independent and carried a cellphone with him, so he could have called for driver services. The SSA stated although Resident 1 did not initiate the request to discharge or intend to leave, he was delayed in returning to the facility and exceeded the allowed hours for being out on pass, then he was considered discharged AMA. During a telephone interview on 10/16/25, from 3:05 p.m.to 3:30 p.m., with the ADON, she stated, Resident 1went out on pass and he did not return before midnight (on 10/6/25), so he was considered discharged AMA from the facility. The ADON further stated she had reminded Resident 1 twice before he left the facility, and on the evening when he did not return before midnight on 10/6/25 that he would automatically be discharged from the facility if he would not return on time. The ADON reviewed the facility's policy on Against Medical Advice- Discharge and verified and admitted that the policy did not indicate any information about discharging a resident automatically AMA when she/he goes out on pass and did not return back to the facility on time during this the temporary leave absence. During a telephone interview on 10/16/25, at 3:32 p.m., with Resident 1's family member (FM), the FM stated she was not able to get hold of Resident 1 after several phone call attempts to his cellphone. The FM also expressed feeling worried about Resident 1's health and safety because his whereabouts could not be determined until this time. During an interview on 10/20/25, at around 9:30 a.m., with the administrator (ADM), the ADM stated Resident 1 returned to the facility at around 2 p.m. on 10/7/25. The ADM confirmed he informed Resident 1 that he was already discharged from their system, and he offered Resident 1 two to three times to be admitted to the hospital across the street of the facility to get authorization (hospital admission to be admitted back to the long-term facility) then he would be able to come back for continued care at the facility. The ADM stated, as long as he goes to the hospital to get authorization then we will be able to get him here, so the only thing he needs to do is going to the hospital across the street, but he refused. He (Resident 1) told us, why would I go to the hospital? I am fine. A review of the facility's undated policy and procedures (P&P) titled, Against Medical Advice (AMA) Discharge Policy-Admission, Transferers and Discharges, the P&P indicated, If a resident or responsible party (RP) chooses to leave AMA, staff will respect their right to self -determination. The attending physician or on-call provider must be notified immediately. The assigned nurse or designee will document in the medical record including resident's or RP 's stated intent to leave AMA. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, revised April 2025, the P&P indicated, 1. Resident are permitted to return to the facility after therapeutic leave. A resident's extended therapeutic leave (in which a resident returns to the facility later than agreed upon) is not grounds for discharge. 2. Upon return, the resident will be assessed for any health consequences of being from the facility longer than expected and provided with any missed medications or treatments. 4. The facility will not discharge the resident unless it has ascertained from the resident or resident representative that he or she does not wish to return.A further review of the facility's undated policy and procedures (P&P) titled, Transfer or Discharge, Resident-Initiated, the P&P indicated, A resident's verbal or written notice of intent to leave against medical advice is considered a resident -initiated discharge. During a review of the Notice of Proposed Transfer or Discharge, dated on 10/7/25, it indicated the notice was completed on 10/8/25 but a copy was not provided Resident 1. During a further review of Resident 1's Medi-Cal (is California's state-r un version of the federal Medicaid program, providing low-cost or no-cost health coverage to low-income Californians, including families, seniors, persons with disabilities, and pregnant women) Long-Term Care Facility admission And Discharge Notification, dated 10/6/25, it indicated, Patient refused signature. During an interview on 10/10/25, at around 1:30 p.m., with the SSD, she confirmed that Resident 1 refused to sign on the Medi-Cal Long-Term Care Facility admission and Discharge Notification form dated 10/6/25 that indicated the date of discharge as 9/20/25. The SSD also indicated, Resident 1 was being transitioned to the community and was looking for placements. 3. During a review of Resident 1's nursing progress notes as late entry, dated 9/5/25, it indicated, Heart failure (HF, a progressive condition where the heart cannot pump blood effectively through the body) clinic called to check up on Resident 1- need daily weight r/t (related to) HF and f/u (follow-up) appointment on 9/9/25 at 2:30 p.m. During a review of Resident 1 skilled nursing facility's encounter notes for History and Physical transition of care dated 9/8/25, it indicated, Resident 1 sent from cardiology clinic presenting with chest pain (CP), SOB and 20 pounds weight gain from the past two weeks. Patient is here for CP and SOB. Reports sore (pain) on [NAME] (left upper chest) s/p (status post, is a medical term meaning after or following a specific event, procedure, or condition ) CRT-D (Cardiac Resynchronization Therapy with Defibrillator, a treatment to help restore the normal rhythm (timing pattern) of the heartbeat.)., s/p TAVR (Transcatheter Aortic Valve Replacement, refers to a minimally invasive procedure used to replace a narrowed or diseased aortic valve in the heart. ) 2022, COPD (chronic obstructive pulmonary disease, refers to a group of lung diseases that cause airflow obstruction and breathing problems), and chronic systolic heart failure (a condition where the heart's left ventricle (main pumping chamber) cannot pump blood effectively . In the ED (Emergency Department, is part of a hospital and provides 24/7 care, access to advanced diagnostics like CT scans, and surgical capabilities) he was found to have uncontrolled hypertension (elevated blood pressure and hypoxemia (a condition in which the blood has lower-than-normal levels of oxygen pressure) with oxygen saturations of 88% on room air. Reports pain over left anterior (front) chest wall at the site of ICD (implantable cardioverter-defibrillator/ a pacemaker, is a small battery-powered device placed in the chest. It detects and stops irregular heartbeats) implantation. During a review and concurrent interview on 10/10/25 at 2:10 p.m. with the DON, the DON confirmed Resident 1's care plans did not include any discharge care plan that would address his discharge needs such as medication management, Home Health referral, DME needed. During a review of Resident 1's social service assessment, dated 9/8/25, it indicated, Resident 1 is anticipated to stay in the facility on a short-term basis. Resident will participate in discharge planning .Resident 1 would like to find placement. Resident 1 needs the following for a successful discharge: HH (home health, is a wide range of health care services that you can get in your home for an illness or injury), REFERRALS FOR SAFE DC DME (discharge durable medical equipment) (IDT). RESIDENT WAS PREVIOUSELY LIVING OUT OF THEIR CAR. UPON DC, RESIDENT WOULD LIKE PLACEMENT. 4. During a record review with SSD on 10/10/25 at 9:40 p.m., she confirmed Resident 1's electronic clinical records indicated no interdisciplinary team (IDT) meeting conducted to address the goal of discharge and planning, and a condition in which the blood has lower-than-normal levels of oxygen facility did not identify the location of his discharge and/or complete a referral to appropriate community agency placement. Resident 1 did not have a discharge summary that would indicate/include the assistance needed for Resident 1 ability to adjust to his new living environment.5. During an interview on 10/20/25, at 9:40 a.m., with the SSD, the SSD confirmed that the IDT meeting or discharge summary and plan for Resident 1 were missing and were not done, because there was no date for him to be discharged from the facility. The SSD further stated that the facility introduced a board and care home to Resident 1 during his facility stay and also upon his return to pick up his belongings, but Resident 1 refused for the referral of board and care home. A review of the facility's policy and procedures (P&P) titled, Discharge Summary and Plan, revised March 2025, the P&P indicated, When a resident's discharge is anticipated, a resident discharge summary is created. Every resident has an individual discharge plan, which begins at admission and is part of the comprehensive care plan. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). The discharge plan is re-evaluated based on changes in resident's condition or needs prior to discharge.

Based on interview and record review, the facility failed to follow their procedure in completing the inventory list of personal effects form (a document used to record a resident's possessions, typically in a specific context like moving into a facility which serves as a record of belongings, often including details like descriptions, values, and dates of acquisition or loss) when the form was not signed by facility staff and resident upon discharge for one of three residents (Resident 1). This failure may lead to issues if the discharged resident claims of any missing items and no proof that this was all accounted for during discharge.Findings:Review of Resident 1's medical record indicated he was admitted to facility on 6/18/25 with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness. He was discharged to assisted living facility (ALF, a residential setting designed to provide housing and supportive services to individuals who need help with daily tasks but do not require the intensive medical care of a nursing home) on 6/26/25.During a review of Resident 1's personal effects inventory list form on 7/8/25 at 9:46 a.m., revealed the signage space on the acknowledgement of receipt on the right bottom part was blank and was not signed by facility staff and Resident 1 upon discharge on [DATE]. There was also no notation by facility staff that Resident 1 refused to sign it.During a review of Resident 1's medical record dated 6/26/25 indicated, Personal belongings discharged with patient.During an interview with the Registered Nurse A (RN A) on 7/8/25 at 10:55 a.m., she confirmed that Resident 1's inventory list form's signage space on the right bottom part was blank and not signed by facility staff and Resident 1 upon discharge on [DATE]. RN A acknowledged it should have been signed by Resident 1 and facility staff as per their facility's procedure.During an interview with the Assistant Director of Nursing (ADON) on 7/8/25 at 11:36 a.m., she stated that the facility staff and Resident 1 should have signed the personal effects inventory list form acknowledgement of receipt upon discharge of Resident 1 on 6/26/25.Review of the facility's policy and procedures titled Inventory of Personal Effects indicated . Resident/Responsible Party and staff member are to sign and date the inventory on admission and again on discharge, acknowledging receipt of items.

Based on interview and record review, the facility failed to ensure service provided to meet professional standards for two of three residents (1 and 2) when their fall risk assessments were not done quarterly. This failure resulted in the residents' fall risk and fall prevention not updated to the residents' conditions to prevent the residents from falling. Findings: Review of Resident 1's Admission Record indicated he was admitted to the facility on [DATE] with respiratory disorders and difficulty in walking diagnoses. Review of Resident 1's clinical record indicated he did not have any quarterly fall risk assessment. Review of Resident 1's Change in Condition Evaluation, dated 2/17/25, indicated Resident 1 slid down from the commode in his restroom and layed on the floor. Review of Resident 2's Admission Record indicated she was admitted to the facility on [DATE] with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) diagnosis. Review of Resident 2's clinical record indicated she did not have quarterly fall risk assessment done in 5/2024. Review of Resident 2's Change in Condition Evaluation, dated 8/7/24, indicated Resident 2 was found sitting on the floor next to the edge of her bed. Resident 2 stated that she tried to ambulate self to bedside commode, felt weak, and sat down to the floor. During an interview with the director of nursing (DON) on 5/14/25, at 4 p.m., she reviewed Resident 1's and Resident 2's clinical records and confirmed that Resident 1 did not have any quarterly fall risk assessment, and Resident 2 did not have quarterly fall risk assessment done in 5/2024. The DON stated the residents' fall risk assessment should be done every quarter. Review of the facility's policy, Fall Prevention Program, dated 3/1/23, indicated . 5. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.

Based on interview and record review, the facility failed to ensure the residents received the necessary care and services 1. For one of three residents (3) when Resident 3's order from the acute care was not followed; and 2. For three of three residents (3, 4, and 5) when the licensed nurses did not administer Resident 3, 4, and 5's blood pressure medications as ordered by the physician. These failures could negatively impact the residents' health and well-being. Findings: 1. Review of Resident 3's Admission Record indicated he was admitted to the facility on [DATE] with benign prostatic hyperplasia (enlarged gland in the male reproductive system) and obstructive and reflux uropathy (a blockage in the urinary tract, preventing normal urine flow, and urine flows backward from the bladder instead of exiting the body) diagnoses. Review of Resident 3's clinical record indicated he had a Foley catheter (a soft and flexible tube inserted into the bladder to drain urine). Review of Resident 3's acute care Interagency Discharge Summary and Orders, dated 2/6/25, indicated that Resident 3 had a urology referral (a formal direction from a primary care physician or other healthcare provider for specialized care related to the urinary system), and his void trial (a clinical procedure involves removing the urinary catheter and monitoring the patient's bladder emptying capabilities) would be under supervision of urology (a part of health care that deals with diseases of the urinary tract) on 2/10/25. However, review of Resident 3's Nurses Progress Note, dated 2/12/25, at 7 a.m., indicated Resident 3's void trial was performed at the facility without supervision of urology. His Foley catheter was removed. Review of Resident 3's Progress Note, dated 2/12/25, at 3:27 p.m., indicated Resident 3's post-void residual (PVR, the amount of urine remaining in the bladder after a person has urinated) was 780 milliliters (ml, a metric unit of volume). The licensed nurse attempted to empty Resident 3's bladder with straight catheter (a flexible tube used to drain urine from the bladder on a temporary basis) three times but was unsuccessful. Resident 3 had discomfort with the procedure performed of emptying the bladder via straight catheter and was sent out to acute care for Foley catheter placement. During an interview with the director of nursing (DON) on 5/14/25, at 4:35 p.m., she reviewed Resident 3's 2/6/25 acute care Interagency Discharge Summary and Orders and stated that Resident 3's void trial should be performed under supervision of urology. Review of the facility's policy, Medication Orders, dated 7/1/23, indicated . 5. c. Written Transfer Orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending physician before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. 2a. Review of Resident 3's Admission Record indicated he was admitted to the facility on [DATE] with hypertension (HTN, high blood pressure) diagnosis. Review of Resident 3's physician order, dated 3/6/25, indicated he had an order for hydralazine (used to treat HTN) 25 milligrams (mg, a metric unit of mass) every 8 hours as needed for systolic blood pressure (SBP, it measures the pressure the blood is pushing against the artery walls when the heart beats) greater than 160. Review of Resident 3's medication administration record (MAR), dated 3/2025, indicated the licensed nurse administered hydralazine 25 mg to Resident 3 on 3/11/25 when his SBP was 151, and the licensed nurse did not administer hydralazine 25 mg to Resident 3 on 3/7/25, 3/14/25, and 3/15/25 when his SBP was 172, 175, and 165. 2b. Review of Resident 4's Admission Record indicated she was admitted to the facility on [DATE] with HTN diagnosis. Review of Resident 4's physician order, dated 4/23/25, indicated she had an order for hydralazine 25 mg every 6 hours as needed for SBP greater than 160. Review of Resident 4's 5/2025 MAR indicated the licensed nurse did not administer hydralazine 25 mg to Resident 4 on 5/6/25 when her SBP was 162. 2c. Review of Resident 5's Admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 5's physician order, dated 3/4/25, indicated she had an order for losartan potassium (used to treat HTN) 25 mg every day for HTN, hold for SBP less than 110. Review of Resident 5's 4/2025 MAR indicated the licensed nurse administered losartan potassium 25 mg to Resident 5 on 4/19/25 when her SBP was 105. During an interview with the director of nursing (DON) on 5/14/25, at 4:20 p.m., she reviewed Resident 3's 3/2025 MAR, Resident 4's 5/2025 MAR, and Resident 5's 4/2025 MAR and confirmed that the licensed nurse administered hydralazine 25 mg to Resident 3 on 3/11/25 when his SBP was 151, and the licensed nurse did not administer hydralazine 25 mg to Resident 3 on 3/7/25, 3/14/25, and 3/15/25 when his SBP was 172, 175, and 165; the licensed nurse did not administer hydralazine 25 mg to Resident 4 on 5/6/25 when her SBP was 162; and the licensed nurse administered losartan potassium 25 mg to Resident 5 on 4/19/25 when her SBP was 105. Review of the facility's job description, Registered Nurse (RN), dated 5/2022, indicated . Resident Care Functions: . Administer medications according to practitioner orders .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were a gallon 340 grams of whole bay leaves stored in the shelved more than one year from the opening date; 2. There were undated and unlabeled food items and staff-stored metal water bottle in the two-unit refrigerator for residents. 3. Metal tray and muffin pans used for food preparation and food service had black, gray, and yellow buildup; 4. A metal pipe in the kitchen faucet one was covered with gray and brown build up or stain; and 5. A sanitizing agent in red bucket were above the acceptable range. These failures had the potential to cause food contamination and food-borne illness to 124 of 124 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 5/19/25 at 8:04 a.m., with the Registered Dietician (RD) and the Dietary Supervisor (DS), observation in the seasoning shelves found a gallon of 350 grams of whole bay leaves with an open date 1/26/24 and UBD (used by date )1/26/25 and it had expired. The RD stated the whole bay leaves is good for 1 year after opening. The RD further stated it should be thrown away. During a review of the facility's P&P titled Date Marking for Food Safety, dated 2023, indicated, 2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) . 2. During a concurrent observation and interview in resident refrigerator unit at station 2 on 5/21/25 at 10:10 a.m., with the Infection Prevention Nurse (IP), Found inside the freezer was one unlabeled Mcflurry, box was slightly open with a wooden spoon. The IP stated it should be labeled with name and date. During an observation and interview in resident refrigerator unit at station 3 on 5/21/25 at 10;12 a.m., with the IP, found a metal water bottle with the name [staff], the IP stated he knows the name and it's a facility staff. The IP further stated the staff should not use the resident refrigerator and should use the staff refrigerator in the breakroom. During a review of facility's policy and procedure titled Use and Storage of Food Brought in by Family or Visitors, dated 7/1/23, indicated, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. 2. All food items that are already prepared by the family or visitor brought in must be labeled and dated.a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator . 3. During an observation in the kitchen on 5/21/25 at 10:49 a.m., observed one big metal tray with black, gray, and brown buildup and four metal muffins pans with black, gray and brown buildup. During a concurrent observation and interview on 5/21/25 at 11:04 a.m., with [NAME] V (CK V), she checks the metal tray and four muffins pan. CK V confirmed the metal tray and four muffin pans has black, gray, and brown buildup. CK V stated the muffin pan is use for baking and the big metal tray is used to place the food after cooking. CK V stated they should be clean. During an interview on 5/22/25 at 10:46 a.m., with the Registered Dietitian (RD), the RD stated the big metal tray, and four muffin pans should be clean or replace. 4. During a kitchen observation on 5/21/25 at 11:17 a.m., observed the metal pipe of faucet 1 in 3-compartment sinks (a type of manual ware washing sink used in commercial kitchens to wash, rinse, and sanitize dishes.) was covered with gray and brown buildup or stain. During a concurrent observation and interview on 5/22/25 at 10:13 a.m., with the Dietary supervisor (DS) check the faucet 1 in 3-compartment sink. The DS confirmed faucet 1 had brown and gray buildup or stain. She further stated maintenance is responsible for cleaning. During a concurrent observation and interview on 5/22/25 at 10:24 a.m., with Facility Service Manager (FSM), the FSM confirmed faucet 1 metal pipe was covered with gray and brown buildup or stain. The FSM further stated it should be clean. 5. During a kitchen observation on 5/22/25 at 10:09 a.m., with the Dietary Supervisor (DS), the DS asked to check the sanitizing steps in red bucket. The DS got the Sink & Surface Cleaner Sanitizer Test Strips, pour a new sanitizer solution into the red bucket and dip the strip, after few seconds the strip turned yellow green indicated the strip result was above the recommended active range of DDBSA (used for sanitization of agricultural equipment, food products, food processing equipment and the food preparation environment) is 272 to 700 ppm. The DS stated the approved range is 700 ppm. During an interview and review of the test strip on 5/23/25 at 1:53 p.m., with the Registered Dietitian (RD), the RD confirmed DDBSA test strips is above the recommended range. The RD further stated the normal range is 272 to 700 ppm. During a review of the facility's policies and procedures (P&P) titled, Sanitation, dated 2023, the P&P indicate, 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. 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .

Based on observation, interview, and record review, the facility did not ensure the steam table was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve food in a safe and sanitary manner. 124 residents are receiving food from the kitchen. During an observation of the lunch trayline meal service on 5/21/25, [NAME] V (CK V), CK V was observed checking the food temperature placed in steam table. She checked the food which included puree biscuit, puree beef, and BBQ sauce then she asked the Dietary Aide (DA) to reheat those food. The steam table was observed missing one out of six switch knobs from the right and missing red light indicator that is on. During a concurrent observation and interview on 5/22/25 at 10:15 a.m., with [NAME] T (CK T), CK T confirmed the switch knob and red light was missing, she stated when turn on right is high, left is low, when it's flat is off. CK T further stated the steam table switch should be fixed and should have a switch knob. During a concurrent observation and interview on 5/22/25 at 10:34 a.m., with the Facility Services Manager (FSM), the FSM checked the steam table switch knob, and he confirmed one of six switch knobs is missing. During an interview on 5/22/25 at 10:52 a.m., with the Registered Dietitian (RD), the RD stated the steam table missing knob should be fix. The RD further stated kitchen equipment should be working properly. During a review of the facility policy titled Sanitation dated 2023 indicated, 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 . 6.Employees are to alert the FNS Director immediately to any equipment needing repair.7.The FNS Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man .

Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented in seven of 26 sampled residents (Residents 81, 96, 115, 375, 109, 45, and 51) when: 1. Registered Nurse (RN) H used one tissue to wipe eye drops from both of Resident 81's eyes, and RN H used a dry tissue to wipe Resident 81's eye drop cap that fell on the floor before capping it back on the bottle, 2. Licensed Vocational Nurse (LVN) E did not wear a gown and did not perform hand hygiene after touching potentially contaminated surfaces during medication administration through a feeding tube (a surgically placed tube used to administer food and medications in individuals who have trouble swallowing) for Resident 96. 3. LVN F did not perform hand hygiene after touching potentially contaminated surfaces during the blood sugar check for Resident 115. 4. Medical records assistant (MRA) did not perform hand hygiene after removal of gloves inside Resident 109's room; 5. Resident 45 was in an Enhanced Barrier Precaution (EBP,an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDRO, these are microorganisms (primarily bacteria) that have become resistant to one or more classes of antimicrobial agents, like antibiotics.]in healthcare settings, particularly nursing homes.) room and certified nursing assistant K (CNA K) did not wear a gown during Resident 45's repositioning; and 6. There were no EBP signage posted outside Resident 51, Resident 115 and Resident 375's room These failures had the potential to put residents, staff and visitors at risk for infections due to cross-contamination. Findings: 1. During a medication administration observation on 5/19/25 at 7:50 a.m., RN H was observed preparing and administering medications to Resident 81, including dorzolamide/timolol eye drops (generic for Cosopt, a medication for glaucoma) into each eye. After instilling a drop into each of Resident 81's eyes, RN H was observed using a single tissue to wipe both of Resident 81's eyes. The eye drop cap fell on the floor. RN H was observed using a tissue to wipe it and capping it back on the eye drop bottle. During an interview with RN H on 5/19/25 at 8:15 a.m., RN H acknowledged she used a single tissue to wipe both eyes. RN H stated she should have used one tissue per eye. RN H also acknowledged she wiped the dropped eye drop cap with a tissue. RN H stated she did not use an alcohol swab to clean the eye drop cap, but said she should have. During an interview with the Infection Preventionist (IP) on 5/20/25 at 9:55 a.m., the IP stated nursing staff should use two separate tissues for eye drop administration to prevent the spread of infection. The IP stated it is not appropriate to wipe a dropped eye drop cap with a dry tissue because you never know what is on the floor. The IP stated the eye drop cap can be cleaned with soap and water and dried with a towel. A review of the facility's policy and procedure (P&P) titled, Administration of Eye Drops or Ointments, implemented 4/1/25, indicated, .h. Wipe off excess solution .with a clean tissue. Use a fresh tissue for each eye to prevent cross-contamination . 2. During a medication administration observation on 5/19/25 at 8:21 a.m., LVN E was observed preparing medications for Resident 96, which were to be given through a feeding tube. A sign was observed outside Resident 96's door, which read, Enhanced Barrier Precautions [EBP] .staff must .wear gloves and a gown for the following high-contact resident care activities .device care or use .feeding tube . LVN E was observed wearing gloves, but no gown as she moved a bedside table and adjusted Resident 96's bed prior to medication administration. LVN E was observed proceeding to administer Resident 96's medications through his feeding tube while wearing the same gloves. During an interview with LVN E on 5/19/25 at 9:46 a.m., LVN E acknowledged she moved a bedside table and used the bed remote while wearing gloves that she later used to administer Resident 96's medications. LVN E stated she should have changed her gloves after touching the furniture in Resident 96's room. LVN E acknowledged she did not wear a gown while administering Resident 96's medications. LVN E stated, I'm supposed to wear a gown for infection control. During an interview with the IP on 5/20/25 at 9:55 a.m., the IP stated nurses need to gown up because of the prolonged contact when administering medications to a resident with a feeding tube. The IP stated, For EBP [enhanced barrier precautions] there has to be gown and gloves to protect against multidrug-resistant organisms (MDROs, germs that are resistant to many antibiotics). The IP stated before providing care to residents, nurses should remove gloves, perform hand hygiene (hand washing, antiseptic handwash or alcohol-based hand rub) and wear new gloves. A review of the facility's P&P titled, Enhanced Barrier Precautions, revised April 2025, indicated, .2. Enhanced barrier precautions apply when .b. a resident .has .[an] indwelling medical device .5. Indwelling medical devices include .feeding tubes .7a. gloves and gown are applied prior to performing high contact resident care activity .8. Examples .include .i. device care or use .feeding tube . 3. During an observation on 5/19/25 at 12:09 p.m., LVN F was observed wearing gloves and moving a bedside table, a folding chair and IV pole, then proceeding to check Resident 115's blood sugar while wearing the same gloves. LVN F was observed washing her hands after checking Resident 115's blood sugar, but the test strip (part of the equipment to test blood sugar; it has a well to put blood in) was still in the glucometer (machine used to measure blood sugar). During an interview on 5/19/25 at 12:18 p.m., LVN F acknowledged she should have changed her gloves after moving the furniture and equipment. LVN F stated, I should have removed [the gloves] and put on new gloves. When asked how she removed the test strip from the glucometer, LVN F stated she removed the test strip with a paper napkin and stated that was her normal process. During an interview with the IP on 5/20/25 at 9:55 a.m., the IP stated if nurses touch surfaces after putting on gloves, then they should remove gloves, perform hand hygiene and wear new gloves. The IP stated it is not okay to remove a used test strip with a paper napkin and no gloves. The IP stated a paper napkin is not a barrier to protect yourself. The IP stated nurses have to put gloves on and remove test strips. A review of the facility's P&P titled, Medication Administration Infection Control, implemented 6/1/24, indicated, 4. Change gloves and perform hand hygiene as indicated to prevent contamination of any handled item .6. DON gloves as indicated. Perform hand hygiene between glove changes as indicated .8. Perform hand hygiene before and after medication pass for each resident and as indicated. 6a. During an observation in Resident 115's room on 5/19/25 at 8:48 a.m., Resident was observed lying in bed. Foley catheter drainage bag was hanging on the side of the bed covered with privacy bag. There were no EBP signage posted in Resident 115' entrance door. During a concurrent observation and interview outside Resident 115's room on 5/19/25 at 10:27 a.m., with the Infection Prevention Nurse (IP), the IP confirmed that there were no EBP signage posted earlier. The IP further stated the resident with Foley catheter should have EBP signage posted outside the door. During a review of Resident 115's clinical record indicated Resident 115 was admitted to the facility with diagnosis including muscle weakness. During a review of resident 115's physician's order dated 5/13/25 (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley's catheter use. During a review of Resident 115' clinical record indicated a care plan, dated 5/13/25 Focus: The resident is on (EBP) Enhanced Barrier Precautions to reduce MDRO transmission/due to increased risk of MDRO transmission indwelling medical device. Interventions:Follow Enhance Barrier Precautions (glovers/gown) during high-contact care activities. Place a sign for (EBP) near entrance of the room . 6b. During an observation in Resident 375' room on 5/19/25 at 10:00 a.m., Resident was observed lying in bed Foley catheter drainage bag hanging on the side of the bed covered with privacy bag. There were no EBP signage posted in Resident 375' entrance door. During a concurrent observation and interview outside Resident 375's room on 5/19/25 at 10:29 a.m., with the Infection Prevention Nurse (IP), the IP confirmed Resident 375 has Foley Catheter, and he also confirmed that there were no EBP signage posted outside Resident 375's entrance door. The IP further stated Resident 375 should have EBP signage posted outside the room. During a review of Resident 375's clinical record indicated Resident 375 was admitted to the facility with diagnosis including malignant neoplasm (cancerous tumor that can spread to other parts of the body) of prostate (gland in the male reproductive system). During a review of Resident 375's physician's order, dated 5/19/25 (EBP) Enhanced Barrier Precautions during high contact activities secondary to h/o indwelling FC (Foley Catheter). 6c. Review of Resident 51's medical record indicated Resident 51 was admitted on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function), and neuromuscular dysfunction of the bladder (condition where the nerves and muscles that control emptying of urine from the bladder don't work properly). During an observation on 5/19/25 at 9:12 a.m. in Resident 51's room, Resident 51 was observed awake and lying in bed with a foley catheter drainage bag with privacy cover hanging on the side of the bed. There was no EBP signage posted on the door or wall outside the entrance to Resident 51's room. During a review of Resident 51's Order Summary Report dated 11/19/24 indicated an order for, (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley's catheter use every shift. During a review of Resident 51's Care Plan Report dated 11/19/24 indicated, Focus: The resident is on (EBP) Enhanced Barrier Precautions to reduce MDRO transmission/due to increased risk of MDRO transmission indwelling medical device. Interventions: Follow Enhance Barrier Precautions (glovers/gown) during high-contact care activities. Place a sign for (EBP) near entrance of the room . During a concurrent observation and interview on 5/21/25 at 10:15 a.m. with the Infection Prevention Nurse (IP) outside Resident 51's room, the IP confirmed that there was no EBP signage posted on the door or wall near the entry of Resident 51's room. The IP stated, Resident 51 has a foley catheter and should have an EBP sign posted outside the room. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions revised April 2025, the P&P indicated, .17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required . 4. During an observation on 5/19/2025 at 8:20 a.m., inside Resident 109's room, MRA was observed holding on to a clipboard to her left hand and wore gloves to her right hand. MRA moved Resident 109's overbed table with the gloved hand, then removed the used gloves and MRA offered to shake the surveyor's hand without hand hygiene. During an interview with MRA on 5/20/2025 at 9:28 a.m., the MRA confirmed above observation and stated she should have performed hand hygiene after removal of used gloves. During an interview with IP on 5/22/2025 at 1:20 p.m., IP stated staff should perform hand hygiene prior to donning of gloves and upon removal of gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 5. Review of Resident 45's clinical record titled, admission Record, dated 5/22/2025, Resident 45 was admitted to the facility with diagnoses including dementia (a progressive state of decline in mental abilities), neuromuscular dysfunction of bladder (a condition where the bladder's function is impaired due to a problem with the nerves controlling it, like damage to the brain, spinal cord, or peripheral nerves), and quadriplegia (a condition in which all four limbs (arms and legs) are paralyzed). Review of Resident 45's order summary report, dated 5/22/2025, indicated an order, (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley catheter [a thin, flexible tube inserted into the bladder through the urethra to drain urine] use every shift. During an observation on 5/19/2024 at 9:28 a.m., inside Resident 45's room who had an EBP signage by the door, Resident 45 was in bed, unable to move all extremities, with foley catheter in placed. CNA entered the room with gloves on, did not wear a gown and assisted Resident 45 in repositioning in bed. CNA K had to move Resident 45's extremities one at a time, and CNA K's clothing had touched Resident 45's beddings, and used pillows. During an interview with CNA K on 5/19/2025 9:39 a.m., CNA K confirmed above observation and stated she should have donned a gown prior to repositioning a totally dependent resident on EBP. During an interview with IP on 5/22/2025 at 1:20 p.m., IP stated staff should wear gown, gloves, and mask/face shield (as needed) whenever they had a prolonged contact with residents on EBP. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, date revised 4/2025, indicated, EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .providing bed mobility.

4. Review of Resident 97's clinical record, indicated, Resident 97 was admitted on [DATE] with diagnoses including sepsis (body's extreme and potentially dangerous response to infection), urinary tract infection (infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), primary osteoarthritis (joint pain and stiffness) left shoulder, anxiety disorder (mental health conditions characterized by excessive and persistent worry, fear, and nervousness). Review of Resident 97's Inventory of Personal Effects, dated 4/17/25, indicated the form was blank. During a concurrent interview and record review on 5/23/25 at 10:04 a.m., with the Director of Nursing (DON), the DON stated the Inventory of Personal Effects must be filled out upon admission. The DON stated there should be a note in the form indicating if the resident does not have any belongings. The DON further stated that the same form will be used for any changes in the resident's belongings. Review of Resident 97's Inventory of Personal Effects, indicated there was a correction made on the date of the form. During a concurrent interview and record review on 5/23/25 at 2:01 p.m., with the NS, the NS stated she used a new Inventory of Personal Effects form when she did not see any form in Resident 97's medical record. The NS stated she made a mistake in writing the date on the form. The NS stated, I thought it was the 21st but was actually 22. The NS stated documentation should be clean and no erasures and no changes. The NS further stated that she should have drawn a line across and initial when she made an error and not write over it. Review of the facility's policy and procedure (P&P), titled Guidelines for Charting and Documentation, undated, indicated If an error was made while recording data in the medical record, line through the error with a single line and then record the correct data. Review of the facility's P&P, titled Documentation in Medical Record, dated 6/1/23, indicated Each resident's medical record shall contain complete and accurate documentation. Based on interview, and record review, the facility failed to maintain an accurate and systematically organized documentation in accordance with accepted professional standards and practices for four of six residents reviewed (Residents 102, 283, 280, and 97) when: 1. Resident 102's Inventory of Personal Effects (also called resident's belonging's list, a document that details a resident's personal belongings when they move into a facility) form was blank three days after readmission and there was no Inventory of Personal Effects found in the old chart; 2. Resident 283's Inventory of Personal Effects was blank three days after admission; 3. Social services and case manager's progress notes related to Resident 280's discharge was documented 51 days after discharge; and 4. Resident 97's Inventory of Personal Effects was not completed. These deficient practices resulted in an inaccurate and inappropriate documentation of Resident 102, 283, 97's belonging's list and Resident 280's progress notes. Findings: 1. Review of Resident 102's clinical record titled, admission Record, dated 5/19/2025, indicated Resident 102's original admission date was 2/19/2025 and was re-admitted back to the facility on 5/18/2025. During a concurrent interview with medical records director (MRD) and record review on 5/20/2025 at 2:32 p.m., MRD reviewed Resident 102's old chart for the Inventory of Personal Effects, and confirmed that the old chart did not have the form. Review of Resident 102's current Inventory of Personal Effects form found at the back of Resident 102's chart revealed, it was blank, or nothing was written on it. 2. Review of Resident 283's clinical record titled, admission Record, dated 5/19/2025, indicated Resident 283 was admitted to the facility on [DATE]. Review of Resident 283's Inventory of Personal Effects form found at the back of Resident 283's chart revealed, it was blank, or nothing was written on it. During a concurrent interview with the assistant director of nursing A (ADON A) and record review on 5/21/2025 at 9:17 a.m., ADON A reviewed Resident 102 and Resident 238's current Inventory of Personal Effects, and confirmed both forms were blank. ADON A stated the admitting certified nursing assistant (CNA) should checked the resident's belongings upon admission and document in the resident's Inventory of Personal Effects form. ADON A further stated the director of staff development (DSD) assistant should follow up the following day. During an interview with director of nursing (DON) on 5/23/2025 at 12:13 p.m., DON stated both licensed nurses and CNAs were responsible in completing the Inventory of Personal Effects form upon resident's admission and it should be completed within 24 hours. During a review of the facility's policy and procedure titled, Admitting the Resident: Role of the Nursing Assistant, date revised 9/2013, indicated, To inventory the resident's personal effects, you should: 1. Ask family member(s) to remain in the room to witness the inventory. 2. Tell the resident that you are going to inventory his or her personal effects. 3. Complete the resident identification portion of the inventory record. 4. Inventory all clothing, equipment, valuables, etc .5. When all personal items have been inventoried and recorded in the Inventory of Personal Effects Record, sign your name and title and instruct the family member that witnessed the inventory to also sign the form. 3. Review of Resident 280's clinical record titled, admission Record, indicated Resident 280 was admitted to the facility on [DATE] with diagnoses including spondylosis in cervical region (age-related wear and tear affecting the spinal disks of the neck), and pneumonia (infection of one or both lungs). Further review indicated, Resident 280 was discharged to home on 3/31/2025. Review of Resident 280's SNF [skilled nursing facility] Beneficiary Protection Notification Review form completed by social serviced director (SSD), it indicated Resident 280's Last covered day [LCD] of Part A Service [Medicare Part A insurance terminated/denied, or resident was discharged ] was 3/30/2025. Further review indicated, it was Resident 280's self-initiated discharge. Review of Resident 280's nurse, case manager and SS progress notes revealed the following: a. It was not indicated in any of nurse's notes that Resident 280 had requested to go home; b. The nurse case manager X's (NCM X) progress notes for 3/28/2025 was CREATED on 5/19/2025 at 4:41 p.m. (5/19-5/23/2025 - recertification survey), it indicated the NCM X spoke to Resident 280 about the discharge plan and Resident 280 requested to be discharged ; and c. The social service assistant Y's (SSA Y) progress notes for 3/28/2025 was CREATED on 5/20/2025 at 11:25 a.m., it indicated Resident 280 requested to be discharge to a car, SSA Y explained the discharge process and the physician agreed for Resident 280 to discharged on 3/31/2025. Further review indicated Resident 280 declined home health services. During a concurrent interview with SSD and review of Resident 280's progress notes on 5/23/2025 at 8:44 a.m., SSD confirmed the nurse case manager X's note was just created on 5/19/2025 and SSA Y's progress notes was created on 5/20/2025 while the recertification survey was being held at the facility. SSD stated staff should document as soon as they met with the resident and implemented some plan of care. SSD further stated SS should document any discharge planning or any teachings provided to residents in a timely manner.

Based on observation, interview, and record review, the facility document review, the facility failed to provide and served food that was palatable. These failures placed the 124 residents eating at the facility at risk of poor food intake further compromising their nutritional status. Findings: During an interview with Resident 102 on 5/19/25 at 8:35 a.m., Resident 102 stated. Food are burnt and cold, dry overcooked. During an interview with Resident 59 on 5/19/25 at 9:01 a.m., Resident 59 stated, the food are terrible and cold. During an interview with Resident 375 on 5/19/25 at 9:59 a.m., Resident 375 stated the food is terrible and sometimes cold. During an interview with Resident 376 on 5/19/25 at 11:09 a.m., Resident 376 stated, the food are terrible and cold. A review of the facility menu for 5/21/2025 lunch indicated, Oven BBQ (barbeque) Beef Roast, Mashed Sweet Potatoes, Fresh Zucchini with Carrots, Cheddar Biscuit, Ice Cream. As a result of the resident complaints about the food, a test tray of regular and puree diet was conducted on 5/21/2025. During the test tray of the lunch meal on 5/21/2025 at 1:30 p.m., in the presence of the Dietary Supervisor (DS), the regular zucchini and carrots appeared bland, and no spices were visible. the regular carrots and zucchini tasted bland, the beef tasted fine, and the sweet potatoes was sweet. The pureed zucchini and carrots also taste bland, there were no taste of spices. The three Surveyors confirmed this tasting observation. The DS stated I could taste the zucchini. A review of the facility's recipe titled, FRESH ZUCCHINI AND CARROTS, indicated, 4. Simmer in boiling water or steam until tender . Drain. Add margarine, dill, salt, and seasonings. May add more dill as desired. A review of the facility's undated policy and procedure titled, Food Preparation Guidelines, dated 6/1/24 indicated, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status.2. Food shall be prepared by methods that conserve nutritive value, flavor and appearance . 3.Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b.Using spices or herbs to season food in accordance with recipes.

Based on interview and record review, the facility failed to ensure seven out of 26 residents (Residents 82, 278, 81, 115, 10, 21, and 25) were free from unnecessary medications when: 1. Residents 82 and 278 received anticoagulants (blood thinners) with incorrect/inappropriate indications for use. This failure had the potential for the facility not having the right plan of care/treatment and monitoring related to anticoagulants for the residents. 2. Lidocaine patch was administered longer than manufacturer's specification for three residents (Residents 81, 115, 278). This failure had the potential for Residents 81, 115 and 278 to experience side effects from excessive duration of lidocaine patch use. 3. Resident 10 received levothyroxine (medication to treat underactive thyroid) without the periodic monitoring for TSH (thyroid stimulating hormone). This failure had the potential for Resident 10 to have thyroid levels outside the acceptable range and experience negative consequences. 4. Resident 21 received Azithromycin (used to treat bacterial infections) tablets without a proper indication for use and a definite end date. 5. Resident 25 received Clopidogrel (medication used to prevent blood clots) without monitoring for sign and symptoms of bleeding. Findings: 1a. A review of Resident 82's clinical record indicated he had a physician's order for apixaban (generic name of Eliquis, a blood thinner) 5 milligram (mg, unit of measurement) tablet, give one tablet by mouth two times a day for A Fib (atrial fibrillation, a type of irregular heart rhythm), dated 5/1/25. Resident 82's clinical record indicated he was previously hospitalized , and his past medical history includes deep vein thrombosis (DVT) [a blood clot in a deep vein] managed with apixaban. During an interview with Resident 82 on 5/21/25 at 10:46 a.m., Resident 82 stated he has been on apixaban for at least 3 years because he had a blood clot in the lungs. During an interview with the Assistant Director of Nursing (ADON) A on 5/21/25 at 10:56 a.m., ADON A stated Resident 82's apixaban was for A Fib. ADON A reviewed Resident 82's hospital record and acknowledged it indicated apixaban was used for DVT. ADON A also reviewed the resident's plan of care for apixaban and acknowledged it was for atrial fibrillation which was incorrect. During an interview with ADON A on 5/21/25 at 4:44 p.m., ADON A stated she clarified the apixaban order with the physician and it is for DVT .I have not figured out where A Fib came from. 1b. A review of Resident 278's clinical record indicated she had an active order for dabigatran (generic for Pradaxa, a blood thinner) 110 mg capsule, give one capsule by mouth two times a day for congestive heart failure (CHF, a condition in which the heart cannot pump blood well enough to meet the body's needs), dated 5/2/25. A drug review of the medication dabigatran on Daily Med, a drug resource site, updated 2/11/25, listed the indications for dabigatran use. They were as follows: - Reduction of stroke risk and systemic embolism (a blood clot that dislodges and ends up in the arterial circulation) in non-valvular atrial fibrillation (A Fib not caused by a heart valve problem) in adult patients - Treatment and risk reduction of DVT and pulmonary embolism (PE, a blood clot in the lungs) in adult patients - Prevention of DVT and PE in adult patients after hip replacement surgery - Treatment and prevention of venous thromboembolic events (blood clots in the deep veins or lungs, includes DVT and PE) in pediatric patients CHF was not listed as an indication of dabigatran. During an interview with the Director of Nursing (DON), ADON A and ADON B on 5/22/25 at 11:45 a.m., ADON A stated Resident 278's clinical record indicated dabigatran was for CHF. The DON stated the diagnosis and indication came from the interfacility transfer order when Resident 278 was admitted to the facility from a hospital and we follow that .if the doctor doesn't change it. During a telephone interview with the Consultant Pharmacist (CP) on 5/22/25 at 1:54 p.m., the CP stated, dabigatran is usually for DVT. CHF? No. During an interview with the DON, ADON A and ADON B on 5/22/25 at 4:14 p.m., ADON A stated she clarified Resident 278's dabigatran order with the physician and the indication was for atrial fibrillation. A review of the facility's policy and procedure (P&P) titled, Unnecessary Drugs, undated, indicated, .4. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed . 2a. A review of Resident 81's clinical record indicated he had an active order for lidocaine (used to treat pain) external patch 4% - apply to knee joint pain topically at bedtime (9 p.m.) for pain management and remove per schedule. Remove at 8:59 p.m. (1 minute from application of a new patch), dated 1/7/25. During a concurrent interview and record review with Registered Nurse (RN) H on 5/19/25 at 2:03 p.m., RN H stated Resident 81's lidocaine patch is removed at 8:59 p.m. RN H stated the timing between the old and new patches is one minute apart. A review of the product labeling on the lidocaine patch 4% carton box which would be used for Resident 81 indicated, use 1 patch for up to 12 hours. 2b. A review of Resident 115's clinical record indicated she had two active orders for lidocaine 4% patch. Her newer order, dated 5/7/25, was for lidocaine external patch 4% - apply to right knee topically one time a day (at 9 a.m.) for knee pain and remove per schedule. Remove at 8:59 a.m. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON B stated Resident 115's lidocaine patch for her right knee is applied at 9 a.m. ADON A stated it is removed at 8:59 a.m. (1 minute apart from the application). 2c. A review of Resident 278's clinical record indicated she had two active orders for lidocaine 4% patch, both dated 5/7/25. The first order was to apply the patch to the lower back topically one time a day (at 9 a.m.) for back pain. The second order was to apply the patch to the mid back topically one time a day (at 9 a.m.) for back pain. Neither order had a scheduled removal time. During a concurrent interview and record review with RN I in the presence of ADON A on 5/22/25 at 11:32 a.m., RN I stated Resident 278 had an order for lidocaine to be applied to the lower back at 9 a.m. When asked when it is scheduled to be removed, ADON A assisted RN I to find that information in Resident 278's clinical record. RN I stated, I don't see it here. When asked when a lidocaine patch is typically removed, RN I stated, it's not good after 12 hours. During an interview with the DON and ADON A on 5/19/25 at 2:20 p.m., both the DON and ADON A acknowledged the lidocaine patch should be used for up to 12 hours. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated Resident 278's lidocaine patch is to be applied at 9 a.m. and should be removed after 12 hours. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated a lidocaine patch should only be applied for 12 hours. The CP stated, if more than 12 hours, it will cause side effects that are not pleasant to the resident like dizziness, irritation, redness. A review of the National Library of Medicine's Medline Plus drug reference site, revised 6/15/21, indicated, wearing lidocaine patches for too long may increase the risk of too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose (https://medlineplus.gov/druginfo/meds/a603026.html, accessed 5/29/25). Some overdose symptoms listed include lightheadedness, dizziness, drowsiness, confusion, ringing in the ears, blurred or double vision, vomiting, twitching, numbness, slow heartbeat or seizures. 3. A review of Resident 10's clinical record indicated she had an active order for levothyroxine 125 microgram (mcg, a unit of measure) tablet - give one tablet by mouth in the morning for hypothyroidism (underactive thyroid) 30 minutes before breakfast, dated 7/31/23. Resident 10's most recent TSH level was done on 1/23/24 (more than a year ago). During a concurrent interview and record review with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated the last TSH level she could see for Resident 10 was one from January 23, 2024. During a telephone interview with the CP on 5/22/25 at 2:21 p.m., the CP stated she could not see any recent TSH levels. The CP stated TSH levels are to be done every six months for residents receiving levothyroxine. A drug review of the medication levothyroxine on Daily Med, a drug resource site, updated 11/6/24, indicated, [i]n patients on a stable and appropriate .dosage, evaluate clinical and biochemical response [biological and chemical reactions in the body] every 6 to 12 months and whenever there is a change in the patient's clinical status [health]. A review of the facility's P&P titled, Medication Utilization and Prescribing - Clinical Protocol, revised April 2018, indicated, .Monitoring 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications . 5.During a review of Resident 25's clinical records indicated Resident 25 was admitted to the facility with diagnosis including type diabetes mellitus (DM, a condition which affects the way the body processes blood sugar). During a review of Resident 25 physician's order indicated an order for Clopidogrel oral tablet 75 mg (milligram, unit of measure) Give 1 tablet by mouth one time a day for cva (cerebrovascular accident, which is another term for a stroke) ppx (prophylaxis, an attempt to prevent disease), dated 11/28/24. During a review of Resident 25's Medication Administration Record (MAR) indicated the nursing staff did not monitor the sign and symptoms of bleeding for Clopidogrel. During a concurrent interview and record review on 5/22/25 at 2:39 p.m., with the Director of Nursing (DON), the DON reviewed Resident 25's physician's order and she confirmed there were no monitoring for sign and symptoms of bleeding for Clopidogrel. The DON further stated Resident 25 should have monitoring every shift for bleeding. During a review of the facility's policy and procedures titled, Medication Monitoring, revision date 2025, indicated, This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. 4. Review of Resident 21's clinical record, indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), pneumonia (infection of the lungs), bronchiectasis (condition where the airways are damaged, widened, and thickened making it harder to clear mucus), pseudomonas (a type of bacteria that can cause infections) as the cause of diseases. Review of the physician's order indicated Resident 21 was on Azithromycin tablet from 6/5/23 to 10/13/24 for prophylaxis chronic bronchitis, 10/28/24 to 11/6/24 for prophylaxis, 11/14/24 to 12/12/24 for prophylaxis, and 12/13/24 to 4/19/25 for pneumonia prophylaxis. Review of the physician's order, dated 4/19/25, indicated Resident 21 was on Azithromycin tablet 250 milligrams (mg, unit of measurement) one time a day every Monday, Wednesday, Friday for Chronic Bronchitis. The physician order does not have an end date. During a concurrent interview and record review on 5/22/25 at 3:57 p.m., with the Infection Preventionist (IP), the IP confirmed that the Azithromycin order did not specify the indication for use and that the order was not complete. The IP stated there should be an indication for use and not just write For Prophylaxis. During a concurrent interview and record review on 5/23/25 at 1:03 p.m., with the Consultant Pharmacist (CP), the CP stated the physician's order for Azithromycin, dated 4/19/25, did not have an end date. The CP stated she should have asked the physician for the end date. During a review of the facility's policy and procedure (P&P), titled Medication Monitoring, dated 6/1/24, indicated Medications shall be prescribed with clear indications for use. During a review of the facility's P&P, titled Medication Orders, dated 3/1/25, indicated Elements of the Medication Order .f. Duration or stop date, (e.g., antibiotics) .j. Diagnosis or indication for use . During a review of the facility's P&P, titled Medication Utilization and Prescribing - Clinical Protocol, undated, indicated When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem which it is being given, or what the medication is supposed to do or prevent) .

Based on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility medication-related irregularities during the monthly medication regimen review (MRR) for three of 26 sampled residents (Residents 81, 37, and 10), as follows: 1. Resident 81 received lidocaine 4% patch (topical medication applied to the skin for pain) longer than manufacturer's specification. 2. Resident 37 received Seroquel (an antipsychotic medication) for over 2 years without a gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and had no risk-benefit assessment for the use of Seroquel and metoclopramide (medication used to treat various digestive conditions), medications that could cause or worsen movement disorders. 3. Resident 10 received levothyroxine (medication to treat underactive thyroid) without periodic monitoring for TSH (thyroid stimulating hormone, this can be measured to determine thyroid function and activity). These failures resulted in excessive durations, unnecessary medications, and inadequate monitoring. Findings: 1. A review of Resident 81's clinical record indicated he had an active order for lidocaine external patch 4% - apply to knee joint pain topically at bedtime (9 p.m.) for pain management and remove per schedule. Remove at 8:59 p.m. (1 minute from application of a new patch), dated 1/7/25. During a concurrent interview and record review with Registered Nurse (RN) H on 5/19/25 at 2:03 p.m., RN H stated Resident 81's lidocaine patch is removed at 8:59 p.m. RN H stated the timing between the old and new patches is one minute apart. A review of the product labeling on the lidocaine patch 4% carton box which would be used for Resident 81 indicated, use 1 patch for up to 12 hours. During an interview with the Director of Nursing (DON) and Assistant DON (ADON) A on 5/19/25 at 2:20 p.m., both the DON and ADON A acknowledged the lidocaine patch should be used for up to 12 hours, based on the manufacturer's specifications. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated a lidocaine patch should only be applied for 12 hours. The CP stated, If more than 12 hours, it will cause side effects that are not pleasant to the resident like dizziness, irritation, redness. The CP acknowledged Resident 81 having a lidocaine patch on for 24 hours was an irregularity. When asked if she made a recommendation to have the lidocaine patch removed after 12 hours of use, the CP stated, I don't see it. I checked. It's one of the recommendations consultants make. I don't know how I missed it . A review of the National Library of Medicine's Medline Plus drug reference site, revised 6/15/21, indicated, wearing lidocaine patches for too long may increase the risk of having too much lidocaine .absorbed into your blood. In that case, you may experience symptoms of an overdose (https://medlineplus.gov/druginfo/meds/a603026.html, accessed 5/29/25). Some overdose symptoms listed include lightheadedness, dizziness, drowsiness, confusion, ringing in the ears, blurred or double vision, vomiting, twitching, numbness, slow heartbeat or seizures. 2. A review of Resident 37's clinical record indicated she was admitted to the facility with diagnoses including abnormal movement disorder and drug-induced akathisia (a condition caused by medications resulting in an inability to stay still and an involuntary urge to move). A review of Resident 37's clinical record indicated Resident 37 had an active order for Seroquel 100 mg, 1 tablet by mouth every 12 hours for bipolar disorder (a condition characterized by extreme changes in mood) with psychotic features manifested by constant pacing and exposing herself, dated 8/2/24. Resident 37's clinical record indicated that she had been on this dose of Seroquel for two years, since April 2023. Resident 37's clinical record also indicated an active order for metoclopramide 5 mg (milligram, a unit of measure) per 5 mL (milliliter, a unit of measure) - give 5 mL by mouth every eight hours as needed for GERD (gastroesophageal reflux disease, a condition in which stomach acid goes up the esophagus, causing symptoms such as heartburn), dated 8/2/24. A review of Resident 37's clinical record indicated there had been no GDR attempts since April 2023; and there was no risk-benefit assessment conducted for the use of Seroquel and/or metoclopramide. A review of the Prescribing Information (PI, a detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Seroquel, dated 2009, indicated it has the ability to cause abnormal movement disorders and akathisia (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). Likewise, a review of the PI for metoclopramide, dated 8/2017, indicated drug-induced akathisia and other extrapyramidal symptoms (group of motor side effects) have been known in patients taking metoclopramide (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). During an interview on 5/22/25 at 11:45 a.m. with the DON, ADON A and ADON B, ADON A stated she, the DON, and ADON B were unable to find a GDR for Seroquel in Resident 37's chart. We reached out to the pharmacist to review [Resident 37's] chart. It was left off the review. ADON A stated she was unable to find a risk-benefit analysis of metoclopramide and Seroquel. ADON A stated she did an AIMS (abnormal involuntary movement scale) assessment yesterday, on 5/21/25, and the AIMS score was 6 (scored from 0-28), which indicated Resident 37 had positive signs and symptoms of abnormal involuntary movements. ADON A stated Resident 37's abnormal movements are related to facial movements and rocking when walking. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated, Somehow Seroquel wasn't included in a [GDR] request six months ago for all psychotropics (medications affecting brain activities associated with mental processes and behavior). The CP also stated that a Seroquel risk-benefit analysis was requested and the physician was given the option to provide risk-benefit analysis documentation four times, as recently as April 2024 and September 2024. During a record review on 5/22/25 at 3:29 p.m. of a years-worth of MRR binders, a risk-benefit analysis was not found. 3. A review of Resident 10's clinical record indicated she had an active order for levothyroxine 125 microgram (mcg, a unit of measure) tablet - give one tablet by mouth in the morning for hypothyroidism (underactive thyroid) 30 minutes before breakfast, dated 7/31/23. Resident 10's most recent TSH level was done on 1/23/24 (more than a year ago). During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated the last TSH level she could find for Resident 10 was one from January 23, 2024. During a telephone interview with the CP on 5/22/25 at 2:21 p.m., the CP stated she could not see any recent TSH levels for Resident 10. The CP stated TSH levels are to be done every six months. The CP stated, I should have asked for one, but apparently I didn't ask for one. A drug review of the medication levothyroxine on Daily Med, a drug resource site, updated 11/6/24, indicated, [i]n patients on a stable and appropriate .dosage, evaluate clinical and biochemical response [biological and chemical reactions in the body] every 6 to 12 months and whenever there is a change in the patient's clinical status [health]. A review of the facility's policy and procedure titled, Medication Regimen Reviews, revised May 2019, indicated, 1. The Consultant Pharmacist performs a medication regimen review .for every resident in the facility receiving medications .upon admission .and at least monthly thereafter .5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example g. incorrect .administration times .h. other medication errors, including those related to documentation .14. The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports .

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with a high abuse potential) when: 1. Registered Nurse (RN) D did not sign out the Controlled Drug Record (CDR, a count sheet nurses sign when administering controlled medications to record the usage and inventory of such medications) sheet after medication administration for six medications in one of three medication carts inspected. 2. Random controlled medication use audit for three out of five sampled residents (Residents 7, 102 and 426) did not reconcile. The residents' medications were signed out of the CDR, but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. These failures resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications. Findings: 1. During an inspection of Station 1A Medication Cart with the Assistant Director of Nursing (ADON) B on 5/19/25 at 10:58 a.m., six medication bubble packs (blister packs, a card with pills in individual bubbles or blisters) did not match the corresponding CDRs. The medications and inventory documentation were as follows: - Oxycodone (a potent narcotic for moderate to severe pain) 5 milligram (mg, a unit of measure) for Resident 278. Number of pills in the bubble pack: 11 Number of pills documented in the CDR: 12 - Hydrocodone/acetaminophen 10-325 mg (a controlled medication used to treat moderate to severe pain) tablet for Resident 36 Number of pills in the bubble pack: 29 Number of pills documented in the CDR: 30 - Modafinil 200 mg (a narcotic to treat excessive daytime sleepiness) tablet for Resident 86 Number of pills in the bubble pack: 4 Number of pills documented in the CDR: 5 - Hydrocodone/acetaminophen 5-325 mg tablet for Resident 1 Number of pills in the bubble pack: 14 Number of pills documented in the CDR: 15 - Pregabalin (medication to treat nerve pain or depression) 100 mg capsule for Resident 425 Number of pills in the bubble pack: 7 Number of pills documented in the CDR: 8 - Tramadol 50 mg (medication for pain) tablet for Resident 425 Number of pills in the bubble pack: 7 Number of pills documented in the CDR: 8 ADON B acknowledged that for each of these six medications, there was one fewer pill in the bubble pack than what was recorded on the CDR. During an interview with RN D and ADON B on 5/19/25 at 11:21 a.m., RN D stated she administered the six medications to the respective residents and documented the administrations on the MAR. RN D stated she was too busy and did not document the controlled drug administrations on the CDR. RN D acknowledged the six CDR sheets were not signed out and that she should have signed the CDRs immediately. ADON B confirmed the CDR sheets should be signed immediately when administering controlled medications. During an interview with ADON B on 5/19/25 at 3:40 p.m., ADON B stated the exact time RN D administered the six medications as documented on the MAR. - RN D administered oxycodone 5 mg for Resident 278 at 9:26 a.m. - RN D administered hydrocodone/acetaminophen 10-325 mg tablet for Resident 36 at 9:32 a.m. - RN D administered modafinil 200 mg tablet for Resident 86 at 8:06 a.m. - RN D administered hydrocodone/acetaminophen 5-325 mg tablet for Resident 1 at 8:27 a.m. - RN D administered pregabalin 100 mg capsule for Resident 425 at 8:16 a.m. - RN D administered tramadol 50 mg tablet for Resident 425 at 8:16 a.m. During an interview with the Director of Nursing (DON) and ADON A on 5/19/25 at 2:24 p.m., ADON A stated nurses are expected to document on the MAR and sign the CDR right away when administering controlled medications. 2. The CDRs for five random residents receiving PRN (as needed) controlled medications were requested for review. a) A review of Resident 7's clinical record indicated she had an order for hydrocodone/acetaminophen 10-325 mg tablet - take one tablet by mouth every 6 hours as needed for pain, dated 2/7/25. During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:03 p.m., a review of Resident 7's CDR for hydrocodone/acetaminophen 10-325 mg and May 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on two occasions: 5/1/25 at 1:10 p.m. and 5/11/25 at 2 p.m. ADON A and ADON B confirmed this finding and stated they could not find MAR documentation on 5/1 or 5/11 for hydrocodone/acetaminophen. b) A review of Resident 426's clinical record indicated he had an order for oxycodone 5 mg tablet - take 1 tablet by mouth every 8 hours as needed for severe pain, dated 5/15/25. During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:10 p.m., a review of Resident 426's CDR for oxycodone 5 mg and the May 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on 3 occasions: 5/16/25 at 9:20 p.m., 5/17/25 at 9 p.m., and 5/19/25 at 12:18 a.m. ADON A and ADON B confirmed this deficiency and stated they could not find any documentation on the MAR for oxycodone on 5/16, 5/17 or 5/19. c) A review of Resident 102's clinical record indicated he had orders for hydrocodone/acetaminophen, including hydrocodone/acetaminophen 5-325 mg tablet - give one tablet by mouth every 4 hours as needed for moderate pain, dated 4/24/25. During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:11 p.m., a review of Resident 102's CDR for hydrocodone/acetaminophen 5-325 mg and the April 2025 and May 2025 MARs indicated nursing staff signed the CDR but did not document on the medication administration on 2 occasions: 4/28 at 3 p.m. and on 5/8/25 at 9:28 p.m. ADON A and ADON B stated they could not find any documentation on the MAR on 4/28 at 3 p.m. or on 5/8/25 at 9:28 p.m. for hydrocodone/acetaminophen. During an interview with the DON, ADON A and ADON B on 5/20/25 at 1:10 p.m., ADON A stated controlled medication administration should be documented on the CDR and MAR. The DON stated it is important for both the CDR and MAR to be signed and match for accuracy and validation. To validate the pain medication is effective. The DON stated it is not acceptable for the CDR and MAR to not match, no, definitely it's a no. A review of the facility's policy and procedure (P&P) titled, Controlled Substance Administration and Documentation, implemented 6/1/24, indicated, .8. The nurse must document on the controlled substance accountability sheet and MAR after administration .

7. A review of Resident 67's physician's order, dated 11/13/24, indicated monitoring episodes of anxiety (a common reaction to stress that involves occasional worry about circumstantial events) manifested by restlessness and agitation. A review of Resident 67's physician's order, dated 12/12/24, indicated monitoring episodes of depression manifested by lack of interest. A review of Resident 67's Interdisciplinary Team (a group of individuals with different expertise and backgrounds who work together to achieve a common goal) on Psychotherapeutic Review, dated 5/13/2025, indicated Resident 67's behaviors exhibited two episodes of restlessness and agitation and one episode of lack of interest. During a concurrent interview and record review with minimum data set nurse (MDSN) S on 5/23/25 at 08:29 a.m., MDSN S reviewed Resident 67's care plan and confirmed no care plan addressing Resident 67's restlessness, agitation, and lack of interest behavior. MDSN S further indicated that the behavior manifested by the resident should be reflected in the care plan to effectively address these concerns. During a concurrent interview and record review with the director of nursing (DON), on 05/23/25 at 10:17 a.m., the DON reviewed Resident 67's care plan and confirmed that there was no care plan addressing Resident 67's behavior. The DON further stated that specific resident behaviors should be included in the focus section of the care plan to ensure patient-centered care. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 3/1/2023, the P&P indicated, .The care planning process will include an assessment of the resident's strengths and needs . 8. A review of Resident 82's admission record, indicated Resident 82 was admitted to facility on 4/30/25 with diagnoses including unspecified protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and energy); chronic kidney disease, stage 3 unspecified (a disease characterized by progressive damage and loss of function in the kidneys) A review of Resident 82's physician order, dated 5/1/25, indicated monitoring of weight weekly x 4 then monthly for new admit. A review of Resident 82's treatment administration record (TAR) and medication administration record (MAR) revealed no weight indicated since admission. A review of Resident 82's care plan, date initiated 5/1/25, indicated resident is at risk for altered nutrition related to refused admission weight. During an interview with the registered dietitian (RD), on 05/22/25 at 4:52 p.m., the RD indicated that Resident 82 declined to undergo weighing upon admission. The RD further stated that she utilized the most recent recorded weight of 70.4 kilogram (155 pounds), obtained from the hospital on 4/27/25, as the baseline measurement. During a concurrent interview and record review with minimum data set nurse (MDSN) S on 5/23/25 at 08:32 a.m., MDSN S reviewed Resident 82's care plan and confirmed that there was no care plan in place addressing Resident 82's noncompliance with the weight order. During concurrent interview and record review with the director of nursing (DON), on 05/22/25 at 9:11 a.m., the DON reviewed Resident 82's care plan and confirmed that there was no care plan addressing Resident 82's weight refusal. The DON stated it's important to weigh Resident 82 according to his diagnosis and the refusal should be included in the care plan. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 3/1/2023, the P&P indicated, .The comprehensive care plan will include measurable objectives and time frames to meet the resident's need as identified on the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress During a tour of facility on 05/19/2025 at 10:40 a.m., Resident 7 was approached by surveyor. Resident 7 said I am hard of hearing while pointing to her right ear for surveyor to come closer and talk in her right ear. When asked if she uses a hearing aid, she shook her head in the negative. Surveyor did not see hearing aid anywhere in the resident's room. During an interview on 05/23/2025 at 08:47 a.m., with Assistant Director of Nursing B (ADON B) in Resident 7's room ADON B confirmed Resident 7 was hard of hearing but she doesn't really know much about the details of her care plan. She acknowledged Resident 7's frustration alongside resident's complaint of being left bed bound for about a month, not being put to sit on her wheelchair for one hour a day by the CNAs like they used to do. During an interview on 5/23/25 at 9:22 a.m., with Certified Nursing Assistant U (CNA U), she stated Resident 7 has hearing problem on right side of the ear. CNA U stated Resident 7 use headset to communicate, speak closer, and use writing to communicate. During a review of Resident 7's Minimum Data Set (MDS, an assessment tool) section B (Hearing, Speech, and Vision Changes), dated April 23, 2025, indicated Resident 7 has impaired hearing. During a review of Resident 7's comprehensive care plan indicated there was no care plan developed for hearing impaired. During a concurrent interview and record review on 5/23/25 at 9:47 a.m., with Minimum Data Set Nurse S (MDSN S), MDSN S reviewed Resident 7's MDS section B (Hearing, Speech and Vision Changes) dated April 23,2025. MDSN S confirmed Resident 7 coded in MDS section B as hearing impaired. MDSN S then reviewed Resident 7's comprehensive care plan. MDSN S stated there were no care plan develop for hearing impaired. MDSN S further stated there should have care plan develop Resident 7. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 4. A review of Resident 37's clinical record indicated that she often refuses her morning and afternoon medications. For the month of March 2025, Resident 37 refused her 9 a.m. medications that were active the entire month 26 times or more. Resident 37 refused her 1 p.m. medications that were active for the entire month 27 times or more. For the month of April 2025, Resident 37 refused her 9 a.m. medications 25 times or more and refused her 1 p.m. medications 27 times. From May 1-May 21, 2025, Resident 37 refused her 9 a.m. medications 19 times or more and refused her 1 p.m. medications 19 times. Resident 37's 9 a.m. medications included, but not limited to the following: - amiodarone (a medication for various heart conditions, include an irregularly rapid heart rate) - cholecalciferol (vitamin D, used to supplement low vitamin D levels) - ferrous sulfate (iron, used to supplement low iron levels) - senna (a laxative) - divalproex sodium (a medication used to treat various neurological and psychiatric conditions) - oyster shell (calcium, used to supplement low calcium) - Seroquel (a medication used to treat various psychiatric conditions) - midodrine (a medication used to treat a drop in blood pressure due to a change in body positioning) - gabapentin (a medication used to treat various neurological conditions) Resident 37's 1 p.m. medications included, but not limited to the following: - divalproex sodium - midodrine During an interview with Resident 37 on 5/20/25 at 4:15 p.m., Resident 37 stated she does not take senna (a laxative) or Seroquel (a medication used to treat various psychiatric conditions). Resident 37 stated, I'm not comfortable with Seroquel because she thought it was for anxiety, but later learned it was for aggressive behavior. Resident 37 stated, I get angry, but I don't lash out. During an interview with Registered Nurse (RN) I on 5/21/25 at 2:27 p.m., RN I stated Resident 37 refuses her morning and afternoon medications most of the time. RN I stated, we offer [the medications] three times within the time [period]. After that, we inform the doctor of medication refusals. RN I stated Resident 37 will refuse medications either because she does not want to take it or will tell nursing staff it is not time to take it and she'll take it later in the afternoon instead. During an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON) A and ADON B on 5/21/25 at 2:48 p.m., the DON stated, The doctor is aware of the refusal. When asked if there was an interdisciplinary team (IDT, team composed of members of multiple healthcare fields to assess how to provide care for residents and meet their individual needs) meeting about Resident 37's repeated medication refusals, DON stated, IDT, I can't find any. When asked if there was a care plan (a document that details a resident's individual needs, treatments and goals) for the medication refusals, ADON A stated, Not that I can see at this point. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated, We weren't able to locate [medication refusals] on the care plan. A review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised February 2021, indicated, .5. If a resident .refuses .treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident .to: a. determine why .she is .refusing .treatment; b. try to address .her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences .of the decision .6 .b. The IDT will assess the resident's needs and offer the resident .alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. 5. A review of Resident 10's clinical record indicated that she had a diagnosis of OCD. Resident 10 had two active orders for OCD: - Fluvoxamine ER (extended release) 150 milligram (mg, unit of measurement) capsule: give one capsule by mouth at bedtime for obsessive compulsive disorder manifested by excessive health concerns related to care, dated 3/7/24. - Fluvoxamine 100 mg tablet: give one tablet by mouth at bedtime for obsessive compulsive disorder, dated 1/20/25. A review of Resident 10's clinical record indicated she did not have a care plan for OCD. During an interview with the DON, ADON A and ADON B on 5/22/25 at 12:14 p.m., ADON A stated fluvoxamine was being used to treat Resident 10's OCD. ADON A stated she could not find a care plan for OCD in Resident 10's clinical record. ADON A acknowledged there should be one. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, implemented, 3/1/23, indicated, .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal .preferences in developing goals of care .2 .Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care .3. The comprehensive care plan will describe .f. Resident specific interventions that reflect the resident's needs and preferences .7 .The facility will attempt alternative methods for refusal of treatment .and document such attempts in the clinical record . Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (identifies residents' concerns and outlines the care and services needed to meet their needs) for 8 of 26 sampled residents (Residents 21, 1, 29, 10, 37, 7, 67 and 82) when: 1. No care plan for the use of side rails for Resident 21; 2. No care plan developed for Resident 1's diagnosis of post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and care plans for use of aripiprazole (brand name: Abilify , an atypical antipsychotic medication used to treat a variety of mental health conditions) and bupropion (brand name: Wellbutrin, an antidepressant medication used to treat depression) were not person-centered without mentioned about the behavior monitoring and the non-pharmacological interventions; 3. Resident 29's care plans for use of mirtazapine (brand name: Remeron, an antidepressant medication used to treat depression) and doxepin (an antidepressant medication, used to treat depression, help manage anxiety, and treat insomnia [a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early]) were not person-centered without mentioned about specific behavior monitoring and the non-pharmacological interventions. 4. The facility failed to develop and implement a comprehensive care plan for Resident 37 who repeatedly refused her medications; 5. Facility did not develop a comprehensive care plan for Resident 10's obsessive compulsive disorder (OCD, a condition characterized by persistent, unwanted thoughts and repetitive behaviors associated with those thoughts) 6. No care plan for hearing impairment for Resident 7; 7. Resident 67's care plan did not reflect the restlessness, agitation, and lack of interest behavior; and 8. Resident 82's care plan did not reflect the resident's noncompliance regarding weight orders and monitoring. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their health, safety and well-being. Findings: 1. Review of Resident 21's clinical record, indicated, Resident 21 was admitted on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body ) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body ) following cerebral infarction (stroke ) affecting left non-dominant side, pneumonia (infection in the lungs) . Review of Resident 21's clinical record indicated he had a physician's order, dated 4/19/25, for bilateral 1/4 upper side rail for functional mobility and to aid in ADL (Activities of Daily Living, basic self-care tasks) care/repositioning. There was no care plan developed to address the application of side rail. During an observation on 5/19/25 at 8:16 a.m., Resident 21 was in bed with two upper side rails raised. During a concurrent interview and record review on 5/23/25 at 10:12 a.m., with the Director of Nursing (DON), the DON acknowledged there was no care plan developed for side rail. During a review of the facility's policy and procedure (P&P), titled Proper Use of Bed Rails, undated, indicated The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan . 2a. Review of Resident 1's clinical record titled, admission Record, dated 5/23/2025, indicated Resident 1 was admitted to the facility with diagnoses including primary osteoarthritis (OA, a degenerative joint disease, in which the tissues in the joint break down over time) of right knee, anxiety disorder (a mental illness that causes constant fear), PTSD, schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation on 5/19/2025 at 10:39 a.m., inside Resident 1's room, Resident 1 was asleep, and intermittently talking while asleep. During another observation on 5/23/2025 at 8:43 a.m., inside Resident 1's room, Resident 1 was eating breakfast in bed and stated she enjoyed playing BINGO. Review of Resident 1's Quarterly review minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1 had PTSD. During a concurrent interview with social services director (SSD) and review of Resident 1's list of care plans on 5/23/2025 at 10:37 a.m., SSD confirmed she couldn't find any care plan related to Resident 1's diagnosis of PTSD. SSD stated a care plan related to Resident 1's PTSD should have been developed for staff to avoid any triggers and to implement a plan of care. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, The comprehensive care plans will describe, at a minimum, the following: .Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 2b. Review of Resident 1's order summary report dated 5/23/2025, indicated the following orders: to monitor episodes of schizophrenia manifested by (m/b) hearing voices that are not real for use of aripiprazole; to monitor episodes of depression m/b episode of crying and anxiety m/b restlessness for use of bupropion; and to attempt non-pharmacological interventions prior to psychotherapeutic agent like provide quiet and dark environment, assess for pain, keep resident comfortable, provide back rub as needed, offer warm beverages, engage resident in preferred activities, and minimize environmental stressors. During a concurrent interview with DON and review of Resident 1's care plans related to use of aripiprazole and bupropion on 5/23/2025 at 12:20 p.m., DON confirmed the mentioned care plans were not person-centered without Resident 1's targeted behavior to be monitored and the non-pharmacological interventions to be implemented. 3. Review of Resident 29's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 29 was re- admitted to the facility on [DATE] with diagnoses including acute (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), end stage renal disease (ESRD, irreversible kidney failure), depression and shortness of breath. Review of Resident 29's order summary report dated 5/21/2025, indicated orders: to monitor episodes of depression m/b insomnia for use of doxepin; to monitor hours of sleep every evening and night shifts; to monitor episodes of poor oral intake for use of mirtazapine; and the use of non-pharmacological approach for use of psychotherapeutic agent like provide quiet and dark environment, assess the presence of pain, keep resident comfortable, provide back rub as needed, and offer warm beverages. During an observation on 5/19/2025 at 11:10 a.m., inside Resident 29's room, Resident 29 was seated at the edge of his bed, played his ukulele (a musical instrument) with O2 therapy at 2 liters per minute (LPM - a unit of measurement that indicates the volume of a fluid or gas, typically measured in liters, that flows in one minute) via (thru) nasal cannula (NC, a tubing used to deliver oxygen from the machine through the nostrils). During a concurrent interview with DON and review of Resident 29's care plans for use of mirtazapine and doxepin on 5/23/2025 at 11:55 a.m., DON confirmed above care plans were not person-centered for not having the specific behavior monitoring and use of non-pharmacological interventions. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

During an observation inside Resident 25's room on 5/19/25 at 9:06 a.m., Resident 25 was observed lying in bed. Her Foley catheter drainage bag was left uncovered hanging on the right side of the bed towards the door. yellow colored urine was visible from the drainage bag. During a concurrent observation and interview on 5/19/25 at 9:12 a.m., with Certified Nursing Assistant Q (CNA Q), She confirmed that Resident 25's Foley Catheter drainage bag was left uncovered with the privacy bag. CNA Q further stated usually it should have cover with privacy bag . During a review of Resident 25's clinical record indicated Resident 25 was admitted to the facility with diagnosis including neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should). During a review of Resident 25's physician's order indicated an order for Indwelling Catheter to straight drainage. Size: 16 FR (French, size is comparable to the circumference of the catheter in millimeters) . dated 4/11/25. During an interview on 5/22/25 at 2:34 p.m., with the Director of Nursing (DON), the DON stated the Foley catheter drainage bag should have privacy bag covered all the time and the catheter drainage bag should be placed away from the door. During a review of the facility's policy and procedures titled, Catheter Care, dated 3/1/23, indicated, It is the policy of this facility to ensure that residents with the indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . 4. Review of Resident 325's clinical record, indicated, Resident 325 was admitted on [DATE] with diagnoses including hereditary and idiopathic neuropathy (nerve damage caused by an unknown genetic defect), malignant neoplasm of prostate (growth of abnormal cells in the prostate, a male reproductive organ), obstructive and reflux uropathy (urine blocked from flowing out of the body and flows backward into the wrong place, such as back into the kidneys). Review of Resident 325's clinical record indicated he had a physician's order, dated 5/6/25, for suprapubic catheter (a tube placed directly into the bladder to drain urine). During a concurrent observation and interview on 5/19/25 at 8:41 a.m., with Certified Nursing Assistant (CNA) J, CNA J emptied the urine drainage bag. CNA J stated that the drainage bag does not need to have a privacy cover. During a concurrent observation and interview on 5/19/25 at 10:33 a.m., with the Director of Nursing (DON), the DON confirmed that the drainage bag did not have a privacy cover. The DON stated that urinary bag should have a privacy cover. Review of the facility's policy and procedure (P&P), titled Catheter Care, dated 3/1/23, indicated Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Based on observation, interview, and record review, the facility failed to maintain respect, and dignity to five of five residents (Residents 71, 108, 284, 325, and 25) when: 1. Certified nursing assistant K (CNA K) addressed Resident 71 as mama several times which could be heard at the facility's hallway; 2. Resident 108's privacy curtain was not fully drawn when occupational therapist M (OT M) was doing exercises with Resident 108; 3. Resident 284's urine drainage bag (a pouch that attaches to a urinary catheter [example is foley catheter, a thin, hollow tube inserted into the bladder to drain urine] and collects urine) was not covered with a privacy bag; 4. Resident 325's urine drainage bag was not covered with a privacy bag; and 5. Resident 25's urine drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1. Review of Resident 71's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 71 was admitted to the facility with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a condition characterized by memory loss) and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with hallucinations (a false perception of objects or events involving the senses: sight, sound, smell, touch and taste). During an observation on 5/19/2025 at 9:58 a.m., CNA K together with certified nursing assistant L (CNA L) went inside Resident 71's room. CNA K stated in a loud voice, mama we will pull you up. CNA K addressed Resident 71 as mama, three more times and it could be heard at the facility's hallway. During a follow-up interview with CNA K on 5/19/2025 at 10:00 a.m., CNA K confirmed above observation and stated she had to address Resident 71 mama because she had a hard time pronouncing Resident 71's name. CNA K further stated she should have addressed Resident 71 with her first or last name. During a concurrent interview with director of nursing (DON) and record review on 5/21/2025 at 9:55 a.m., DON reviewed Resident 71's list of care plans. DON stated staff could call or address residents mama, if it was the resident's preference. DON confirmed there was no preference care plan to address Resident 71 mama, and stated staff should address residents by their name. 2. Review of Resident 108's clinical record titled, admission Record, date 5/22/2025, indicated Resident 108 was admitted to the facility with diagnoses including gout (a type of inflammatory arthritis caused by a buildup of uric acid in the body), and muscle weakness (generalized). During an observation on 5/21/2025 at 12:48 p.m., at the facility's hallway, in front of Resident 108's room, Resident 108 was observed seated at the left side of the bed in front of OT M who was standing, and the privacy curtain was not fully drawn. OT M was giving some exercise instructions to Resident 108 who wore the facility's gown, tied at the back of her neck, her back down to her disposable brief was exposed and every time Resident 108 lifted her arms up, the side of her right breast could be seen at the hallway by any passersby. During an interview with OT M on 5/21/2025 at 12:57 p.m., OT M confirmed the above observations and stated she should have pulled the privacy curtain to provide Resident 108 dignity. During an interview with DON on 5/23/2025 at 11:20 a.m., DON stated the privacy curtain should always be drawn whenever staff were assisting residents with exercises or activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) to provide some privacy. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 3/1/2022, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, including privacy .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .When interacting with a resident, pay attention to the resident as an individual 3. Review of Resident 284's clinical record titled, Order Summary Report, dated 5/23/2025, it indicated an order of foley catheter attached to a bedside drainage bag for diagnosis of urinary retention (a condition when the patient is unable to completely empty their bladder). During a concurrent observation and interview with Resident 284 on 5/19/2025 at 10:21 a.m., inside Resident 284's room, Resident 284 was in bed, and a urine drainage bag was observed hanged at the lower part of the bed without a privacy bag. The urine drainage bag had yellow urine at 400 milliliter (ml, volume of measurement) which could easily be seen by any visitor inside the room. Resident 284 stated that she was not sure if the urine drainage bag had to be covered. Resident 284 further stated she did not mind if it was not covered as long as there was no urine in the urine drainage bag. During a concurrent observation and interview with CNA L on 5/19/2025 at 12:46 p.m., inside Resident 284's room, Resident 284 was eating lunch in bed, the urine drainage bag did not have a privacy bag. CNA L confirmed the above observation and stated the urine drainage bag should have been covered for privacy reasons.

3. Review of Resident 89's clinical record, indicated, Resident 89 was admitted to the facility on [DATE] with diagnoses including encephalopathy (condition affecting how the brain works), acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), anemia (a condition where the body does not have enough red blood cells to carry enough oxygen to the body), thrombocytopenia (having a low number of platelets [tiny blood cells to stop the bleeding] in the blood). Review of the physician's order dated 5/2/24 and 9/5/24, indicated Resident 89 was on enteral feeding (liquid nutrients given through a tube inserted in the stomach) and enteral bolus feeding (liquid nutrients given over a short period multiple times a day), and was discontinued on 10/4/24. A care plan for tube feeding was initiated on 5/2/24 and was not revised (to change) and resolved (completed) after the order was discontinued. Review of the physician's order dated 1/30/25 and 2/19/25, indicated Resident 89 was on Fluconazole (used to treat fungal infection) tablet 150 milligram (mg, unit of measurement) for possible infection for one day, and Macrobid (used to treat urinary tract infection, UTI) capsule 100 mg two times a day for UTI for 7 days. A care plan for antifungal therapy (Fluconazole) was initiated on 1/30/25, and a care plan for antibiotic therapy was initiated on 2/19/25. The care plan was not resolved after completion of the antibiotics. During a concurrent interview and record review on 5/23/25 at 8:28 a.m., with the Minimum Data Set Nurse (MDSN) S, the MDSN S confirmed the care plan for the antibiotics was not resolved and should have been resolved as soon as the medication were completed or discontinued. The MDSN S also confirmed that Resident 21 was no longer on tube feeding and the care plan was still active. MDSN S further stated that the care plan should have been resolved because the tube feeding was discontinued in 2/2025. During a concurrent interview and record review on 5/23/25 at 9:49 a.m., with the Director of Nursing (DON), the DON confirmed the tube feeding was discontinued on 2/5/25 and the care plan was still active. The DON stated the care plan should have been resolved when it was discontinued. The DON also confirmed the care plan for the antibiotics was still active and should have been resolved when the medication was completed. 4. Review of Resident 21's clinical record, indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), pneumonia (infection of the lungs), bronchiectasis (condition where the airways are damaged, widened, and thickened making it harder to clear mucus), pseudomonas (a type of bacteria that can cause infections) as the cause of diseases. Review of the physician's order indicated Resident 21 was on Azithromycin (used to treat bacterial infections) tablet from 6/5/23 to 10/13/24, 10/28/24 to 11/6/24, 11/14/24 to 12/12/24, and 12/13/24 to 4/19/25; Meropenem (used to treat bacterial infections) intravenous (administering medications into a vein) solution from 11/8/24 to 11/14/24; and Vancomycin (used to treat infections caused by bacteria) intravenous solution from 10/13/24 to 10/26/24, and 11/8/24 to 11/14/24. The care plan for the use of antibiotics was initiated but not revised and resolved. During a concurrent interview and record review on 5/21/25 at 2:11 p.m., with the DON, the DON verified that the care plan for the antibiotic was not updated, revised or resolved. The DON stated care plans must be reviewed quarterly and revised. During a concurrent interview and record review on 5/23/25 at 8:28 a.m., with the MDSN S, the MDSN S confirmed the care plan were not resolved and should have been resolved as soon as the medications were completed or discontinued. During an interview on 5/23/25 at 10:38 a.m., with Registered Nurse (RN) I, RN I stated care plans should be reviewed and resolved when the medications have been discontinued or completed. Based on observation, interview, and record review, the facility failed to ensure care plans were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward the common goal for the resident) for 4 of 26 sampled residents (Residents 1, 54, 89, and 21) when: 1. Resident 1's care plans for use of aripiprazole (brand name: Abilify , an atypical antipsychotic medication used to treat a variety of mental health conditions) and bupropion (brand name: Wellbutrin, an antidepressant medication used to treat depression) were not updated or revised with specific manifestations of Resident 1's behavior; 2. Resident 54's care plan for behavior problem was not updated or revised when Resident 54's use of olanzapine (brand name: Zyprexa, an antipsychotic medication that can treat several mental health conditions like schizophrenia [a mental illness that can affect thoughts, mood, and behavior] and bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs] ) was discontinued, and there was a refusal to be seen by a psychiatrist; 3. Resident 89's care plan for enteral tube( a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) feeding, bolus tube feeding (a method when liquid nutrition [formula] is delivered through a feeding tube using a syringe, typically in a few larger doses throughout the day) and antibiotic (medications used to treat infections caused by bacteria and other microorganisms) use were not resolved; and 4.Resident 21's care plan for antibiotic use were not revised or resolved. This deficient practice had the potential to compromise resident's health, safety and psychosocial well-being. Findings: 1. Review of Resident 1's clinical record titled, admission Record, dated 5/23/2025, indicated Resident 1 was admitted to the facility with diagnoses including primary osteoarthritis (OA, a degenerative joint disease, in which the tissues in the joint break down over time) of right knee, anxiety disorder (a mental illness that causes constant fear), PTSD, schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 1's Quarterly review minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated a brief interview for mental status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 5/19/2025 at 10:39 a.m., inside Resident 1's room, Resident 1 was asleep, and intermittently talking while asleep. During another observation on 5/23/2025 at 8:43 a.m., inside Resident 1's room, Resident 1 was eating breakfast in bed and stated she enjoyed playing BINGO. Review of Resident 1's order summary report dated 5/23/2025, indicated the following orders: to monitor episodes of schizophrenia manifested by (m/b) hearing voices that are not real for use of aripiprazole, order dated 4/2/2025; to monitor episodes of depression m/b episode of crying, order dated 4/2/2025 and anxiety m/b restlessness for use of bupropion, order dated 2/20/2025; and to attempt non-pharmacological interventions prior to psychotherapeutic agent like provide quiet and dark environment, assess for pain, keep resident comfortable, provide back rub as needed, offer warm beverages, engage resident in preferred activities, and minimize environmental stressors, order dated 2/20/2025. Review of Resident 1's care plan related to use of Abilify date initiated 1/31/2025, indicated it was not updated when the order on 4/2/2025 to monitor episodes of schizophrenia m/b hearing voices and the order on 2/20/2025 to attempt non-pharmacological interventions were not added to the care plan. Review of Resident 1's care plan related to use of bupropion date initiated 4/20/2023, indicated it was not updated when the specific behavior monitoring of episode of crying for depression was ordered on 4/2/2025 and restlessness for anxiety ordered on 2/20/2025. Further review indicated in one of the interventions, Monitor Dosage - Use of two or more antidepressants simultaneously may increase risk of side effects. Date initiated: 04/20/2023 and Resident 1 was only taking one antidepressant which was bupropion. During a concurrent interview with director of nursing (DON) and review of Resident 1's care plans related to use of aripiprazole and bupropion on 5/23/2025 at 12;20 p.m., DON confirmed the mentioned care plans were not updated or revised. DON stated care plans should be updated or revised whenever there was a change in plan of care. DON confirmed Resident 1 was only taking one antidepressant and the intervention about the use of two or more antidepressants should have been discontinued. 2. Review of Resident 54's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 54 was admitted to the facility with diagnoses including other psychotic disorder (a severe mental disorder that cause abnormal thinking and perceptions) bipolar disorder, depression, and Alzheimer's disease (a progressive disease that destroys memory and mental functions). Review of Resident 54's quarterly MDS assessment dated [DATE], indicated a BIMS score of 4 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further indicated Resident 54 had disorganized thinking (also known as thought disorder, refers to a disturbance in the way an individual processes and organizes their thoughts, leading to difficulties in expressing ideas coherently and logically). During a concurrent observation and interview with Resident 54 on 5/19/2025 at 10:55 a.m., inside Resident 54's room, Resident 54 was in bed, lying on her left side, and showed her left upper arm with purplish, yellow discoloration. Resident 54 stated someone punched her and she did not tell anybody about it. Resident 54 was not able to state who punched her. During a follow up interview with Resident 54 on 5/20/2025 at 9:32 a.m., Resident 54 stated she stayed awake at night when certain people are in the property. Resident 54 stated she was okay now, and managers are taking care of it. Review of Resident 54's order summary report dated 5/22/2025, it indicated an order dated 1/16/2023, May have psychology consult and treatment PRN [as needed] Further review indicated Resident 54 had no order for any psychotropic medications. Review of Resident 54's care plan on behavior problem related to diagnoses of bipolar and psychotic disorder, date initiated 12/29/2023, indicated, Resident is verbally aggressive and at time refuses ADL [activities of daily living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)] care. Further review indicated the interventions were dated 12/29/2023 and 3/5/2024. One of the interventions dated 3/5/2024, indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. During a concurrent interview with services director (SSD) and review of Resident 54's list of care plans on 5/23/2025 at 8:56 a.m., SSD confirmed Resident's care plan related to behavior problem should have been reviewed and revised for any changes in plan of care. SSD stated she was not sure about Resident 54's psychiatry consultation and she would get back to the nurse surveyor. During a concurrent interview with DON and review of Resident 54's care plan related to behavior problem, DON confirmed the care plan was not updated when the use of an antipsychotic was discontinued. During a concurrent interview with SSD and review of Resident 54's physician progress on 5/23/2025 at 4:05 p.m., SSD confirmed the progress note was dated 5/23/2025, the use of olanzapine had been discontinued in the past and Resident 54 had been refusing psychiatry visits. During a review of the facility's policy and procedure dated 3/1/2023, indicated, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

3. Review of Resident 10's clinical record titled, admission Record, indicated Resident 10 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, condition that limits airflow to the lungs), obstructive sleep apnea (disorder that affects breathing while sleeping), diabetes mellitus (a condition which affects the way the body processes blood sugar) and chronic kidney disease. During an observation on 5/19/25 at 8:54 a.m. in the room of Resident 10, Resident 10 was observed in bed receiving oxygen therapy at 2 L/min via nasal cannula. The O2 concentrator's filter located at the back of the equipment had grayish substance build up. During a concurrent observation and interview on 5/19/25 at 12:30 p.m. with the Director of Staff Development (DSD) in the room of Resident 10, the DSD confirmed the filter should not have grayish substance build up. During an interview on 5/20/25 at 11:00 a.m., with the Director of Nursing (DON), the DON stated the oxygen air filter should not have substance build up on it and should be cleaned or replaced regularly by the nursing staff. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 5/1/2023, indicated, Cleaning and care of equipment shall be in accordance with facility policies for such equipment. Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for three of four residents (residents on oxygen therapy) (Residents 29, 88, and 10) when: 1. Residents 29's O2 concentrator's (a device which concentrates the oxygen from ambient air) filter had some grayish substance build up and there was no O2 saturation (O2 sat, to measure how much oxygen the blood is carrying. A healthy level is between 95% and 100%)) monitoring for Resident 29's continuous use of O2; 2. Resident 88's O2 concentrator' filter had some grayish substance build up; and 3. Resident 10's O2 concentrator's filter had some grayish substance build up. These deficient practices had the potential for Resident's 29, 88, and 10 to have complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 29's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 29 was re- admitted to the facility on [DATE] with diagnoses including acute (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), end stage renal disease (ESRD, irreversible kidney failure) and shortness of breath. During an observation on 5/19/2025 at 11:10 a.m., inside Resident 29's room, Resident 29 was seated at the edge of his bed, played his ukulele (a musical instrument) and with O2 therapy at 2 liters per minute (LPM - a unit of measurement that indicates the volume of a fluid or gas, typically measured in liters, that flows in one minute) via (thru) nasal cannula (NC, a tubing used to deliver oxygen from the machine through the nostrils). It was observed the filter located at the back of the O2 concentrator had grayish substance build up. During a concurrent observation and interview with certified nursing assistant W (CNA W) on 5/19/2025 at 11:13 a.m., inside Resident 29's room, Resident 29's O2 concentrator's filter had grayish substance build up. Resident 29 confirmed the observation and stated the filter had a dust build up. During a concurrent observation and interview with licensed vocational nurse F (LVN F) on 5/19/2025 at 11:17 a.m., LVN F confirmed the above observation and stated the oxygen concentrator's filter had a dust build up. LVN F further stated it was the central supply (CS) person's responsibility to check the oxygen concentrator. 1b. Review of Resident 29's Order Summary Report, dated 5/21/2025, it revealed an order on 11/22/2024 for use of O2 at 2 LPM via NC continuously. Further review revealed the following orders: a. May administer O2 at 2L/min via nasal cannula for dx [diagnosis] SOB [shortness of breath], chest pain, oxygen saturation less than 90% and notify MD (medical doctor). as needed. May titrate as needed to maintain O2 sat above 90%. Order dated 10/16/2024. b. May administer O2 at 2L/min via nasal cannula for Oxygen saturation of <90% and notify MD. May titrate as needed to maintain O2 sat above 90%. As needed. Order dated 1/21/2023. c. May titrate up to 4:/min for O2 saturation less than 86% Order dated 11/22/2024. d. There was no order to monitor Resident 29's O2 sat. Review of Resident 29's nurse's progress notes and May 2025 medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), it indicated nurses had no documentation of Resident 29's O2 saturation monitoring every shift. During a concurrent interview with minimum data set nurse S (MDSN S) and record review on 5/22/2025 at 11:07 a.m., MDSN S reviewed Resident 29's progress notes and the May 2025 MAR and confirmed there were no documentation that nurse's had checked and monitored Resident 29's O2 sat. MDSN S stated nurses should have monitored Resident 29's O2 sat to determine if Resident 29 was getting enough O2. During a concurrent interview with DON and record review on 5/23/2025 at 12:08 p.m., DON reviewed Resident 29's progress notes and the May 2025 MAR and DON confirmed there was no O2 sat monitoring done for Resident 29. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 5/1/2023, 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. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy .Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. Monitoring for complications associated with the use of oxygen. 2. Review of Resident 88's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 88 was admitted to the facility with diagnoses including malignant neoplasm (also known as cancer) of endometrium (the inner lining of the uterus, also known as the womb), encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and respiratory disorders (are conditions that affect the lungs and other parts of the respiratory system, impacting the body's ability to breathe) in diseases classified elsewhere. During a concurrent observation and interview with certified nursing assistant L (CNA L) on 5/19/2025 at 9:51 a.m., inside Resident 88's room, Resident 88 was in bed with oxygen therapy at 1.5 LPM via nasal cannula. The O2 concentrator's filter located at the back of the equipment had some grayish substance build up. CNA L confirmed the observation and stated nurses should be the one to change the O2 filter. During an interview with director of nursing (DON) on 5/21/2025 at 9:56 a.m., DON stated the CS person was responsible for the oxygen concentrator's filter. DON further stated nurses should also check the O2 concentrator's filter in a weekly basis.

Based on interview and record review, the facility (Facility A) failed to permit five of 21 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) to remain at the facility and not transfer to another facility without appropriate reason/s for discharge when: 1. Resident 1 was transferred to Facility B by a facility-initiated discharge (a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request) without an appropriate reason for discharge in accordance with CFR 483.15(c)(regulation with specific criteria for discharge/transfer of residents). 2. Resident 2 was transferred to Facility B by a facility- initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). 3. Resident 3 was transferred to Facility C without documented evidence indicating Resident 3 requested the discharge. 4. Resident 4 was transferred to Facility B without documented evidence indicating Resident 4's responsible party (health care decision maker) requested the discharge. 5. Resident 5 was transferred to Facility B by a facility-initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). These failures contributed to: a. Psychosocial harm to Resident 1 evidenced by, difficulty with transition to new facility (Facility B), difficulty of friends to visit new facility due to farther distance, and Resident 1 expressing a repetitive sadness and depressed mood from lack of visitors. b. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 2 and Resident 3, when their environments changed without a timely notice of discharge, and opportunity to refuse the transfer/discharge. c. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 4 using the reasonable person standard as evidenced by family being unable to visit as frequently as before the transfer due to facility being further away from Resident 4's responsible party's residence. Resident 4 had the potential to experience depression and or loneliness. d. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 5 using the reasonable person standard as evidenced by friend being unable to visit facility since transfer due to facility being farther away. Resident 5 has potential to experience depression and or loneliness. Findings: 1. During a review of Resident 1' Facesheet (demographic document, typically include the patient's name, address, date of birth, insurance information, and emergency contact information), undated, it indicated, Resident 1 was admitted to Facility A on 4/27/24, and Resident 1 was her own responsible party. Review of Resident 1's Social Service Assessment for admitted d 4/27/24, completed by social services director (SSD), the assessment indicated, Option 2 was selected for long term stay Discharge Planning Anticipated Length of Stay as: 2) Long Term. SW met with [Resident 1] and friend as POA [Power of attorney-a legal document that allows someone else to act on your behalf] at bedside.No behavior issues or mental health. Review of Resident 1's Notice of Proposed Transfer or discharge date d 6/11/24 by SSD, the Notice indicated, the discharge type was selected as facility initiated, and the resident did not require care at facility. 1. Transfer or Discharge Type 2. Facility Initiated Transfer.4. Date of Transfer/Discharge 6/11/2024.Reason for Discharge in accordance with CFR 483.15 (c) (F622) 1. Resident's health has improved sufficiently that the resident no longer needs the services provided by the facility.Transfer or Discharge Address [Facility B Address- Another Skilled Nursing Facility]. During an interview on 6/25/24, at 10:36 a.m., with the SSD, the SSD stated, I selected the option in the discharge reason for Resident 1, that the residents health improved because no other option applied to her. The SSD confirmed Resident 1 would be receiving the same care at the other facility (Facility B) where she was transferred/or discharged to and still needed long term care. During an interview on 6/20/24, at 2:15 p.m., with Friend A (FA), FA stated, they are friends with Resident 1 for over [AGE] years now. FA stated, the SSD told her they needed to move Resident 1 to their sister facility (Facility B) because they needed her bed for other prospective patients. I think they [facility] got exasperated with [Resident 1] because she is not an easy person to deal with, they did not offer her long-term stay. FA also stated, [Resident 1] didn't want to leave, she wasn't happy about it. FA stated, they [facility A] told us they needed the bed space for other patients. FA stated, she had not visited Resident 1 at Facility B because its too far away, previously she would visit several times a week when Resident 1 was still in Facility A. During an interview on 6/20/24, at 4:30 p.m., with Friend B (FB), FB stated, he had been friends with Resident 1 for over [AGE] years. FB stated, the SSD told him, Resident 1 was transferred to another facility because they were running out of room and they needed the bed. FB stated, the SSD was the one who told this to him. FB stated, there is no way Resident 1 would have requested to go, she is so demented, she sees objects that are not there in the room. FB hasn't been able to visit Resident 1 because the new place (Facility B) was too far away. During an interview on 6/21/24, at 9:15 a.m., with Friend J (FJ), FJ stated, she had the POA for Resident 1, and neither her nor Resident 1 requested the transfer. FJ stated, the SSD told us they are just holding Resident 1 at the facility (Facility A) until there is space at Facility B. FJ stated, the SSD told her they are transferring her to Facility B because it is more of a long-term care place, and she can get physical therapy there. FJ stated, when I visited her (Resident 1) first week at [Facility B], she had a horrible week, she was confused, she seemed depressed, the facility had to call me almost every day to get her to take her medications, Resident 1 was so upset she had to move. FJ stated, (Resident 1) kept asking her Why did they make me leave the other place. During an interview on 6/24/24, at 1:17 p.m., with Physician D (PD), PD stated, he was Resident 1's Primary Physician in both Facility A & Facility B. PD stated, Resident 1 still required long term care, she is getting the same level of care at [Facility B]. PD also stated, he was not sure why Resident 1 was transferred, the only reason to transfer to another skilled nursing facility was if the family or the resident requested to be transferred. Review of Resident 1's Admission Agreement, dated 3/12/24, it indicated, VI. Transfers and Discharges. The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate. 6) Material or fraudulent misrepresentation of your finances to us. No documented evidence reasons (1-6) were applicable to Resident 1's reason for transfer were found. During an interview on 6/26/24, at 11:22 a.m., with Resident 1 in her room at Facility B, Resident 1 stated, she was not sure why she was transferred to Facility B. Resident 1 stated, her other friends were not able to visit her yet because of the distance and it made her feel depressed. 2. During a review of Resident 2's Facesheet dated 6/19/24, the Facesheet indicated, Resident 2 was admitted to Facility A on 3/3/24, and was her own responsible party. During a review of Resident 2's Admission Social Service Assessment completed by the SSD on 4/9/24, it indicated, Anticipated length of stay 2) Long term Care. During a review of Resident 2's Notice of Proposed Transfer or Discharge, completed by the SSD on 6/11/24, Notice indicated, Resident 2 was transferred by the facility because she no longer needed services, Transfer or Discharge Type: 1.Facility initiated Discharge.Date of discharge 6/11/24. 5. Transfer or Discharge Address [Facility B address-another skilled nursing facility]. Reason for Discharge in accordance with CFR 483.15 (c) 1. Resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. During an interview on 6/20/24, at 3:46p.m., with Physician C (PC) PC stated, she was Resident 2's Primary Physician while at Facility A. PC stated, they did not initiate the transfer to another facility for Resident 2. PC stated, the facility notified PC the Resident is being transferred. PC stated I assume either the Resident or the family requested the transfer, that is usually the only reasons for transfer to another skilled nursing facility. During an interview on 6/25/24, at 10:36 a.m., with the SSD, the ]SSD stated, I selected the option in the discharge reason for [Resident 2], that the residents health improved because no other option applied to her, the SSD stated Resident 2 is receiving the same level of care at Facility B. During a review of Resident 2's Admission Agreement, dated 3/3/24, it indicated, VI. Transfers and Discharges. The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate. 6) Material or fraudulent misrepresentation of your finances to us. No documented evidence reasons (1-6) were applicable to Resident 1's reason for transfer were found During an interview on 6/26/24, at 11:20 a.m., with Resident 2, Resident 2 did not respond to any questions, she stared blankly straight ahead without eye contact. During a review of Resident 2's BIMS (Brief Interview for Mental Status-an assessment tool used to identify cognitive status) score dated 6/11/24, indicated a score of 9, indicating moderate cognitive impairment. 3. During a review of Resident 3's Facesheet indicated, Resident 3 was admitted to Facility A on 5/23/24 and her own responsible party. During a review of Resident 3's Admission Social Service assessment dated [DATE], it indicated, DC plan either return to B&C [board and care-a licensed residential home that provides non-medical care] or long term care. During a review of Resident 3's Notice of Proposed Transfer or Discharge completed by Social Services E (SS E) dated 6/15/24, it indicated, Resident 3 requested a transfer, and no longer needs services, 1. Transfer or Discharge Type 4. Resident/Resident Representative requested transfer. Date of Transfer/Discharge 6/16/24.6. Reason for Discharge in accordance with CFR 483.15(c)(F622) 1. The Resident's health has improved sufficiently that the resident no longer needs the services provided by the facility. During an interview on 6/20/24, at 4:30 p.m., with SS E, SS E stated, I think Resident 3's daughter requested Resident 3 to be transferred to [Facility C] to be closer to her. During an Interview on 6/21/24, at 10:16 a.m., with the Assistant Administrator (AA), Surveyor requested documentation indicating Resident 3 had requested for the transfer. The AA stated Resident 3 had a progress note that indicated Family L (FL) requested the transfer. During a review of Resident 3's Progress note dated 6/14/24, it indicated, [FL] would like referral to go to [Facility C] and if not accepted is agreeable to dc [discharge to] [Facility B], only if resident agreeable. No documentation was available to support Resident 3 agreed or requested to transfer to another facility being her own self-responsible for decision making. During an interview on 6/20/24, at 1:15 p.m., with FL, FL stated, I don't know why [Resident 3] was transferred, you'd have to ask her FL stated, she didn't request anything. During an interview on 6/24/24, at 1:17 p.m., with PD, PD stated, he was the Primary Physician for Resident 3 at former facility. PD stated, he assumed Resident 3 was transferred to be closer to family, since she went to Facility C . PD stated, It is primarily the Social Workers who are involved with transfers, so they would know the reason. During an interview on 6/26/24, at 9:10 a.m., with Resident 3 at Facility C, Resident 3 stated, The reason they transferred me to Facility C was They [Facility A] told me they didn't have a bed for me to stay. I asked them what about the bed I'm in now? They said they didn't have any long term beds available. I don't remember who spoke with me, but they did not give me the option to stay. Resident 3 stated, I would have loved to stay there [Facility A] for long term, they told me they wouldn't have accepted me if I was going to stay long term. Resident 3 stated, she had to either transfer to Facility B or Facility C. Resident 3 stated, I'm more sad. I wish I could have stayed and not moved. Resident 3 stated, she is still receiving the same level care, and is continuing physical therapy. During a review of Resident 3's Admission Agreement, dated 5/23/24, Agreement indicated, VI. Transfers and Discharges. The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate. 6) Material or fraudulent misrepresentation of your finances to us. No documented evidence reasons (1-6) were applicable to Resident 1's reason for transfer were found 4. During a review of Resident 4's Facesheet dated 6/19/24, Facesheet indicated, Resident was admitted to Facility A on 6/4/22, with Family F (FF) listed as responsible party. During a review of Resident 4's Notice of Proposed Transfer or discharge date d 5/29/24 completed by the SSD, indicated, Resident representative requested the transfer, 1. Transfer or Discharge Type 4. Resident/Resident Representative Requested Transfer.4. Date of Transfer 5/29/24. 5. Transfer or Discharge Address [Address of Facility B-Another Skilled Nursing Facility]. 6. Reason for Discharge in accordance with CFR 483.15(c) 1. The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility During an interview on 6/25/24, at 10:36 a.m., with the SSD, the SSD stated, I selected the option in the discharge reason for Resident 4, that the residents health improved because no other option applied to him, he is receiving the same care at the other facility. During an Interview on 6/21/24, at 10:16 a.m., with AA, a request was made for documents to indicate Resident 4's responsible party requested for transfer. During a review of requested documentation from AA for Resident 4's request for transfer, dated 5/28/24, indicated, Left voicemail for [FF] of [Resident 4] in regards to transferring him to our sister facility [Facility B]. During an interview on 6/21/24, at 10:30 a.m., with Family G (FG), FG stated he is the power of attorney for Resident 4, makes his health care decisions. FG also stated, he should be listed as RP, it's not FF since he lives out of state and is too busy. FG stated, neither me or any family member requested to have Resident 4 discharged or transferred to another facility. FG stated, he was contacted after they (Facility A) transferred Resident 4 to Facility B, by the staff at Facility B. FG stated, he was not able to visit as frequently because the facility is even farther from where I live now, which made him (Resident 4) sad. During a review of Resident 4's POA document dated 1/9/24, it indicated FG has the POA for Resident 4, signed by both parties (Resident 4 and FG). 5. During a review of Resident 5's undated Facesheet, it indicated, Resident 5 was admitted to Facility A on 1/18/24. Resident 5's responsible party and POA was listed as Friend I (FI). During a review of Resident 5's Notice of Proposed Transfer or discharge date d 6/17/24, Notice indicated, Resident Responsible party requested a transfer, and no reason for discharge was noted Notice of Proposed Transfer or Discharge 1. Transfer or Discharge Type 1. Facility Initiated Discharge.Date Resident/Responsible Party Notified of Discharge/Transfer 6/17/24. 4. Date of Transfer/Discharge 6/17/24. transfer or Discharge Address [Facility B address-another skilled nursing facility]. Reason for Discharge in accordance with CFR 483.15(c)(F622) [no option was selected]. During an interview on 7/1/24, at 11:57 a.m., with FI, FI stated, she's the POA for Resident 5. FI stated, she did not request Resident 5's transfer to another facility. FI stated, Resident 5 was transferred to Facility B because they [Facility A] stated to me, they needed to provide care at a smaller facility. FI stated, someone from Facility A called me to say they could transfer him to (Facility B), but now I cannot visit him because it takes me 2 hours to drive there, so he hasn't had any visitors. He loves it when I visit because it is the only familiar face to him. FI also stated, now she has to transfer him to another facility so she can finally visit him. During a review of Resident 5's Progress Notes dated 6/17/24, Notes indicated, spoke to resident and rp in regards for their request to dc. informed her at this time i can transfer resident to a smaller facility and work with my resources for a more permanent solution. may apply to alwp [assisted living waiver program]. she agreed to dc to [Facility B] and will findout [sic] more about his income for the alwp and get back to me. During an interview on 6/25/24, at 10:36 a.m., with the SSD, the SSD stated, she did not select a reason for transfer. The SSD stated, the RP requested a transfer to a smaller facility. The SSD was unable to provide sufficient evidence Resident 5's RP made the request to transfer Resident 5 to another facility (Facility B). Review of the Facility's Policy & Procedure (P&P) titled, Bed Hold Notice Upon Transfer, dated 2023, the P&P indicated, 3. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid for under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paper work for third party payment or after the third party, including if Medicare or Medicaid denies the claim and the resident refuses to pay for his or her stay. Policy Bed Hold Notice Upon Transfer For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge only allowable charges under Medicaid. f. The facility ceases to operate. Review of the Facility's Policy & Procedure (P&P) titled, Discharge Planning Process, undated, P&P Indicated, The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge.

Based on interview and record review, the facility failed to safely monitor the administration of [MEDICATION(S)] in water (D5W) intravenous (IV, tube inserted into a vein) fluid for one of 12 sampled residents (Resident 49) when a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .These failures resulted in Resident 49's fluid overload (too much fluid in the body) which may have caused, or contribute to, Resident 49's deterioration in health, and ultimate death. Findings: Review of Resident 49's undated face sheet indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents 49's minimum data set, (MDS, an assessment tool) dated 2/10/21, indicated she had a brief interview for mental status (BIMS, cognitive status) score of 99 (a score of 99 if the resident was unable to complete the interview) with short term and long term memory problem. Resident 49's functional status in bed mobility, transfer, dressing, eating, toileting, and personal hygiene required staff assistance. The MDS also indicated Resident 49 had no weight loss and no weight gain. Review of Resident 49's fluid imbalance care plan, dated 3/19/20, indicated she had a risk for fluid imbalance related to cognitive problems, extensive assistance with feeding, drinking fluids and the intervention was to monitor for signs of fluid imbalance such as mentation changes, and [CONDITION(S)]. There was no documented evidence in Resident 49's medical record the facility monitored for signs of fluid imbalance such as mentation changes, and [CONDITION(S)]. Review of Resident 49's nutritional assessment dated [DATE], indicated Resident 49's total fluid requirement was 1600 milliliters (ml, unit of measurement) per day. During an interview with the registered dietician (RD) on 5/6/21 at 3:36 p.m. she confirmed Resident 49's total fluid requirement was 1600 ml per day. Review of Resident 49's BMP collected on 2/21/21, indicated the sodium (NA, electrolyte and minerals in the body) level was 180 milliequivalent per liter (NA normal level 136-145). Review of Resident 49's nursing note, dated 2/22/21, indicated Resident 49's sodium level was critical (180 mEq per liter). The physician was notified regarding the critical sodium level. The physician ordered to check BMP daily, and administer D5W IV fluids at 75 cubic centimeter (cc, unit of measurement) per hour with no stop date (75 cc per hour= 1800 cc per day). Further review of Resident 49's medical records, indicated there was no documented evidence BMP was checked daily on 2/23/21, 2/24/21, and 2/25/21. Review of Resident 49's nursing note, indicated on 2/23/2021 at 6:00 a.m., Resident 49 had shortness of breath, so administered 4 liters per minute of oxygen, and continued to receive D5W IV fluids at 75 cc per hour. Review of Resident 49's physician order, dated 2/23/21, indicated to administer 2-5 liters of oxygen for shortness of breath, chest pain, wheezing as needed. The physician also ordered on 2/23/21 [MEDICATION(S)] 20 milligrams (mg, unit of measurement) per 2 ml vial to give IV push, then 10 mg IV push after 1 hour for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 49's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's nursing notes, dated 2/24/21, indicated on 2/24/21 at 1:41 p.m., Resident 49 had shallow and labored breathing with 5 liters of oxygen, mottled skin, and D5 IV fluids was stopped. Review of Resident 49's nursing notes, dated 2/25/21 at 9:19 p.m., indicated at 8:25 p.m., Resident 49 was unresponsive, stopped breathing and the two RNs confirmed death. During an interview and record review with licensed vocational nurse C (LVN C) on 5/6/2021 at 10:55 a.m., she confirmed Resident 49's NA level was high at 180 mEq per liter. LVN C stated the physician ordered to check the BMP daily and administer D5W IV at 75 cc per hour with no stop date. LVN C also stated there was no monitoring listed on the medical records regarding the amount D5W IV fluids administered to Resident 49 on 2/22/21, 2/23/21, and 2/24/21. During an interview and clinical record review with registered nurse D (RN D) on 5/7/21 at 7:01 a.m., she confirmed Resident 49 had D5W IV listed on the medical records on 2/22/21, 2/23/21, and 2/24/21. She also stated the physician ordered BMP daily but BMP was not checked daily to monitor the electrolyte treatment given to Resident 49. RN D stated Resident 49 had a fluid imbalance care plan but there was no monitoring on the medical record related to fluid imbalance. RN D also stated Resident 49 had fluid overload or fluid imbalance related to D5W IV fluids and could cause weakness, deterioration, and death. During an interview with the medical doctor (MD) on 5/7/21 at 8:15 a.m., the MD confirmed she ordered BMP daily on 2/22/21 and D5W IV with no stop date. MD stated she ordered D5W IV to remove the sodium in the body and she was not sure if the BMP was checked daily in the facility. The MD also stated she ordered [MEDICATION(S)] 20 mg via IV to remove the fluids in the lungs, crackles, and shortness of breath. The MD stated Resident 49 should have been monitored for fluid imbalance and daily BMP level. The MD stated the licensed nurse should have monitored the daily BMP for Resident 49. During an interview with the director of nursing (DON) on 5/7/21 at 9:33 a.m., she stated the daily BMP should have been checked daily and the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also stated the care plan for fluid imbalance was not implemented related to monitoring for signs of fluid imbalance. During an interview with the pharmacy consultant (PC) on 5/7/21 at 2:22 p.m., he stated Resident 49 should have been monitored for IV fluid infused related to D5W IV. The PC also stated it could also cause electrolytes imbalance such as decrease in potassium, NA, and sugar in the body. The PC stated the daily BMP was important to check how the resident's body responds to D5W IV fluids which could cause fluid overload of the cardiovascular system or heart problems. Review of the facility's 2008 policy, Intravenous Fluid and Drug Administration General Practices, indicated the nurse should monitor the resident's therapeutic response, recognize indications of untoward reactions, and implement nursing intervention. Monitoring the residents should be ongoing. Review of the facility's undated policy, Peripheral IV Catheter Insertion, indicated to provide safe peripheral IV for the administration of fluids, or medications and the following information should be recorded in the resident's medical record, the amount of solution or medication to be infused, and the resident's response to treatment.

Based on observation, interview, and record review, the facility failed: A. to ensure the sanitation of the kitchen when sewage water backed up onto the floor of the kitchen, and the facility did not take immediate steps to repair and sanitize the kitchen to ensure it was safe and sanitary. This failure had the potential to cause food-borne illness in a vulnerable population and had the potential to affect all residents (based on a census of 83). On 2/25/2020 at 9:35 a.m., the survey team called an Immediate Jeopardy (IJ, immediate danger or harm to residents or likelihood to harm residents if not corrected immediately) with the administrator (ADMIN) when sewage water backed up onto the floor in the kitchen from two floor drains and the kitchen staff did not take any necessary steps to respond and ensure a sanitary kitchen. On 2/25/2020 at 4:32 p.m., after the survey team received evidence of an acceptable removal plan/plan of action, related to the sewage backup in the kitchen, the survey team removed the immediate jeopardy with the ADMIN. B. to ensure food safety by: proper storage of food in the kitchen; a sanitary kitchen; equipment in use in the kitchen were not worn out; an ice machine in the memory unit and food preparation sinks in the kitchen had no air gap (a gap of air between the drain pipe of the equipment (sink/ice machine) and the floor to prevent backflow); proper storage of food and items under a sink in the activity/dining room; and proper monitoring of nursing refrigerators Findings: A. During an observation on 2/25/2020 at 8:20 a.m., in the facilities kitchen, while observing dishwashing at the 3 compartment sink, water was observed flowing on the floor between the dishwashing machine counter (where dirty dishes were placed prior to rinsing and running through the dishwashing machine) and the clean dish racks (tall metal racks on wheels containing clean dishes). Further observation indicated, the water was sewage water, overflowing from two floor drains, one under the dishwashing machine counter and one under the clean dishes rack. The sewage water was pooling under the floor mats; the space between the dishwashing machine counter and clean dish racks; under the dirty dishes counter; under the 3 compartment sink; under the clean dish racks; under the tall rack storing multiple loaves of bread; and towards the prep table holding 4 types of cereals in 5 gallon buckets as well as white rice; brown rice; cornmeal, and a small container of rice. The sewage water was cloudy and had a foul odor. The drains were caked with debris and had a black and white residue. During a further observation on 2/25/2020 at 8:25 a.m., kitchen staff, including the Dietary Manager (DM) and Dietary Staff (DS) I, were observed continuing to work in the kitchen, walking through the sewage water and doing their kitchen tasks without any interventions. Also, DS J was observed washing dishes at the 3 compartment sink and had not plugged the 3rd compartment as outlined in the 3 compartment sink operating instructions that was posted on the wall above the sink. Therefore, the water was going down the drain. During an observations on 2/24/2020 from 8:35 a.m. to 10:45 a.m., during the kitchens initial tour, indicated the concrete floor had numerous unsealed cracks and disintegrating/crumbling concrete where it was not sealed, throughout the kitchen. Further observations from the initial tour on 2/24/2020 from 8:35 a.m. to 10:45 a.m., and during the incident on 2/25/2020 at 8:30 a.m., indicated the wheels on the bottom of the clean dishes rack, located behind the 3 compartment sink, was caked with a black/brown residue and the bottom racks had an orange colored residue that wiped off with a paper towel. The clean dishes rack held two totes on the bottom rack, one filled with drinking cups and one filled with various lids. Another rack under the drain held numerous black plastic plate covers used to keep food warm and covered during transport. Other racks, counters, and refrigerators near the drains had a black/brown residue on the bottom castors of the equipment. The garbage disposal also was caked with a black substance. During an interview on 2/25/2020 at 8:22 a.m., with the DM, the DM stated the wastewater the surveyors observed was overflowing from the floor drain under the dishwashing machine counter. The DM also stated the overflow occurred occasionally. When asked when this last occurred, the DM stated last week. The DM further stated the only intervention after the water backup was to mop the floors. During an interview on 2/25/2020 at 8:30 a.m., with Maintenance Staff (MS) N, MS N stated the cause of the backflow of water was from overusing water at the 2 compartment sink and the dishwashing machine. He stated it occurred when they were used at the same time. He stated the drain would have to be snaked (snaked - a type of tool created and designed to clean the inside of a drain). During an interview on 2/25/2020 at 9:10 a.m., with the Environmental Services Director (ESD), the ESD stated sewage water backed up occasionally because the drains were combined and occurred when the dishwashing machine and sinks were used at the same time. The ESD stated she was aware the drains backed up last week. However, when maintenance went to inspect, the area was already cleaned and no more water was backing up from the sewage drain. Therefore, she did not do any interventions. When asked how the kitchen staff cleaned after the sewage water backup, the ESD stated the kitchen staff cleaned the floor and nothing else was done. During an interview on 2/25/2020 at 9:15 a.m., with the Registered Dietician (RD), the RD gave an update on the current situation with the sewage water backup. The RD stated the floor was mopped, so the problem was taken care of. The RD confirmed that was the only corrective action that took place. On 2/25/2020 at 9:35 a.m., the survey team called an IJ and informed the ADMIN to provide the survey team with an immediate measure that would be taken to ensure the safety of the residents. The ADMIN stated she was not informed of the backup of water from the drains in the kitchen that staff reported happened last week. During an interview on 2/25/2020 at 9:45 a.m., with DS H, DS H stated he was here last week when the drain clogged and sewage water backed up. DS H stated it occurred when the 3 compartment sink was used at the same time as the dishwashing machine and was the same amount of sewage water as today. DS H stated the kitchen staff dried, mopped, sanitized and moved the floor mats to clean. During an interview on 2/26/2020 at 1:40 p.m., the RD stated sanitation inspection rounds were done monthly in the kitchen. The RD stated, she and the DM alternated monthly to do the inspections. The RD stated no inspections were done for February yet. During an interview on 2/27/2020 at 1:44 p.m., the ADMIN stated the facility did not have a specific policy for the wastewater drain in the kitchen, so they made one. During a review of the description of work performed invoice from the plumbing company, dated 2/25/2020, indicated FOUND GREASE TRAP EXIT LINE BACKING UP INTO 2 FLOOR DRAINS IN KITCHEN AREA(.) RAN CABLE SEVERAL TIMES IN BOTH FLOOR DRAINS TO CLEAR BLOCKAGE (.) ALSO RAN GREASE TRAP EXIT LINE SEVERAL TIMES BACK & FORTH TO CLEAR FLOOR DRAINS & EXIT LINE(.) RAN LOT(S) OF WATER ALL CLEAR. During a review of the grease trap maintenance records from the company AARON'S INDUSTRIAL PLUMBING, for the past 4 months indicated the grease trap was usually pumped every 4 weeks, however between January and February it was 6 weeks between pumping. The following was documented when the grease trap was pumped: Solid Compartment: 11/12/19: Grease 15%; Food 2%; 12/13/19: Grease 15%; Food 2%; 1/15/2020: Grease 18%; Food 2%; and 2/26/2020: Grease 20%; Food 3%. During a review on 2/27/2020 at 1:30 p.m., of the facility's policy and procedure (P&P) untitled and undated, indicated The grease traps are cleaned and maintained on a regular basis for it to work effectively .(contractors name) is scheduled once a month (every four weeks) to make sure that the trap is well- maintained and unclogged the drains. During a review on 2/27/2020 at 1:30 p.m., of the facility's P&P, Cleaning Kitchen Drain undated, indicated Maintenance will remove the drain cover. Maintenance will use grease remover and disinfect the drain. Maintenance will use cleaning brush to clean out the drain. Maintenance will clean out the drain quarterly or as needed. On 2/25/2020 at 4:32 p.m., after the survey team reviewed the evidence of an acceptable removal plan/plan of action, related to the sewage water backup in the kitchen and sanitation procedures, the survey team removed the IJ with the ADMIN. The removal plan/plan of action was as follows: 1. City Water & Sewer Inspector, inspected the property and flushed out the main public pipe connected to the facility's property. 2. The facility engaged a private plumber to immediately flush out the facility's main sewer line. 3. Environmental health of Santa Clara County was contacted and arrived at 12 p.m. 4. Kitchen area where sewer water overflowed was cordoned off and sanitized. Kitchen employees were restricted access until cleared by county inspector. 5. Once kitchen is cleared by county inspector, the kitchen will be deep cleaned, following the PureForce 3 Step Process (wash, rinse, and sanitize) going from top to bottom, before any usage. 6. The facility will sanitize all inventory & equipment with P 12 S Liquid (sanitizing rinse). 7. The facility will continue to monitor all drains in the kitchen every hour until 10:00 p.m., to ensure there is no further overflow. 8. In-serviced all kitchen staff regarding what to do in case of a sanitation sewer overflow. 9. Kitchen employee's shoes were disinfected and/or provided booties to wear. 10. The facility will discard food exposed in the kitchen during the time of the incident and will bring out emergency food supply to be served to the residents. 11. Only disposable equipment will be used to cook and serve the residents. 12. The facility will serve emergency food until the kitchen is clear and will prepare it in the sanitized area of the kitchen. 13. The ESD/Maintenance Director to give in-service to all her maintenance staff to monitor other sewer outlets in the building to ensure that the issue has not carried over to other outlets. Will monitor 3-6 outlets every hour until 10 p.m. After 12 hours, check outlets every day for 72 hours. 14. In-serviced all maintenance and housekeeping staff on duty regarding sanitation and sewer back flow. 15. In-service nursing staff to monitor signs and symptoms of food borne illness for 72 hours; care plan changes; monitor and report sewer overflow; and steps to take in case of food borne illness. 16. Infection control nurse to log and track any food borne illnesses. 17. Notified all facility medical directors regarding the incident. During a review of the FDA (Food and Drug Administration) Food Code 2017 ( .a model for safeguarding public health .It represents FDA's best advice for a uniform system of provisions that address the safety and protection of food offered at retail and in food service), indicated the following: 1. 4-202.16 Nonfood-Contact Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. Well-designed equipment enhances the ability to keep nonfood-contact surfaces clean. 2. 4-602.13 Nonfood-Contact Surfaces. 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. 3. 5-402.10 Establishment Drainage System. The drainage system must be designed and installed properly to prevent the backup of sewage and the possible contamination of foods or food-contact surfaces in the establishment. 4. 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. It may also adversely affect the operation of equipment such as warewashing machines. 5. 4-202.16 Nonfood-Contact Surfaces .shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 6. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . Nonfood -Contact Surfaces of Equipment, shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a review of the facility's P&P titled, SANITATION, from RDs for Healthcare, Inc. 2018, indicated, All equipment shall be maintained as necessary and kept in working order and replaced as necessary. The policy did not specify how to sanitize the kitchen. B. Food was not stored properly as evidenced by: 1. Large box of thickener was not sealed. 2. Dented cans. 3. Lid of bin to potatoes dirty. 4. Pan of margarine exposed to dust from pipe above. 5. Opened food containers: 1 box of instant mashed potatoes, 2 boxes of uncooked, dried cereal. 6. Food not covered: thawing fish 7. Food not covered: uncooked rolls and cooked brownies. The kitchen was not sanitary as observed with: 1. Dirty vent and fan from cooler in dry food storage room. 2. Kitchen towels/rags used to sanitize kitchen food preparation surfaces - stained and discolored. 3. Tape dispenser dirty. 4. Upper kitchen cabinets, dirty, inside and out. Hinge on cabinet door broken. Paint peeling on shelves. 5. Drawer containing dirty, hand appliances. 6. Multiple dirty equipment in the kitchen: bottom of racks, refrigerator, freezer, garbage disposal. An upright 2 metal pipe coming up through the floor, with debris. 7. Juice dispenser area, dirty with sticky substance on shelves and cabinet doors where juice was stored, on nozzles of the juice dispenser and around the juice machine. 8. Metal cabinet in juice dispensing area, paint peeling on shelves. 9. Dirty industrial can opener. 10. Electrical junction boxes behind the toaster with dust and debris. 11. Electrical switch cover and switches dirty. 12. 2 Fire alarm boxes above the handwashing sink and flexible conduit with fuzzy gray substance all over the surface. 13. Foot stool and garbage can dirty. 14. Mechanical area between the oven and stove, dusty and dirty. [MEDICATION NAME] pipe above stove dirty. 15. Dirty drawer in tray line area. 16. Pans stacked wet. 17. Pans stacked that were still dirty. 18. Small metal serving cups stacked wet. 19. Proper sanitation procedure in the 3 compartment sink. The following defective or worn equipment were noted in the kitchen: 1. Rubber spatulas, broken and cracked. 2. Metal vegetable strainer discolored. 3. Plastic cutting boards, scratched and edge peeling. 4. Large knives in drawer with dirty handles. 5. 3 frying pans, warped, discolored and inner coating scratched and peeling. 6. Can opener - outer coating peeling of at the blade. 7. White storage bins, outer containers scratched and dirty. 8. Scale for ounce weights was not working. There were no air gap at the 2 food preparation sinks in the kitchen as well as the ice maching in the memory unit. There were undated/labeled food stored in cupboards and small appliances and bottled water stored under the sink in the dining room. Refrigerators in the nursing units were not monitored correctly. All of the above observations were confirmed by the facility's kitchen staff during the survey days.

Based on observation, interview, and record review, the facility failed to implement their prevention of pressure ulcers (injury to the skin and the underlying tissue resulting from prolonged pressure on the skin) policy including evaluating and assessing the residents' clinical conditions, implementing interventions, and monitoring and evaluating the impact of the interventions to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Residents 1, 2, and 3). These deficiencies resulted in the further development of pressure sores and other injuries. Findings: 1. Resident 1's clinical record was reviewed and indicated he was admitted in 2/2017 for rehabilitation following spinal surgery. His Minimum Data Set (MDS, an assessment tool), dated 2/17/17, indicated he was incontinent (insufficient control) of urine and feces and had [MEDICAL CONDITION] (a disorder of the central nervous system affecting movement and often including tremors). His admission assessment did not indicate he had any pressure sores. Resident 1's Wound Assessment Report, dated 2/17/17, indicated he had a moisture related excoriation (abrasion or wearing off of the skin) on his coccyx (tailbone) measuring 8 centimeters (cm, unit of measurement) in length and 5 cm in width with a small amount of serosanguinous drainage (drainage composed of plasma and blood). His nurses' notes, dated 2/17/17, indicated he was subsequently seen by a nurse practitioner (NP) later the same day who staged (classified) the open area on his buttocks as a Stage II (presents as an abrasion, blister or shallow crater) pressure ulcer. The facility's 24 Hour Reports (reports completed each shift to monitor nursing home residents and documenting any changes in the residents' status), dated 2/17/17, 2/18/17, and 2/19/17 indicated there was no documentation regarding Resident 1's pressure sore. The nursing notes, dated 2/18/17, 2/19/17, and 2/20/17 did not document any further assessments of his pressure sore and any evaluation of the impact of the interventions. Resident 1's physician progress notes [REDACTED]. His right buttock had a Stage II pressure ulcer and his left buttock had an unstageable deep tissue injury (injury to tissues under the skin) with a larger area of non-blanchable [DIAGNOSES REDACTED] (intact skin with redness in a localized area not affected by light finger pressure). Resident 1's Wound Assessment Report, dated 2/21/17, indicated he had a deteriorated pressure ulcer on his coccyx measuring 8 cm in length by 6 cm in width. His nurses notes, dated 2/21/17, indicated a physician reassessed his pressure sore and determined the wound was unstageable because the base of the ulcer was covered by eschar (dark patch of dead skin on the wound surface). Resident 1's laboratory tests, dated 2/22/17, indicated he had an infection. He was started on antibiotics. Resident 1's nurses notes, dated 2/23/17, indicated he had an 0.1 cm by 0.1 cm open area draining 120 cubic centimeters (cc, unit of measurement) of fluid, in addition to the pressure sore. His physician progress notes [REDACTED]. He was transferred to the acute hospital for further evaluation. Resident 1's hospital records, dated 2/23/17, indicated he was taken to the operating room for debridement (removal of damaged tissue) from the buttock wound. On 2/24/17, he returned to the operating room for further debridement. On 2/25/17, he returned again to the operating room for an incision and drainage (minor surgical procedure to release pus or pressure build up under the skin) of a perianal abscess (a collection of pus around the anus) and a [MEDICAL CONDITION] (a surgical operation in which a piece of the intestine is diverted to an artificial opening in the abdomen to bypass the damaged portion of the intestine). During an interview on 3/7/17, at 12:45 p.m., with the director of nurses (DON), she stated Resident 1 had back surgery and was admitted to the facility for rehabilitation. She stated he was up and walking with physical therapy and could walk to the bathroom. During an interview on 3/7/17, at 2:25 p.m., with certified nurse assistant A (CNA A), she stated she provided care for Resident 1 on 2/11/17, 2/12/17, 2/17/17, and 2/18/17. She stated on 2/11/17 and 2/12/17, the skin on Resident 1's buttocks was fine. She stated on 2/17/17, she noted a purple discoloration around his rectum. CNA A stated she called her supervisor, the treatment nurse, and the case manager. She stated the treatment nurse applied some cream. During an interview on 3/7/17, at 2:35 p.m., licensed vocational nurse B (LVN B) stated she was the supervisor CNA A called after the purple discoloration was noted on Resident 1's buttocks. She stated she thought Resident 1 had an excoriation around his anus. She stated she called the treatment nurse and the NP. LVN B stated the NP thought he had a Stage II pressure ulcer. LVN B stated Resident 1's physician came in a few days later and said he had a Stage II pressure ulcer on the right buttock and a deep tissue injury on the left buttock. She stated a few days after the physician diagnosed the pressure ulcer and the deep tissue injury, the treatment nurse asked her to look at Resident 1's buttocks. LVN B stated she observed a boil (painful, pus-filled bump under the skin) on his scrotum which was draining fluid in addition to the pressure sore and the deep tissue injury. She stated she called the case manager who called the physician. During an interview on 3/7/17, at 2:45 p.m., with CNA C, she stated she provided care for Resident 1 on 2/13/17, 2/14/17, 2/15/17, and 2/19/17. She stated he walked to the bathroom by himself and on 2/13/17, when she was helping him clean up, she noted he had redness on his buttocks. She stated she reported her findings to the charge nurse, registered nurse D (RN D). She stated she did not know what the RN did after she made her report. During an interview on 3/7/17, at 2:55 p.m., with LVN E, she stated she was one of the treatment nurses who are LVNs. She stated as a LVN, she provided treatment but she did not assess or describe the wound. She stated the RNs were supposed to assess the wound every shift for 72 hours after the resident had a change in condition. She stated the discovery of Resident 1's pressure sore on 2/17/17 was a change of condition and there should have been an assessment every shift for the next 72 hours. She reviewed Resident 1's clinical record and stated there were no assessments of Resident 1's pressure sore between 2/17/17 and 2/21/17 and no evaluation of the impact of the interventions. During an interview on 3/17/17, at 1:05 p.m., with LVN F, she stated she was one of the treatment nurses. She stated she performed Resident 1's initial skin assessment when he was admitted and she did not see any discoloration or pressure sores on his buttocks. She stated she was asked to see Resident 1 on 2/17/17 and she saw an excoriation on his buttock. She stated the charge nurse called the case manager and Resident 1 was seen by the NP who thought the resident had a Stage II pressure sore. LVN F stated when a resident has a change of condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours. She reviewed the clinical record and stated there was no charting regarding Resident 1's pressure sore for the next three days. During an interview on 3/17/17, at 1:55 p.m., RN D stated she was the nurse who provided care for Resident 1 from 2/12/17 through 2/15/17 and on 2/18/17 through 2/21/17 on the day shift. She stated she has no recollection of anyone telling her Resident 1 had redness on his buttocks on 2/14/17. She also stated she has no recollection of anyone telling her he had a Stage II pressure ulcer on his buttocks on 2/18/17, 2/19/17, and 2/20/17. She stated when a resident has a change in condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours. She stated she did not assess his pressure sore from 2/18/17 through 2/20/17, because she did not know he had a pressure sore. She also stated there was no documentation on the 24 Hour Report indicating Resident 1 had a pressure sore until 2/20/17. During an interview on 3/17/17, at 2:20 p.m., with the director of staff development (DSD), she stated when a resident has a change in condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours and the information regarding the change of condition should be documented on the 24 Hour Report. She reviewed the 24 Hour Reports from 2/17/17 through 2/20/17 and stated there was no documentation indicating Resident 1 had a pressure sore until 2/20/17. 2. Resident 2's clinical record was reviewed and indicated she was admitted in 2/2017 following a cerebral infarction (a lack of blood flow resulting in severe brain damage) with left sided [MEDICAL CONDITION] (paralysis), a [MEDICAL CONDITION] (a tube inserted in her windpipe to open a restricted airway and enable breathing), a gastrostomy tube (a tube inserted through the abdominal wall into the stomach for the infusion of nutrition and medications), and an indwelling catheter (a tube inserted into the bladder to drain urine). Her initial assessment indicated she was incontinent. No discoloration on her buttocks was noted. A physician order, dated 2/9/17, indicated a barrier cream was to be applied to Resident 2's buttocks every shift as a preventive measure. Her Treatment Administration Record (TAR) indicated the barrier cream was applied only once a day. Resident 2's nurses note, dated 2/16/17, indicated she had an excoriation on her left buttock with no bleeding or drainage noted. Her Wound Assessment Report, dated 2/16/17, indicated the excoriation was 4 cm by 3 cm and red. Resident 2's nurse's note, dated 2/23/17, indicated the excoriation on her buttock was reassessed and was healing well. Her Wound Assessment Report, dated 2/23/17, indicated her excoriation was 4 cm by 2.7 cm. Resident 2's nurse's note, dated 3/2/17, indicated the excoriation on her buttocks increased in size and the drainage remained the same. Her Wound Assessment Report, dated 3/2/17, indicated her excoriation was 5 cm by 4 cm and had increased in size. Resident 2's nurse's note, dated 3/9/17, indicated the excoriation on her buttocks increased in size and scant sanguineous drainage (fresh blood) was noted. Her Wound Assessment Report, dated 3/9/17, indicated her excoriation was 7.3 cm by 5 cm and the size and the amount of drainage had increased. Resident 2's nurse's note, dated 3/16/17, indicated the DON reassessed the left coccyx wound and noted the 8 cm by 8 cm wound was a suspected deep tissue injury due to a rapid deterioration of the wound with 50% granulation (indication healing taking place) and 50% eschar tissue. Her Wound Assessment Report, dated 3/16/16, indicated she had an unstageable 8 cm by 8 cm pressure sore. The pressure sore was unstageable due to slough (yellow nonviable tissue) and eschar. Resident 2's nurses notes for the 72 hours after the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift. The nurses notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours. The nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed. During an interview on 3/17/17, at 2:30 p.m., with the director of staff development (DSD), she reviewed Resident 2's chart and stated there was an order to apply a barrier cream to the resident's buttocks every shift for preventative measures starting 2/9/17. She stated the documentation in the chart indicated the cream was only applied once a day and not every shift. She also stated when a resident has a change in condition, the RN on each shift should chart an assessment of the excoriation or pressure sore for the next 72 hours. She confirmed the nurses notes for the 72 hours after the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift; the nurses notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours; and the nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed. 3. Resident 3's clinical record was reviewed and indicated he was admitted in 2/2017 following a left total knee revision due to an infected total knee arthroplasty (surgical reconstruction or replacement of a joint). His initial assessment did not indicate he had any pressure ulcers on his heels. Resident 3's nurses notes, dated 2/9/17 through 2/27/17, indicated he had a foot cradle (a wire frame raising sheets, blankets, and covers up above the users feet, keeping the weight off the lower legs and feet) in place. On 2/27/17, his nurses notes indicated he was seen by his physician because his right foot was irritated by the foot cradle and some blanchable redness (loss of all redness when pressed) was noted on his heel. The foot cradle was removed and a longer bed was requested to accommodate his height. Resident 3's nurses notes, dated 2/28/17, indicated he was seen by a NP who assessed his right heel and noted a suspected deep tissue injury. His physician order, dated 2/28/17, indicated he was to wear heel protectors while he was in bed. During an observation on 3/17/17, at 2:50 p.m., Resident 3 was sitting up in bed reading. He was dressed in a hospital gown with a blanket over his legs but not his feet. His feet were exposed and he was not wearing any heel protectors. During an interview and observation on 3/17/17, at 3 p.m., RN D confirmed Resident 3 was not wearing any heel protectors. She stated he was supposed to wear heel protectors while he was in bed. Review of the facility's 2001 policy, revised in 10/2010, Prevention of Pressure Ulcers, indicated a timely assessment should be performed and pressure sores are made worse by continual pressure, moisture, and irritating substances on the resident's skin such as feces and urine. A change in the condition of the pressure sore should be recognized, evaluated, reported to the physician, and addressed timely. The condition of the resident's skin should be routinely assessed and documented and signs of a developing pressure ulcer should be immediately reported to the supervisor. Efforts should be made to stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Causes of moisture should be addressed, skin should be protected by a skin barrier, and heels should be protected with devices prescribed by the physician.

Based on interview and record review, the facility failed to ensure medication was administered as prescribed for one (Resident A) of one sampled resident. For Resident A, an excessive amounts of diabetic medication (insulin) were received, resulting in a clinically evident overdose of the diabetic medications, and Resident A was transferred to a hospital emergency department service. Findings: Resident A was admitted on [DATE] with [DIAGNOSES REDACTED]. The 01/23/12 Minimum Data Set (MDS, a resident assessment) indicated Resident A was able to understand others and to express his ideas and needs; Resident A needed extensive assistance for transfer from a bed to a chair, dressing, toilet use, and bathing; Resident A used a walker with total dependence of the staff assistance or a wheelchair for mobility. On 03/15/12 at 7:10 a.m., Resident A received a clinically evident overdose of diabetic medications (Insulin NPH ([MEDICATION NAME] N) and Insulin [MEDICATION NAME] ([MEDICATION NAME])). Nurse A had administered 100 units (u) of a diabetic medication (Insulin NPH) instead of 14 units. Nurse A also administered 100 units of another diabetic medication (Insulin [MEDICATION NAME]) instead of six (6) units. Resident A was treated with orange juice (OJ) and one milligram (1 mg) injection of a sugar substance ([MEDICATION NAME]) intramuscularly (IM, into the muscle) to raise blood sugars. Resident A was then sent to an acute care hospital emergency department (ED) and then later transferred to the hospital intensive care unit (ICU) for another day. During an interview on 03/07/13 at 12:08 p.m., Nurse A stated she had administered 100 units of a diabetic medication (Insulin [MEDICATION NAME]) instead of six units; and 100 units of another diabetic medication (Insulin NPH) instead of 14 units. Nurse A also stated that she had confused the concentration (100 u/ml (milliliter) with the dose. She said that it was the first week she had worked by herself and she had two weeks training after taking over a year off. During an interview on 03/07/13 at 1:00 p.m., Director of Nursing (DON) stated she had no documentation on a policy and procedures (P&P) for administration of the diabetic medication (insulin) and/or training and evaluation of the staff member's ability to administer the diabetic medication. Record review of Resident A's physician's orders [REDACTED]." Record review of Resident A's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident A's Nurses Progress Notes, dated 03/15/12 at 9:50 a.m., Nurse A documented, "I gave patient 100 units of [MEDICATION NAME] N 100 u/ml instead of 14 units and 100 units of [MEDICATION NAME] 100 u/ml instead of 6 units at 7:10 a.m. Patient given 2 cups of OJ (orange juice) blood glucose at 7:30 a.m. was 106 (Reference value was 70-110 mg/dL (deciliter or 100 ml). Given 1 cup OJ with sugar. Blood glucose at 7:55 a.m. was 82. Given 1 cup OJ with sugar. Blood glucose at 8:30 a.m. was 101. Given 1 cup of sugar. Blood glucose at 9 a.m. was 101. Blood glucose at 9:30 a.m. was 112. Pt Alert, verbally responsive, says he feels wheezy from drinking so much OJ ...will continue to monitor patient." Review of Resident A's nurses progress notes, dated 03/15/12 at 11:00 a.m., indicated, "Ambulance came and transported resident to Kaiser hospital at Santa Clara, via gurney accompanied by staff member, at 10:19 a.m. IM [MEDICATION NAME] given to pt as ordered to L (left) upper arm ...says he feels "wheezy" from drinking orange juice ..." Review of Resident A's telephone contact summary (documented calls to physician or nurse practitioner (NP)), dated 03/15/12 at 10:24 a.m., indicated, "Please call...ED to arrange for Transfer ...Reason for Transfer: Was to get [MEDICATION NAME] N 14 units and [MEDICATION NAME] 6 units-was given 100 units of each-FS (finger stick) at 10:00 am 90 ...SNF (skilled nursing facility) nurse ...will monitor closely till ambulance arrives...03/15/12 10:09 AM ...Spoke with NP and patient also to be given 1 mg of [MEDICATION NAME] IM stat (immediately) and will send patient in to the hospital for frequent monitoring of blood sugars ...03/15/12 at 9:41 AM ...SNF nurse ...states pt should get [MEDICATION NAME] N 14 units and [MEDICATION NAME] 6 units-she gave 100 units of each ...NP give 3 glasses of OJ with sugar now-then 1 glass with sugar q (every) 1 hr x 4 hrs-give pt hard candy ...Call 911 with acute changes." Review of Lexicomponline.com:(<http://www.lexicomponline.com/lco/action/doc/retrieve/docid/patch_f/ 1...04/02/2013>; copyright (c ) Lexi-Comp, inc. 2013) information for insulin indicated concerns for adverse effects included: [DIAGNOSES REDACTED] (low blood sugar): The most common adverse effect of insulin is [DIAGNOSES REDACTED]. The timing of [DIAGNOSES REDACTED] differs among various insulin formulations. [DIAGNOSES REDACTED] may result from increased work or exercise without eating ...Profound and prolonged episodes of [DIAGNOSES REDACTED] (adverse effects of low blood sugar) may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death. ..The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Review of Resident A's hospital history and physical note in the emergency department (ED), dated 03/15/12 at 12:03 p.m., indicated, "Accidentally getting 100 units of NPH and 100 units of regular insulin at ...SNF ...insulin overdose, accidental/major ...FSG (finger stick glucose) 60s (low blood sugar)...discharge Diagnosis: [REDACTED]. Review of Resident A's hospital history and physical note in ICU, dated 03/15/12 at 2:00 p.m., indicated, "Accidentally given 100 u of insulin NPH ...blood sugar checks are around 48-66 at this time in the ED. One Mg (milligram) [MEDICATION NAME] given at SNF ...monitor FSBG (finger stick blood glucose) every hour, continue at D10gtt (10% [MEDICATION NAME] drip, a sugar liquid) at 75/hr. If consistently BS (blood sugar) over 150 start [MEDICATION NAME] sliding scale. Expect NPH to act for at least 18 hours." Review of Resident A's hospital critical lab values on 03/15/12 and 03/16/13 indicated the following: On 03/15/13 at 2:30 p.m., FS=63 (low blood sugar); at 5:00 p.m., FS=49 (low blood sugar); at 5:21 p.m., FS=112 (excessive blood sugar); on 03/16/13 at 11:47 a.m., FS=409 (excessive blood sugar). Review of Resident A's hospital discharge summary, dated 03/23/12 at 9:47 a.m., indicated "Date of admission..03/15/12 ...Date of discharge 03/23/12 ...Hospital course and significant findings...was given per report 100 units of NPH & 100 [MEDICATION NAME] at SNF and found to have sugars 40-60s (low blood sugar)."