Every finding on record at Pacific Hills Post Acute

Based on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for pharmacy services overview for supply of prescribed medications (any substance used to diagnose, treat, relieve, or prevent diseases, and requires a written or verbal order from a licensed healthcare professional to be legally dispensed) were available to administer for one of two sampled resident (Resident 1).Above this failure had the potential to affect Resident 1's medical condition and well-being. Findings:Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility initially on 1/25/2026 and readmitted to facility on 6/11/2026. Review of Resident 1's diagnoses included hypertensive heart disease with heart failure (a condition occurs when unmanaged high bold pressure [force of blood pushing against blood vessel walls consistently high] force heart muscle to thicken and strain) and acute pulmonary edema (a serious health condition caused by an abnormal buildup of excess fluid in the lungs [a pair of spongy organs in the chest, responsible for air exchange).Review of Resident 1's order summary report indicated an order for chlorthalidone (medication to treat high blood pressure and reduce excess fluid retention) 25 mg (milligrams, a unit of mass, equal to one thousandth of a gram), 1.5 tablet via PEG-Tube (a flexible feeding tube placed directly into abdominal wall in to stomach to deliver medications and liquid nutrition) one time a day for hypertension (HTN, high blood pressure), dated 6/11/2026.Review of Resident 1's order summary report indicated an order for hydralazine (medication to treat HTN) 50 mg, 1.5 tablet via PEG-Tube four times a day for HTN, dated 6/11/2026. An order for labetalol (a medication to treat HTN) 200 mg via PEG-Tube two times a day for HTN, dated 6/11/2026. Another order for amlodipine (medication to treat HTN and prevent chest pain)10 mg via PEG-Tube one time a day for HTN, dated 6/11/2026 and lisinopril (a medication to treat HTN by relaxing and widening blood vessels to lower blood pressure) 5 mg via PEG-Tube one time a day for HTN, dated 6/11/2026.Review of Resident 1's electronic medication administration record (EMAR, a digital version used by healthcare professionals to schedule, track and document medications administration to residents) for June 2026 indicated on 6/12/2026 at 9:00 a.m., medication amlodipine, chlorthalidone, lisinopril, labetalol not administered due to pending delivery of medications from pharmacy. Medication hydralazine not administered on 6/12/2026 at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m., due to pending delivery of medications from pharmacy.Review of document for shipping manifest pharmaceuticals from facility's consulting pharmacy (a health science and profession, responsible to prepare, dispense and monitoring of medications for residents in facility) dated 6/12/2026 indicated medications amlodipine and lisinopril were delivered to facility on 6/12/2026 at 1:21 p.m. Medications chlorthalidone and hydralazine were delivered on 6/12/2026 at 9:51 p.m. No documented evidence of medication labetalol delivery to facility.During an interview with licensed vocational nurse A (LVN A) on 6/16/2026 at 1:27 p.m., LVN A confirmed unable to administered above medications on 6/12/2026 as ordered for Resident 1 on 6/12/2026. LVN A stated facility did not receive medications from pharmacy to administer to Resident 1 on 6/12/2026. LVN A also stated pharmacy should have delivered medications to administer on 6/12/2026 for Resident 1. During an interview with facility's director of nursing (DON) on 6/16/2026 at 2:40 p.m., DON stated above all medications should have available for license nurse (LN) to administer as ordered for Resident 1 on 6/12/206. DON also stated consultant pharmacy should have delivered medications to facility when Resident 1 readmitted and communicated with pharmacy to dispense on 6/11/2026. Review of facility's P&P titled, Pharmacy Services Overview, revised April 2019, the P&P indicated, Pharmacy services are available to residents 24 hours a day, seven days a week. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.

Based on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for hospice program (a specialized medical care and support for residents with a terminal illness who have an estimated life expectancy of six months or less) and nursing facility service agreement for one of three sampled resident (Resident 1) when: No documented evidence for coordinated plan of care between facility and hospice provider (a specialized healthcare organization that provides hospice care) for Resident 1. Above this failure had potentially affected person-centered plan of care (individual care, treatments, and goals to resident's cultural, personal values, and lifestyle), health, and psychosocial well-being for Resident 1. Findings:Review of Resident 1's face sheet (FS, a document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on [DATE] and expired in facility on [DATE].Review of Resident 1's FS also indicated Resident 1 was self-responsible for decision making while in facility.Review of Resident 1's minimum data set (MDS, resident assessment tool) assessment dated [DATE] indicated brief interview for mental status (BIMS) score of 13/15 (score of 0-7, severely impaired cognition, 8-12, moderately impaired cognition, 13-15, intact cognition).Review of Resident 1's order summary report indicated an order for refer to hospice evaluation dated [DATE].Review of physician (medical doctor, a licensed healthcare professional trained to diagnose and treat medical conditions)'s order dated [DATE] indicated admit to hospice care with diagnosis of cerebral atherosclerosis (a condition of narrowing and hardening of arteries [blood vessels that carry blood from heart to body tissues] of the brain [the body's central command center], that restricts blood flow, causes serious medical conditions).Review of Resident 1's nursing progress notes, dated [DATE] indicated, Resident 1 was placed on hospice care.Review of a document from hospice provider for Resident 1 indicated, admit date [DATE], diagnosis of cerebral atherosclerosis. This document also indicated nurse, social worker (trained professional dedicated to help resident and families to cope with end of life challenges), chaplain (a religious support for emotional, moral and spiritual care), and nurse aide (a healthcare professional who provides basic bedside care to resident) scheduled visit information left blank and incomplete.Review of Resident 1's hospice provider's document titled, Coordinated Care Plan for Facility Patients, indicated, coordinated care between hospice provider and facility left blank, not completed. This document also indicated plan of care and coordination not reviewed and signed by Resident 1, facility staff, and hospice staff. Review of Resident 1's nursing progress notes dated [DATE] indicated, Resident 1 expired at 9:00 a.m. During an interview with licensed vocational nurse A (LVN A) on [DATE] at 2:45 a.m., LVN A stated increased risk of confusion for facility's nursing staff for meeting resident's care needs and addressing medical condition if there was no documented care coordination between facility and hospice provider.During a concurrent review of Resident 1's hospice provider's document for coordinated care plan and interview with facility's director of nursing (DON) on [DATE] at 3:10 p.m., DON confirmed there was no documented care coordination between facility and hospice provider for Resident 1. DON stated above document not completed, left blank. DON also stated hospice provider's staff should have completed care coordination document, reviewed with facility staff and Resident 1 when admitted Resident 1 under their care. DON further stated facility staff should have verified for completion of this document to provide plan of care between facility's staff and hospice provider's staff for Resident 1.During an interview with facility's administrator (ADMN) on [DATE] at 3:16 p.m., ADMN stated hospice provider should have completed documentation for care coordination between facility and hospice provider and reviewed with resident and facility's staff before admitted Resident 1 to hospice care.Review of facility's P&P titled, Hospice Program, revised [DATE], the P&P indicated, Hospice providers who contract with this facility:must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency. Collaborating with hospice representative and coordinating facility staff participation in the hospice care planning process for residents receiving these services.Review of facility's contract with hospice provider titled, Nursing Facility Service Agreement, dated [DATE], this contract indicated, Coordination of Care.2.4.2 Design of Plan of Care. In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice patient. Hospice retains primary responsibility for development of the plan of care.

Based on interview, and record review, the facility failed to ensure to schedule, conduct, and document interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) care conference with resident/resident's representative (RP, an individual chosen by resident to act on behalf of resident for day today and healthcare decision making for resident) for four out of four sampled residents (Resident 1, 2, 3, and 4) when:There was no documentation for initial and quarterly IDT care conference for Resident 1;There was no documentation for initial IDT care conference for Resident 2; There was no documentation for quarterly IDT care conferences for Resident 3;There was no documentation for quarterly IDT care conferences for Resident 4.This failures had the potential for lack of opportunity for resident/ RP's right to participate in development and implement person-centered (individual care, treatments, and goals to resident's cultural, personal values, and lifestyle) plan of care decisions for Resident 1, 2, 3, and 4.Findings:1.Review of Resident 1's face sheet (FS, a document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on 1/25/2026. Review of this FS also indicated Resident 1 was assigned a significant family member (SFM) as Resident 1's RP.Review of Resident 1's minimum data set (MDS, resident assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS) score of 10/15 (score of 0-7, severely impaired cognition, 8-12, moderately impaired cognition, 13-15, intact cognition), moderately impaired cognition.Review of Resident 1's clinical documentation indicated there was no documented evidence for initial or quarterly IDT care conferences were scheduled or conducted with Resident 1's RP.During an interview with the MDSC on 5/12/26 at 1:17 p.m., the MDSC stated facility's social service department was responsible to schedule, conduct, and document initial and quarterly IDT care conference with resident/resident's RP.During an interview with facility's social service director (SSD) on 5/12/2026 at 1:40 p.m., SSD confirmed there was no documented evidence for initial and quarterly IDT care conferences were scheduled and conducted with Resident 1's RP. SSD stated social service department should have scheduled and conducted initial and quarterly IDT care conferences with Resident 1's RP to facilitate open communication and discuss plan of care for Resident 1.2. During an interview with Resident 2 on 5/18/2026 at 12:50 p.m., Resident 2 stated facility staff did not arrange or invite to attend care conference after admitted to facility. Resident 2 also stated her SFM requested a meeting today (5/18/2026) with facility team to discuss some concerns. Resident 2 further stated her SFM requested this meeting, not initiated by facility.Review of Resident 2's FS indicated Resident 2 was admitted to facility on 4/23/2026. Review of this FS also indicated, Resident 2 self-responsible for daily decision making.Review of Resident 2's MDS assessment dated [DATE] indicated, Resident 2's BIMS score of 15/15, intact cognition.Review of Resident 2's clinical documentation indicated, there was no documented evidence for initial IDT care conference scheduled or conducted for Resident 2.During an interview with facility's SSD on 5/18/2026 at 1:20 p.m., SSD confirmed there was no documented evidence for initial IDT care conference scheduled and conducted for Resident 2 after admitted to facility on 4/23/2026. SSD stated Resident 2 should have completed initial care conference to discuss plan of care needs. SSD also said IDT care conference scheduled for today (5/18/2026) with Resident 2 and her SFM.3. Review of Resident 3's FS indicated Resident 3 was admitted to facility on 7/17/2025. Review of this FS also indicated, Resident 3 was assigned a SFM as Resident 3's RP.Review of Resident 3's MDS assessment dated [DATE] indicated Resident 3's BIMS score of 7/15, severely impaired cognition. Review of Resident 3's clinical documentation indicated, there was no documented evidence for quarterly IDT care conferences scheduled or conducted with Resident 3's RP after admitted to facility on 7/17/2025.During an interview with facility's SSD on 5/18/2026 at 1:29 p.m., SSD confirmed there were no quarterly IDT care conferences scheduled or conducted with Resident 3's RP for Resident 3. SSD stated social service department should have scheduled and conducted quarterly IDT care conferences to discuss plan of care with RP for every quarter.4. Review of Resident 4's FS indicated Resident 4 was admitted to facility on 12/17/2024. Review of this FS also indicated Resident 4 was assigned a SFM as Resident 4's RP.Review of Resident 4's MDS assessment dated [DATE], staff assessment for mental status indicated, Resident 4 had short term memory problem (inability to retain and recall recent information or events) and long term memory problem (inability to retain or recall information for an extended period). Review of Resident 4's clinical documentation indicated there was no documented evidence for quarterly IDT care conferences scheduled or conducted with Resident 4's RP after Resident 1 admitted to facility on 12/17/2024. During an interview with facility's SSD on 5/18/2026 at 1:32 p.m., SSD confirmed there was no documented evidence for quarterly IDT care conferences scheduled or conducted with RP for Resident 4. SSD stated social service staff should have scheduled, discussed plan of care, and documented for Resident 4 for each quarter.During an interview with facility's administrator (ADMN) on 5/18/2026 at 2:33 p.m., ADMN stated facility's SSD responsible to schedule, conduct, and document initial and quarterly IDT care conferences for all residents in the facility. ADMN also stated SSD should have scheduled and completed initial IDT care conference within 72 hours after admission and every quarter thereafter for residents. ADMN further stated potentially missing open communication and discussing plan of care with resident/resident's RP if facility did not do IDT care conferences.Review of facility's policy and procedure (P&P) titled, Interdisciplinary Team meeting Policy, created date 4/21/2025, the P&P indicated, a. IDT meetings shall occur: i.Upon admission for initial care planningii. Quarterly in conjunction with required assessmentsa. Documentation shall include but not be limited to:i. Date of meetingii. Participantsiii. Issues discussediv. Care plan updates (if applicable)v. Follow -up actions (if applicable)b. Documentation shall be maintained in the resident's medical record in accordance with facility policies and regulatory requirements.Review of facility's P&P titled, Director of Social Services, revised July 2024, the P&P indicated, Participate in care planning meetings and help develop goals and objectives addressing each resident's identified problems and needs.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when:1. Staff incorrectly tested the Quaternary sanitizer solution; and,2. Staff performed incorrect thermometer calibration These failures had the potential to negatively impact the nutrition and health status of the facility's 95 residents.Findings:1. During a concurrent observation and interview on 12/4/25, at 9:30 a.m., with Dietary Aide (DA) K, in the kitchen, DA K demonstrated testing of the strength of the quaternary (chemicals used in cleaners because of their antiviral and antibacterial properties) sanitizing solution in the red bucket by immersing a chemistry test strip into a red bucket filled with the sanitizing solution, for about 5 seconds. When DA K was asked how long the test strip should stay in the solution to test the strength, DA K stated, A few seconds. DA K compared the test strip to the color-coded graph on the chemistry test strip container (measures the concentration of sanitizer in solution), and stated, It's zero but should be 150. The color of the chem strip indicated zero PPM (parts per million) when compared to the graph on the container.During a concurrent observation and interview on 12/4/25, at 10:15 a.m., DA L filled another red bucket with sanitizing solution located in the kitchen. DA L proceeded to use a different chem strip to test the solution, and DA L stated, It's between 150-200. DA L stated DA K used the wrong test strips to test the sanitizing solution in the red bucket.During an interview on 12/4/25 at 10:18 a.m. with the Registered Dietitian (RD), The RD stated DA K received an in-service on sanitizer testing upon hiring one month ago and should know the proper technique and equipment to use when testing the sanitizer used in the kitchen. A review of the manufacturer's guidance indicated when using the quaternary test strips to check the concentration, typically 150-400 ppm for food safety, dipping times should be 10 seconds followed by immediate color matching to the chart. A review of the facility's Policy and Procedure (P&P) titled, Sanitization, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner . 9. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration.A review of the facility's P&P titled, Food Preparation and Service, revised November 2022, indicated, Food Preparation Area. 4. Appropriate measures are used to prevent cross-contamination. These include: . c. sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution (at concentrations specified by the manufacturer of the solution used).2. During an observation 12/5/20 at 10:20 a.m., [NAME] (CK) M demonstrated thermometer calibration. CK M took a medium sized clear plastic cup and filled it with ice and water, then placed four thermometers inside the cup with the tips of the thermometers visibly touching the bottom of the cup and two thermometers resting along the side of the cup. CK M then proceeded to check the thermometer temperature readings.During an interview on 12/4/25 at 10:25 a.m. with the RD, the RD stated, She should know, she's the cook. And proceeded to conduct an on the spot in-service with CK M regarding thermometer calibration.Review of the USDA recommendation for thermometer calibration dated March 2025 indicated, Ice Water Method: Prepare: Fill a glass with crushed ice and cold water. 2. Immerse: Place the thermometer stem at least 2 inches deep, ensuring it doesn't touch the bottom or sides.Review of the facility's P&P titled, Food Preparation Service, revised November 2022, indicated, .5. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy.

Based on observation, interview, and policy review, the facility failed to ensure medications were stored and labeled appropriately when medications were found past their discard date in Station 3 and Station 4 medication carts. This failure resulted in expired medications being administered to the residents.Findings:1. On 12/1/25, at 11:05 a.m., during an observation of Station 3 medication cart with licensed vocational nurse F (LVN F), one Artificial Tears (eye drops used to lubricate dry eyes) bottle for the resident in room [ROOM NUMBER]B was labeled as opened on 9/25/25 and one Refresh Tears (lubricant eye drops) bottle for the resident in room [ROOM NUMBER]A was labeled opened on 10/16/25 were found in active use areas within the medication cart. 2. On 12/1/25, at 11:20 a.m., during an observation of Station 4 medication cart with licensed vocational nurse E (LVN E), the following were found:a. One bottle of latanoprost 0.005% (used to lower high pressure inside the eye) for Resident 61 labeled discard on 11/9/25.b. One bottle of latanoprost 0.005% for Resident 97 labeled discard after 11/3/25.c. One bottle of olopatadine Hcl 0.2% (used to treat allergies in the eyes and nose) for Resident 83 labeled discard on 11/30/25.d. One Artificial Tears bottle for the resident in room [ROOM NUMBER]A labeled discard on 10/25/25.e. One Artificial Tears bottle for the resident in room [ROOM NUMBER]A had no open date.f. One Refresh Tears bottle for the resident in room [ROOM NUMBER]C labeled open on 9/15/25.g. One Refresh Tears bottle for the resident in room [ROOM NUMBER]A labeled open on 9/28/25.h. One Systane Zaditor (used to relieve itchy allergy eyes) bottle labeled open on 10/21/25 and had no resident name or room number on it.During a concurrent interview with LVN E, she stated eye drop medication should be labeled with resident name, room number, open date and should be discarded 30 days after it was opened.Review of the facility's policy, Medication Labeling and Storage, dated 2/2023, indicated . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to ensure their policy and procedures (P&P) for advance directives (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) were followed for five of nine sample residents (Residents 1, 23, 123, 57, and 97) when there was lack of evidence advance directives were discussed and/or carried out with them. These failures could lead to the delivery of medical services against residents' goals and wishes.Findings: Review of Resident 1's admission Record (summary page of a patient's important information) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's clinical record indicated there was no advance directive. Review of the social services notes indicated there was no documentation that the facility verified, offered, assisted, or obtained an advance directive for Resident 1. Review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives) form dated 10/27/25 indicated, section D, No Advance Directive was selected. Review of Resident 23's admission Record indicated Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's clinical record indicated there was no advance directive. Review of the social services notes indicated there was no documentation that the facility verified, offered, assisted, or obtained an advance directive for Resident 23. Review of Resident 23's POLST form dated 9/18/25 indicated, section D, No Advance Directive was selected. Review of Resident 123's admission Record indicated Resident 123's initial admission to the facility was on 12/6/22 and re-admitted to the facility on [DATE]. Review of the social services notes indicated there was no documentation that the facility verified, offered, assisted, or obtained an advance directive for Resident 123. Review of Resident 123's POLST form dated 12/6/22 indicated, section D, No Advance Directive was selected. During a concurrent interview and record review of the POLST forms for Residents 1, 23, and 123 with the Social Service Director (SSD) on 12/4/25 at 12:36 p.m., the SSD confirmed there was no documentation of advance directives for the above three residents. The SSD stated she should have verified, offered, assisted, or obtained an advance directive for the residents. During an interview with the Director of Nursing (DON) on 12/5/25 at 10:11 a.m., the DON stated the SSD should have verified and assisted residents with obtaining an advance directive. The DON also stated the SSD should have documented the efforts to obtain an advance directive during resident assessments, upon admission, and as needed. Review of Resident 57's clinical record were as follows: The face sheet (FS: a document that gives a resident's information at a quick [NAME]) indicated Resident 57 was admitted to facility on 4/2/2025. The POLST form, dated 4/12/2024, had a section D for advance directive that indicated, Advance Directive not available. There was no documented evidence the facility offered and assisted to execute an advance directive for this resident. Review of Resident 97's clinical record were as follows: The FS indicated Resident 97 was admitted to facility on 10/18/2017. The POLST form, dated 12/21/202, had a section D for advance directive that indicated, No Advance Directive. There was no documented evidence the facility offered and assisted to execute an advance directive for this resident. During an interview with facility's social service director (SSD) on 12/4/2025 at 12:36 pm., SSD confirmed there was no advance directives for Resident 57. SSD stated social service department did not offer and assist to execute advance directives for this resident, and should have. During an interview with facility's director of nursing (DON) on 12/5/2025 at 11:58 a.m., DON confirmed POLST form section D indicated there was no advance directives for Resident 97. DON further stated SSD should have offered and assisted to execute advance directives for Resident 57. Review of facility's policy and procedure (P&P) titled, Advance Directives, revised September 2022, indicated, If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Review of facility's P&P titled, Code Status, Advance Directives, and POLST, undated, indicated, Upon admission, the facility will ask whether an Advance Directive exits and provide information regarding the residents' right to make such decisions. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record.

Based on observation, interview, and policy review, the facility failed to implement infection control practices when:1. Certified nursing assistant I (CNA I) did not remove gloves before walking out of Resident 45's room;2. Registered nurse G (RN G) picked up the water pitcher on her medication cart with her contaminated gloved hand;3. Licensed vocational nurse H (LVN H) did not cleanse her hands and change gloves before administering eye drop to Resident 93; and,4. LVN H administered oral medications to Resident 76 with a contaminated spoon.These failures had the potential to spread infection in the facility.Findings:1. During an observation on 12/1/25, at 10:55 a.m., CNA I was helping Resident 45 in his room. Then CNA I carried a bag with soiled diaper inside with her gloved hands, walked out of Resident 45's room and in the hallway to throw the bag in the hamper.During a concurrent interview with CNA I, she stated she was changing Resident 45's brief. CNA I stated she should remove her gloves in Resident 45's room before walking out in the hallway.Review of the facility's policy, Personal Protective Equipment - Using Gloves, dated 9/2010, indicated . 2. Discard used gloves into the waste receptacle inside the examination or treatment room. 2. During a medication pass observation with RN G on 12/1/25, at 12:20 p.m., RN G sanitized her hands, put on gloves, brought Resident 117's medications to her room to administer them to her. RN G picked up Resident 117's bed remote control and raised Resident 117's head of bed up. RN G found out Resident 117 had no water. She went back to her medication cart, and with the same gloves on her hands, RN G picked up the water pitcher on her medication cart, poured water to the cup, and brought the cup of water to Resident 117.During an interview with RN G on 12/1/25, at 12:45 p.m., she acknowledged that she should remove gloves and cleanse hands before picking up the water pitcher on her medication cart. 3. During a medication pass observation with LVN H on 12/2/25, at 4:01 p.m., LVN H administered oral medications to Resident 93, then without cleansing her hands, LVN H put on gloves and administered two drops of Refresh Plus (used to relieve dry, irritated eyes) in both of Resident 93's eyes.During an interview with LVN H on 12/2/25, at 4:26 p.m., she acknowledged that she should cleanse her hands before giving eye drops to Resident 93.Review of the facility's policy, Instillation of Eye Drops, dated 1/2014, indicated . Steps in the Procedure: . 2. Wash and dry your hands thoroughly. 3. Put on gloves. 4. During a medication pass observation with LVN H on 12/2/25, at 4:39 p.m., LVN H brought Resident 76's medications and a spoon to Resident 76's room. LVN H placed the spoon on Resident 76's overbed table, then used the spoon to pick up the medications in the medication cup and put them in Resident 76's mouth.During an interview with LVN H on 12/2/25, at 4:50 p.m., she acknowledged that Resident 76's overbed table might not be clean and could contaminate the spoon.Review of the facility's policy, Administering Medications, dated 4/2019, indicated Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to ensure communication with the hospice facility for one of seven residents (Resident 7) who were admitted to hospice, when a plan of care from hospice was not located. This failure had the potential to negatively affect the proper care and coordination of care of residents admitted to Hospice.Findings: During a record review of Resident 7's hospice binder located at nurse station 2, it lacked a plan of care. During an interview with the DON on 12/04/2025 at 2:44 p.m., the DON stated she was not sure about the hospice care plans for Resident 7 and stated she will check about care plans being in Resident 7's record or hospice binder. During a review of the facility's agreement with the hospice facility titled, First Amendment to Agreement for Nursing Facility, Inpatient and Inpatient Respite Services, effective 9/20/2019, indicated, . 2.1.7 Plan of Care. Per Section 2.1 of Appendix C and Section 2.2 of Appendix D of the Agreement, [the Hospice company] shall establish, modify as appropriate, and provide Facility with a copy of, a Hospice Plan of Care for each Hospice Patient admitted to Facility . Appendix C.II. [Hospice company] OBLIGATIONS. 2.1 Hospice Plan of Care. For each Residential Hospice Patient, [Hospice company] will (i) develop a Hospice Plan of Care, and (ii) furnish Facility a copy of such Residential Hospice Patient's Hospice Plan of Care at the time he/she is admitted to the Hospice or, in the case of a Hospice Patient who becomes a resident of Facility after admission to the Hospice, at the time the Hospice Patient is admitted to Facility. [Hospice company] will update each Hospice Plan of Care as required under the Conditions, and as otherwise required hereunder . Appendix D.2.2 Plan of Care: Interdisciplinary Team. For each Hospice Patient provided Inpatient and Inpatient Respite Services hereunder, [Hospice company] shall (i) establish, revise (as necessary), and provide Facility with a copy of a Plan of Care, and (ii) designate an Interdisciplinary Team.

Based on observation, interview, and record review, the facility failed to ensure food was prepared palatable (quality of taste) for one of eight sample resident (Resident 97) when food was overcooked and lacked flavor. This failure had the potential to affect meal intake and the nutritional value of the food served to Resident 97. Findings:During an interview with Resident 97 on 12/2/2025 at 11:40 a.m., Resident 97 stated vegetables always served mushy, overcooked, no flavor, and do not feel like eating vegetables with meals.Review of Resident 97's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 97 was admitted to facility on 10/18/2017.Review of Resident 97's order summary report indicated an order for heart healthy diet, regular texture, NAS (no added salt) dated 12/21/2022.Review of facility's lunch menu for 12/4/225 indicated, seasoned zucchini for vegetable item.During a lunch test tray and interview with facility's cook and registered dietician (RD) on 12/4/2025 at 1:12 pm., the regular texture zucchini tasted bland, and was soft and mushy. The cook tasted the regular texture zucchini from meal tray and confirmed it was oversoft, over cooked, and bland. The RD stated the zucchini was on the softer side and tasted bland. The RD also stated the cook should have cooked this vegetable with less time to prevent the softness.Review of facility's policy and procedure (P&P) titled, Food Palatability & Nutritive Value Policy, revised 2025, indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Providing meals that are varied in color and texture.

Based on observation, interview and record review, the facility failed to accommodate food preferences for one of 4 sample resident (Resident 85). This failure had the potential for decreased meal intake, thus negatively affecting the health and well-being for the sampled resident.Findings:During an initial dining room observation for lunch meal on 12/1/2025 at 12:26 p.m., noted Resident 85 was received lunch meal with no cranberry juice.Review of Resident 85's face sheet (FS, document that gives resident's information at a quick [NAME]) indicated Resident 85 was admitted to facility on 12/31/2025.Review of Resident 85's lunch tray card dated 12/1/2025 indicated that, Cranberry JC (juice) mildly TH (thick, flows easily but slower than water) 1/2 C (cup).During an interview with certified nursing assistant J (CNA J) on 12/1/2025 at 12:36 p.m., CNA J confirmed Resident 85's lunch tray card indicated cranberry juice 1/2 cup; and that, Resident 85 did not receive this juice with the lunch meal. CNA J stated Resident 85 should receive cranberry juice along with lunch meal items. CNA J also stated kitchen staff should have sent this juice for Resident 85. CNA J requested dietary staff to send cranberry juice for Resident 85.During an interview with facility's registered Dietitian (RD) on 12/5/2025 at 8:50 a.m., RD stated kitchen staff should read meal tray cards with each meal and accommodate resident's food preferences. RD also stated kitchen staff should have sent cranberry juice to Resident 85 with lunch meal on 12/1/2025. RD further stated kitchen staff were educated for reading meal tray cards and accommodating food preferences as documented in the meal tray card for each resident.Review of facility's policy and procedure (P&P) titled, Food and Nutrition Services, revised October 2017, the P&P indicated, Reasonable efforts will be made to accommodate resident choices and preferences. Food preferences are implemented and included on the residents tray card for the dietary staff guidance in the resident's meal preparation.

Based on observation, interview, and record review, the facility had a medication error rate of 12% when 3 medication errors occurred out of 25 opportunities during medication administrations for two out of 10 residents (27 and 72). This failure resulted in medications to not be given in accordance with the prescriber's orders.Findings:1. During a medication pass observation with licensed vocational nurse E (LVN E) on 12/1/25, at 12:54 p.m., LVN E stated per the physician order, Resident 27 was to receive 9 units of insulin aspart (used to control high blood sugar) before meals. LVN E drew 8 units of insulin aspart 100 units/ml, brought the syringe with 8 units of insulin aspart to Resident 27, and was about to administer this to the resident.During a concurrent observation on the syringe with insulin aspart and interview with LVN E, she confirmed that she drew 8 units of insulin aspart to give to Resident 27 and not 9 units.Review of Resident 27's physician order, dated 4/6/25, indicated Resident 27 was to receive 9 units of insulin aspart 100 units/ml before meals three times a day. 2. During a medication pass observation with licensed vocational nurse C (LVN C) on 12/3/25, at 9:58 a.m., LVN C crushed one tablet of Zinc Sulfate (used to increase the amount of zinc in the body) 220 milligrams (mg, a metric unit of mass), mixed with water, and administered to Resident 72 via his gastrostomy tube (G-tube, a tube that is inserted through the abdominal wall and into the stomach).During a medication pass observation with LVN C on 12/3/25, at 10:56 a.m., LVN C administered Artificial Tears Solution (eye drops used to lubricate dry eyes) to Resident 72, one drop in each eye.Review of Resident 72's physician orders, dated 10/14/25 and 10/16/25, indicated Resident 72 was to receive Zinc Sulfate 50 mg one time a day for supplement and two drops of Artificial Tears Solution in both eyes three times a day for dry eye.During an interview with LVN C on 12/4/25, at 11:30 a.m., he reviewed Resident 72's physician orders and confirmed that the physician ordered Zinc Sulfate 50 mg via G-tube and two drops of Artificial Tears Solution in each eye for Resident 72, but he administered Zinc Sulfate 220 mg via G-tube and one drop of Artificial Tears Solution in each eye to Resident 72.Review of the facility's policy, Administering Medications, dated 4/2019, indicated . 10. Ensure that the six rights of medication administration are followed: a. Right resident; b. Right drug; c. Right dosage; d. Right route; e. Right time; f. Right documentation.

Based on interview and record review, the facility failed to identify fall risk to prevent falls for one of five residents (87) when Resident 87's fall risk was not assessed after he fell. This failure had the potential for Resident 87's fall risk score and interventions to be inaccurate.Findings:Review of Resident 87's admission Record indicated he was admitted to the facility on [DATE] with muscle weakness diagnosis.Review of Resident 87's Fall Report of Incident and Change of Condition Fall indicated he fell on [DATE] and 11/25/25. However, there were no indications that Resident 87 was assessed for fall risk after he fell.During an interview with the director of nursing (DON) on 12/5/25 at 1 p.m., she reviewed Resident 87's clinical record and confirmed that Resident 87 was not assessed for fall risk after he fell on [DATE] and 11/25/25. The DON stated the residents should be assessed for fall risk after the fall.Review of the facility's policy, Fall Risk Assessment, dated 3/2018, indicated . the nursing staff and the 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 observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of four residents (87 and 132) when:1. Resident 87's oxygen tubing was not changed weekly as ordered by the physician; and,2. Licensed vocational nurse C (LVN C) and licensed vocational nurse D (LVN D) did not know Resident 132 had a pacemaker (a small, battery-operated electronic device implanted in the body to regulate heartbeats), and Resident 132's pacemaker information was not in his medical records.These failures had the potential for adverse effects on the patients' health and well-being.Findings:1. Review of Resident 87's admission Record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, diseases that restrict the breathing) diagnosis.Review of Resident 87's physician orders, dated 11/18/25 and 10/23/25, indicated he had orders for oxygen at 2 liters (L, a metric unit of volume) per minute as needed and change his oxygen tubing every week and as needed.During an observation with licensed vocational nurse B (LVN B) on 12/1/25, at 10:49 a.m., Resident 87's oxygen tubing had a label dated 11/16/25.Review of the facility's undated policy, Verbal Orders, indicated . 6. Follow through with orders by making appropriate contact or notification . 2. Review of Resident 132's admission Record indicated he was admitted to the facility on [DATE] with presence of cardiac pacemaker diagnosis.Review of Resident 132's physician order, dated 11/29/25, indicated he had an order for the license nurse to monitor signs and symptoms of pacemaker malfunction such as change in level of consciousness, chest pain, shortness of breath, slow or fast heartrate, blood pressure changes, dizziness, prolonged hiccups, and notify the physician every shift.During an interview with LVN C on 12/4/25, at 1:33 p.m., he stated Resident 132 had a Continuous Glucose Monitor (CGM, a wearable device that tracks a person's sugar levels every few minutes) on his arm, and that's all. Resident 132 did not have any other device.During an interview with LVN D on 12/4/25, at 4:33 p.m., he stated Resident 132 had a CGM on his arm, and he did not recall that Resident 132 had any other device.Review of Resident 132's medical records indicated a lack of his pacemaker information, other than what is indicated in this write-up.During an interview with the director of nursing (DON) on 12/5/25, at 11:30 a.m., she reviewed Resident 132's clinical record and could not located his pacemaker information. The DON stated Resident 132's pacemaker information should be reported in his medical records.Review of the facility's policy, Care of a Resident with a Pacemaker, dated 12/2015, indicated . Documentation: 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate.

Based on interview and record review, the facility failed to update and revise comprehensive and individualized care plans for hospice care (a specialized support system, focusing on resident's comfort, quality of life and dignity than cure for residents with serious illnesses with prognosis of six months) after hospice care services was discontinued for one of three sample resident (Resident 57).This failure in care planning had the potential for not meeting Resident 57's needs.Findings:Review of Resident 57's face sheet (FS: a document that provides resident's information at quick glance) indicated Resident 57 was admitted to facility on 4/2/2025.Review of Resident 57's discontinued orders indicated Resident 57 was discontinued from hospice care services on 11/18/2025.Review of Resident 57's care plans indicated care plans for hospice services, self - care deficit, at risk for falls and injuries, mood problem, depression, potential for pressure ulcer development, impaired skin integrity, incontinent of bowel and bladder, actual/chronic pain related to hospice care, dated 4/17/2025, psychosocial well-being problem, on hospice, dated 6/21/2025, long term stay for custodial care/hospice, dated 5/21/2025, and altered nutrition and hydration, on hospice care, dated 4/9/2025. Review of above care plans indicated current goals and objectives related to hospice care for Resident 57.During a concurrent record review of hospice discontinuation order and care plans for Resident 57 with facility's director of nursing (DON) on 12/4/2025 at 10:42 a.m., DON confirmed above findings. DON stated nursing staff should review, update and discontinue care plans related to hospice care and services for Resident 57 when off from hospice services on 11/18/2025. DON also stated nursing staff should have reviewed, updated and discontinued care plans related to hospice care after discontinued hospice for Resident 57.Review of facility's undated policy and procedure for care planning indicated, Goals and objectives are reviewed and/ or revised . When there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to develop or implement comprehensive and person -centered care plans that included target symptoms, measurable objectives, and interventions for two of eight sampled residents (Resident 35 and 3) when:1.Intervention not followed for risk for fall care plan for Resident 35; and,2. No care plan developed related to use of medication quetiapine (anti-psychotropic medication, used to treat mental health conditions with behavior concerns) for Resident 3.These failures had the potential to result in not meeting sampled residents' needs and plan of care.Findings:1. During room rounds on 12/3/2025 at 2:00 p.m., observed Resident 35 was in bed, sleeping and Resident 35's bed was not placed in low position.Review of Resident 35's FS indicated resident 35 was admitted to facility on 12/17/2024.Review of Resident 35's diagnoses included alzheimer's disease (a progressive brain disorder that slowly destroy memory, thinking and carry out daily living tasks), syncope (passing out or loss of consciousness), and anxiety (a mental health condition of excessive, persistent and uncontrollable worry of day to day situations).Review of Resident 35's comprehensive care plan for at risk for falls and injuries, dated 12/18/2024 with interventions included Low Bed, dated 12/18/2024.During an interview with certified nursing assistant N (CNA N) on 12/3/2025 at 2:10 pm., CNA N confirmed bed was not in low position while Resident 35 was in bed. CNA N stated due to risk for fall and injury, Resident 35's bed should be in lowest position while in bed. CNA N also stated nursing staff should have positioned bed to lowest position for when Resident 35 in bed. CNA N adjusted Resident 35's bed to lowest position before left the room.During an interview with DON on 12/4/2025 at 10:37 a.m., DON stated nursing staff should have kept bed in low position when Resident 35 was in bed. DON also stated nursing staff should have followed the care plan intervention for low bed to prevent risk of injury from the fall for Resident 35.2. Review of Resident 3's face sheet (FS: a document that provides resident's information at a quick glance) indicated Resident 3 was admitted to facility on 10/7/2021. Review of Resident 3's diagnoses included psychosis (a mental disorder with disorganized thinking, speech, and behavior).Review of Resident 3's order summary report indicated, quetiapine 50 MG (milligrams, a unit of mass equal to one thousandth of a gram) at bed time for psychosis, dated 10/3/2025.Review of Resident 3's care plans indicated there was no documented evidence for comprehensive care plan for use of medication quetiapine.During a concurrent interview and record review with the facility's director of nursing (DON) on 12/5/2025 at 12:14 p.m., Resident 3's medication orders and care plans were reviewed with the DON, who confirmed the above findings. DON stated Resident 3 should have a care plan for use of medication quetiapine.Review of facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, revised April 2009, the P&P indicated, Care plan goals and objectives are defined as the desired outcome for a specific resident problem.Review of facility's P&P titled, Psychotropic Medication Use,, undated, the P&P indicated, In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.

Based on interview and record review, the facility failed to ensure to complete significant change in status assessment (SCSA: a comprehensive assessment after a major change in improvement or decline in resident's health condition using minimum data set tool [MDS: resident assessment tool]) within 14 days after discontinued hospice care (a specialized support system, focusing on resident's comfort, quality of life and dignity than cure for residents with serious illnesses with prognosis of six months or less) for one of three sample resident (Resident 57).This failure had the potential for putting into effect inappropriate plans of care for Resident 57.Findings:Review of Resident 57's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 57 was admitted to facility on 4/2/2025.Review of Resident 57's physician orders indicated hospice care was discontinued on 11/18/2025.Review of Resident 57's nurse practitioner's (NP: a registered nurse with advance education and training allowing to provide a wide range of healthcare services, including diagnosing and treating illnesses) notes dated 11/18/2025 indicated Resident 57 graduated from hospice.Review of Resident 57's MDS assessments indicated there was no documented evidence of SCSA assessment completed within 14 days after Resident 57 graduated from hospice care on 11/18/2025.During a concurrent record review of physician orders and MDS assessments for Resident 57 with facility's MDS coordinator (MDSC) on 12/4/2025 at 11:35 a.m., MDSC confirmed Resident 57 graduated from hospice, and that hospice care orders were to be discontinued on 11/18/2025. MDSC also confirmed there was no SCSA for improvement of health status completed within 14 days after discontinuation of hospice care for this resident. MDSC stated per guidelines, Resident 57 qualified for SCSA for significant improvement in health condition and was taken off from hospice care on 11/18/2025. MDSC also stated MDS staff should have completed SCSA assessment within 14 days after Resident 57 was off from hospice.Review of facility's policy and procedure (P&P) titled, Comprehensive Assessments, revised October 2023, the P&P indicated, Significant Change in Status Assessment (SCSA) - The SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team, group of healthcare professionals from different specialties work together for resident's plan of care) has determined that a resident meets the significant change guidelines for either major improvement or decline. Chapter 2 of the Resident Assessment Instrument (RAI [detailed guidelines for healthcare facilities on using MDS for residents to ensure quality of care]) User Manual provides detailed Guidelines for Determining a Significant Change in a Resident's Status.

Based on interview and record review, the facility failed to ensure Residents were free from unnecessary psychotropic medications (medications capable of affecting the minds, emotions, and behaviors) for one of three sampled residents (Resident 35) when there was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before psychotropic medications (used to treat mental health condition) were administered for Resident 35.This failure had the potential for sampled resident 35 to receive unnecessary psychotropic medications. Findings:Review of Resident 35's face sheet (FS: a document that gives a resident's information at a glance) indicated Resident 35 was admitted to facility on 12/17/2024.Review of Resident 35's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest with daily living) and anxiety (a mental health condition of excessive, persistent and uncontrollable worry of day to day situations). Review of Resident 35's order summary report indicated an order for lorazepam (a psychotropic medication to treat anxiety) 81 MG (milligrams, a unit of mass or weight, equal to one thousandth of a gram) two times a day for anxiety, dated 11/11/2025 and sertraline (a psychotropic medication to treat depression) 100 MG one time a day for depression, dated 10/23/2025.Review of Resident 35's electronic medication administration record (EMAR, a digital system used in healthcare setting to track and document the administration of medications to residents) for November 2025 and December 2025 indicated no documented evidence of non-pharmacological approaches attempted before lorazepam and sertraline administered for Resident 35.During a concurrent record review and interview with director of nursing (DON) on 12/5/2025 at 12:14 p.m., DON reviewed physician orders for lorazepam, sertraline and EMAR for Resident 35. DON confirmed there was no documented evidence of attempted non-drug approaches before administered above both psychotropic medications to Resident 35. DON also confirmed there was no contraindication for above resident to attempt non-drug approaches. DON stated license staff should have attempted non-drug approaches before both psychotropic medications were administered to minimize the need and allow the lowest possible dose for these two medications to Resident 35.Review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, undated, indicated, Non-pharmacological approaches will be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.

Based on interview and record review, the facility failed to obtain informed consent (IC: written permission before implementing a healthcare intervention) prior to administrating an increased dose of anti-psychotropic medication (medication capable of affecting the mind, emotions, and behavior) for one of three sampled residents (Resident 57).This failure resulted in the sampled resident receiving psychotropic medication without being informed about the risks and benefits of an increased dose.Findings:Review of Resident 57's clinical record yielded the following: The face sheet (FS, a document that gives resident's information at a quick glance) indicated Resident 57 was admitted to facility on 4/2/2025 with diagnoses including psychosis (a mental disorder with disorganized thinking, speech, and behavior). The FS also indicated Resident 57 had an assigned responsible party (RP, a person designated to make health care and treatment decisions on behalf of the resident). Review of Resident 57's IC for quetiapine indicated 25 MG two times a day, dated 4/2/2025. The order summary for discontinued medication orders indicated quetiapine 25 MG twice a day dated 4/2/2025. The order summary report indicated Resident 57 had an order for quetiapine (anti-psychotropic medication, used to treat mental health conditions with behavior concerns) 25 MG (milligrams, a unit of mass equal to one thousandth of a gram) every day and 50 MG in the evening for psychosis, dated 5/21/2025. The electronic medication administration record (EMAR, digital system for documenting medication administration) for October/2025, November 2025, and December 2025 indicated Resident 57 received quetiapine 25 MG at 0900 and 50 MG at 1700 every day. During an interview with Resident 57's RP over the telephone on 12/2/2025 at 2:28 pm., RP stated she was not aware of the quetiapine dose increase for Resident 57. RP also stated facility did not inform increased medication dose, risks versus benefits with increased dose and did not give informed consent (IC) for increased medication dose for Resident 57.During an interview with facility's director of nursing (DON) on 12/5/2025 at 12:14 p.m., DON confirmed Resident 57 currently receiving quetiapine 25 MG once a day and 50 MG every evening. DON also confirmed IC for 25 MG two times a day. DON stated Resident 57's medication order for quetiapine had been increased 25 MG more for every evening on 5/21/2025. DON also stated when dose increased, nursing staff did not inform RP of it, nor the risks and benefits of this increased dose. DON further stated nursing staff should have informed the RP and received the IC before administering the medication.Review of facility's policy and procedures (P&P) titled, Psychotropic Medication Use, undated, it indicated, Prior to initiating or increasing a psychotropic medication, the resident, family and /or resident representative must be informed of the benefits, risks, and alternatives for the medication .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of three residents investigated, (Resident 1), when Resident 1 did not have a care plan for his broken tooth. This failure had the potential to result in the resident, not receiving the proper intervention and monitoring necessary to maintain his highest level of well-being. Findings: During the observation of Resident 1 on 8/12/25 at 3:00 p.m., Resident 1 was in his room, laying in bed. He's alert, oriented, calm, comfortable and verbally responsive. Resident 1 confirmed that he had a broken tooth, but it was already extracted. Review of Resident 1's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including encounter for palliative care (specialized medical approach that focuses on improving the quality of life for people with serious or life-threatening illnesses), alcoholic cirrhosis of liver (chronic condition characterized by permanent scarring of the liver tissue) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease) and type 2 diabetes mellitus (chronic condition characterized by high blood sugar, insulin resistance, and relative lack of insulin) with other specified complication (secondary disease, condition, or issue that arises during the course of a primary disease or after a medical procedure or treatment). Review of Resident 1's care plans indicated, Resident 1 did not have a care plan created when he had a change of condition (any significant, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains that may require a change in their plan of care) for his broken tooth, including the interventions to be done and the monitoring of it. During the concurrent review of Resident 1's care plans and interview with the director of nursing (DON) on 8/12/25 at 2:20 p.m., DON acknowledged that Resident 1 did not have a care plan initiated for his change of condition, for having a broken tooth. DON further acknowledged that a care plan should have been made for Resident 1's broken tooth to address Resident 1's needs but there was no care plan at all, and she further stated that she would update his care plan. During another interview with DON on 9/10/25 at 1:00 p.m., DON verified that for Resident 1's broken tooth, a care plan should have been created for proper monitoring, interventions and follow up. Review of the facility's policy and procedure titled, Care Plan, Episodic, dated August 2014 indicated, It is the policy of the facility to develop an episodic/short term care plan for acute temporary changes and/or condition. Entries will be realistic and have measurable goals and timeframes and responsibility for meeting the specific goals Review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 2008 indicated, It is the policy of the facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life The Care Plan is individualized by identified resident problems, unique characteristics, strengths, and individual needs Review of the facility's policy titled, Change of Condition, dated 2016 indicated, Purpose: To appropriately assess, document and communicate changes of condition To provide treatment and services to address changes in accordance with resident needs and existing Advance Directives

Based on interview and record review the facility failed to have a procedure in place to ensure a resident who displays, or who has a mental disorder, receives appropriate treatment and services to correct the assessed problem for one of two sampled residents (Resident 1). The facility did not implement the psychiatry recommendations timely for Resident 1 after their assessment and psych evaluation was completed due to the facility not having a procedure to follow up with the recommendations from outside referrals. This failure resulted in a delay of starting Resident 1's new treatment plan by three weeks. This failure had the potential to negatively affect Resident 1's behavior and the safety of other residents in the facility. Findings: During a review of Resident 1's Diagnosis Information, undated, document indicated, Resident 1 was diagnosed with Schizophrenia, Unspecified [a serious mental health condition that affects how people think, feel and behave]. During a review of Resident 1's Care Plan dated, 6/28/22 indicated, a Focus of Potential Behavior disturbance Related to DX [diagnosis of] Schizophrenia manifested by restlessness with agitation.Interventions/Tasks. Monitor for behavior. During a review of Resident 1's Care Plan dated, 2/26/24 indicated, a Focus of Resident has a positive indication of Mental Illness.Interventions/Tasks.follow up with psych service as needed. During a review of Resident 1 and Resident 2's Verification of Incident Investigation dated 9/10/24, indicated and allegation of physical abuse was investigated between Resident 1 (alleged aggressor) and Resident 2 (alleged victim). During a review of Resident 1's Progress Note dated 9/6/24 note indicated, given he [Resident 1] has had 2 altercations with other PT's [patients] recently NP [Nurse Practitioner] will order a Psych eval [Psychiatric Evaluation] to evaluate possible restart of Zyprexa [antipsychotic medication that can treat several mental health conditions like schizophrenia]. Signed by Resident 1's Physician. During an interview on 10/8/24, at 1:45 pm, with Social Services Director (SSD) SSD stated, she sent the referral to the NP for a psych eval for Resident 1. SSD stated, she did not see the recommendation by the NP until today (10/8/24), and the medication order from her recommendation was ordered today. SSD stated the facility did not have a procedure how to follow up the recommendations from the psychiatry referral made by the NP. During a review of Resident 1's Psychiatry Diagnostic Interview(psych eval) dated 9/18/24, Interview indicated, NP conducted a psych eval on Resident 1. Interview indicated, Reason for visit: Diagnostic evaluation due to altercation with another resident, concern for agitation or aggression.Recommend increase Mirtazapine [antidepressant medication] to 15 mg nightly for depression m/b [manifested by] verbalizations if sadness.Consideration should be given to adding mood stabilizing agents such as Depakote sprinkles [This medication is used to treat seizure disorders and mental/mood conditions] 125 mg BID [twice daily] for irritability and aggression, given two aggressive episodes in the past year and mild agitation with staff in hallways.Redirect patient when possible. Use caution given his history of physical aggression. During an interview on 10/10/24 at 8:06 a.m., with NP, NP stated, she performed a psychiatric assessment for Resident 1 on 9/18/24 and uploaded her eval/assessment with her recommendations that same day. NP stated, she does not send the recommendations to the facility, but the staff there have access to an online portal and can access her recommendations as soon as she uploads them. NP stated she was not contacted by the facility until 10/8/24 when they asked her for the psych assessment for Resident 1 and she provided a copy. During a review of Job Description for Social Services Director, undated, Job Description indicated, Manages department to assure assessments, discharges and psychological needs of residents are met.

Based on interview and record review, the facility failed to ensure that one out of four sampled residents (Resident 1), who was admitted to the facility with an indwelling urinary catheter (tube inserted into the bladder to drain urine) received appropriate care and services to prevent and to promptly treat urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) as indicated in the facility's policy and procedure by failing to: 1. Appropriately assess and document Resident 1's urine color, character, and output (amount of urine a resident excretes). 2. Initiate a care plan for indwelling urinary catheter care and assessment, and 3. Remove the indwelling urinary catheter per the medical doctor's (MD's) orders. These failures resulted in a delay of care for Resident 1 who was transferred on 10/30/18 via 911 (emergency services) to a general acute care hospital (GACH) and subsequently admitted with a [DIAGNOSES REDACTED]. Resident 1 was a [AGE] year-old male who was admitted to the facility on [DATE] for rehabilitation after [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke-when blood flow to a part of the brain stops). Resident 1 had a history of [REDACTED]. as a pump is inadequate to meet the body's needs). Resident 1 had an indwelling urinary catheter in place on admission to the facility due to [MEDICAL CONDITION] bladder (a condition in which problems with the nervous system affect the bladder and urination). During a review of the clinical record for Resident 1, the Order Review Report indicated on 10/22/18, the MD ordered to continue the indwelling urinary catheter every shift for two days, may re-insert indwelling urinary catheter as needed for malfunction (not working), and Remove indwelling urinary catheter for voiding trial (to assess patients' ability to empty their bladder successfully following the removal of indwelling urinary catheter) in 2-3 days. Bladder scan (test to measure the amount of urine in the bladder) every 6 hours x (times) 4 days after indwelling urinary catheter is removed. Replace indwelling urinary catheter for post-void residual (urine left in the bladder) (greater than) 250 ml (milliliters, a unit of measurement) .monitor. During a review of the clinical record, the Progress Notes dated 10/27/18 at 3:00 p.m., indicated the indwelling urinary catheter was draining. There was no description of the urine (color, character or amount). There was no other documentation that the nurse assessed the indwelling urinary catheter every shift. There was no documentation which indicated the indwelling urinary catheter was removed for a voiding trial per the MD's orders. There was no documentation of a bladder scan or monitoring after indwelling urinary catheter removal. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she stated the indwelling urinary catheter had been removed, but was reinserted for urine retention (inability to empty the bladder completely). She could not state when the catheter was removed or reinserted. She reviewed the clinical record for Resident 1 and was unable to find documentation the indwelling urinary catheter was removed, or the indwelling urinary catheter was reinserted due to [MEDICAL CONDITION]. During a review of the clinical record for Resident 1, there was no documentation of intake and output monitoring (measuring fluid which goes into and out of the body, for fluid balance) during Resident 1's eight-day admission. There was no documentation of a care plan for the indwelling urinary catheter. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of intake and output monitoring or a care plan for the indwelling urinary catheter. During an interview with the Director of Nursing (DON) on 12/21/18 at 10:45 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of an indwelling urinary catheter care plan, intake and output, indwelling urinary catheter monitoring/assessment, or indwelling urinary catheter removal and reinsertion. During a review of the clinical record for Resident 1, the Change in Condition Evaluation, dated 10/30/18 at 8:47 a.m., indicated Resident 1 had abdominal distention and did not have any urine output from his indwelling urinary catheter. Resident is noted to be more confused, lethargic (a lowered level of consciousness marked by listlessness, drowsiness, and apathy), abnormal vs (vital signs), distended abdomen (when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion) (and) no urinary output with (catheter) in place . Resident 1's blood pressure was 76/56 (normal blood pressure is considered 120/60). His heart rate was 106 (normal heart rate ranges from 60-100). Resident 1's temperature was 100.5 degrees Fahrenheit (normal body temperature ranges from 97 to 99 degrees Fahrenheit). During an interview with LN A on 12/21/18 at 10:45 a.m., she reviewed the clinical record for Resident 1 and verified he had a change in condition on 10/30/18 and was transferred to the GACH via ambulance. The facility's policy and procedure, Catheter Care, Indwelling Catheter, indicated Assessment Guidelines may include, but are not limited to .Color, consistency, amount of urine .Pain, burning, discomfort .Hydration and fluid balance status .Documentation Guidelines .Date, time, procedure .any unusual condition or change in condition .Color, amount, consistency and odor of urine .intake and output and evaluation of intake and output .Care Plan Guidelines .Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. The use of an indwelling catheter is an approach to a specific problem. Develop a care plan with the objective of removing the catheter when the problem is resolved, whenever possible. During a review of the GACH Discharge Summary Notes, dated 11/1/18, the Hospital Course and Significant Findings indicated, Per admission H&P (history and physical): 'Resident 1 is a [AGE] year-old man presenting from his SNF (skilled nursing facility) for [MEDICAL CONDITION] for the last few days. History obtained from chart review, SNF documentation, and (Resident 1's) wife as (resident) is currently nonverbal. Reportedly, (resident's) .catheter stopped draining 2-3 days ago. (Resident 1) has also been shivering for the last 3 days. Also, after the catheter stopped draining, (resident) started to appear uncomfortable, and he eventually developed abdomen distention (Resident 1) has reportedly been febrile (had a fever) at his SNF over the last 1-2 days. Blood pressure today at SNF, prior to arrival here was 76/56 (low blood pressure is less than 90/60). (Resident) has also been lethargic and somewhat confused over the past 1-2 days.

Based on interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (1) while smoking. This failure resulted in Resident 1 sustaining second degree (partial [MEDICAL CONDITION] affect the epidermis and the dermis (lower layer of skin) that cause pain, redness, swelling, and blistering) burn wounds on his face and left hand. Findings: Resident 1 was admitted with [DIAGNOSES REDACTED]. His minimum data set (MDS-an assessment tool), dated 3/5/18, indicated he had no cognitive impairment. There was a physician's orders [REDACTED]. During an interview with Resident 1 on 5/30/18 at 2:50 p.m., he stated certified nursing assistant A (CNA A) accompanied him during a smoke break on 4/29/18 around 10 a.m He stated he was sitting in his wheelchair with a portable oxygen container located at the back of his wheelchair. Resident 1 stated CNA A lit up his cigarette. During an interview with CNA A on 5/30/18 at 2:57 p.m., he stated he accompanied Resident 1 during a smoking break on 4/29/18 around 10:00 a.m. Resident 1 was sitting in his wheelchair with a portable oxygen container located at the back of the wheelchair. He stated Resident 1 was smoking and suddenly complained of being lightheaded. CNA A handed the nasal cannula to Resident 1 which started the ignition. CNA A stated he immediately applied wet towels to Resident 1's face. He stated Resident 1 suffered [MEDICAL CONDITION] his nostrils. Review of Resident 1's nurse's progress notes dated 4/29/18, indicated Resident 1 [MEDICAL CONDITION] both nostrils, left hand middle finger, neck, and eyebrows. Nurse's progress notes, dated, 4/30/18 revealed a blister on his left middle finger measuring 2 x 2 x .0.1 cm (centimeters, unit of measurement) During an interview with treatment nurse B (TN B), on 6/5/18 at 8:51 a.m., he stated Resident 1 suffered multiple burn injuries including blisters on his left middle finger. TN B further stated Resident 1 was referred to the wound doctor (WD). During an interview with the WD, on 6/6/18 at 3:04 p.m., he stated Resident 1 had second [MEDICAL CONDITION] his face and hand. Review of Resident 1's Wound Care Specialist Evaluation, dated 5/2/18, indicated Resident 1 had second degree burn wounds on his face and left hand from cigarette/oxygen combustion. The burn wound on his face measured 2.5 x 5.5 cm and the burn wound on his left hand measured 1.5 x 2.5 x 0.1 cm. During an interview with medical director (MD) on 6/5/18 at 12:03 p.m., he stated Resident 1 [MEDICAL CONDITION] his nostrils, nasal area, clavicle area, and left middle finger. He further stated he had informed facility staff not to allow residents to smoke while on oxygen during a smoke break. Review of the facility's policy dated 2/2018, Smoking Policy, indicated to monitor and evaluate residents for safety related to smoking. It further indicated portable oxygen tanks and/or other oxygen delivery systems are NEVER allowed in designated smoking areas, even if oxygen is turned off.

Based on observation, interview, and record review, the facility failed to ensure adequate assistance to prevent accident and injury for one of 20 sampled residents (Resident 8). The facility failed to assist the resident during activities of daily living (ADLs, such as bed mobility, transfer, toileting, personal hygiene, and ambulation); failed to provide a mattress on the floor, and failed to implement interventions in response to Resident 8's frequent falls. These failures resulted in Resident 8's left forehead laceration (tear in skin) and acute right subdural hematoma (a collection of blood under the skull and outside the brain as a result of a blow to the head). Findings: Review of Resident 8's clinical record indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS, an assessment tool) dated 2/25/17, indicated the resident had a severely impaired cognition (mental process), and required assistance for bed mobility, transfer, ambulation, toileting, and personal hygiene. Resident 8's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) Fall Report of Incident indicated he had falls on 3/14/17, 3/16/17, 3/19/17, 4/6/17, 4/18/17, 4/27/17, 4/29/17, 5/7/17, 5/11/17, 5/12/17, 5/21/17, 5/29/17, 6/6/17, and 8/17/17 (total of 14 falls). Review of Resident 8's Fall Risk assessment dated [DATE] indicated he had a score of 75. A score of 45 and higher represents a high risk for fall. Review of Resident 8's Self Care Deficit care plan dated 2/18/17 indicated the resident required assistance with ADLs related to confusion and weakness. Review of Resident 8's High Risk for Fall Care Plan related to history of falls, weakness, dementia, and lack of safety awareness, dated 2/18/17, indicated the resident used a bed or sensor pad alarm (to indicate if a resident is getting up from a bed). Review of Resident 8's Actual Fall Care Plan, dated 2/22/17, indicated use of a mattress on the floor and sensor pad alarm in bed. Review of Resident 8's SBAR Fall Report of Incident, dated 5/13/17, indicated the resident had an unwitnessed fall from his bed when he tried to ambulate with no assistance. Resident 8 was found on the floor next to his bed with no mattress on the floor. The intervention to prevent falls was to place a mattress on the floor. Review of Resident 8's SBAR Fall Report of Incident 5/21/17 indicated the resident had an unwitnessed fall from his bed when he tried to get up with no assistance. Resident 8 was found on the floor with a laceration to his forehead and was later transferred to the acute hospital. There was no documentation the mattress on the floor was in place. The intervention was to place a sensor pad alarm and mattress on the floor. During an interview with licensed vocational nurse H (LVN H) on 8/17/17 at 9:40 a.m., LVN H acknowledged Resident 8 had no mattress on the floor when he fell on [DATE]. LVN H stated the resident was found on the floor next to his bed, hit his head, and there was blood on the floor. A review of the consulting physician notes from the acute hospital dated 5/21/17 indicated Resident 8 fell and struck his head on a hard surface resulting in closed head injury with left frontal laceration. Review of Resident 8's Acute Hospital Chart Print Report dated 5/24/17 indicated the resident had left forehead stitches and a [DIAGNOSES REDACTED]. Resident 8 was admitted to the intensive care unit (ICU) for close neurological surveillance (observe and monitor the patient's condition). During an observation on 8/16/17 at 8:25 a.m., Resident 8 was lying on his bed sleeping with the sensor pad alarm, but the cord was not connected to the machine. During an observation and interview with certified nurse assistant I (CNA I) on 8/17/17 at 9:25 a.m., she confirmed the sensor pad alarm cord was not connected to the machine. She stated the sensor pad alarm would not work if the cord was not connected. CNA I acknowledged the sensor pad alarm should have been connected to the machine to work. During an observation on 8/16/17 at 8:26 a.m. and 8/18/17 at 8:02 a.m., Resident 8 was sleeping on his bed with the floor mattress folded and placed on the side of the bedside table. During an observation and interview with the director of staff development (DSD) on 8/18/17 at 8:10 a.m., Resident 8 was sleeping on his bed and there was no mattress on the floor. The DSD stated the resident should have a mattress on the floor to prevent injury, especially because he had previously hit his head on the floor during a fall. During an interview and record review with the director of nursing (DON) on 8/18/17 at 11:35 a.m., she stated Resident 8 was a high risk for falls and required assistance during his ADLs. She stated the fall care plan intervention should have been implemented to prevent falls. The DON confirmed the mattress on the floor should have been in place to prevent injury. Review of the facility's 8/2014 policy, Fall Management, indicated nursing staff and interdisciplinary team (IDT, team members from different department involved in a resident's care) will evaluate the risk factors, provide interventions to minimize the risk, injury, and occurrences; review, revise, evaluate care plan effectiveness to minimize falls, and injuries.