Every finding on record at Palomar Heights Post Acute

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were met in the Food and Nutrition Services Department when eight cutting boards were observed to have deep cuts and discoloration. These failures had the potential to cause widespread foodborne illness in the residents who consume food from the facility's kitchen. The facility census was 93.Findings: A joint kitchen observation on 8/18/26, at 7:54 A.M. was conducted with the Dietary Director (DD). Cutting boards were observed on a rack under a counter. Four white cutting boards had deep cuts and discoloration. A red and yellow cutting boards were pulled and showed deep cuts and discoloration. The DD pulled out two other cutting boards because they had deep cuts and gave them to the cook. The DD stated the cutting boards with deep cuts and discoloration should not be used in the kitchen. During a follow up interview with the DD on 8/21/26, at 11:26 A.M., the DD stated cutting boards with deep cuts were hard to clean and could have bacteria which can cause illness. During an interview on 8/21/26, at 1:40 P.M. with the Registered Dietician (RD), the RD stated germs can enter cutting boards with deep cuts because raw vegetables and meat were cut using the cutting boards. The RD further stated if the cutting board was used to cut contaminated meat, residents could get sick. A review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated November 2022 was conducted. The P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.General Guidelines 1. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. 2. Cross- contamination can occur when harmful substances.microorganisms are transferred to food by hands.food contact surfaces.

Based on observation, interview, and record review, the facility failed to maintain the dignity of one of five sampled residents, resident 45. This failure had the result of resident 45 being labeled a feeder. Findings: Per the facility's admission Record, Resident 45 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes partial weakness or reduced muscle control on one entire side of the body, including the arm, leg, and face) following cerebral infarction (a medical emergency that happens when a blocked blood vessel cuts off blood and oxygen to a part of the brain, causing tissue death) affecting left non-dominant side. During an observation of facility assignment sheets, the document titled [NAME] Heights Post Acute Rehab Daily Assignment indicated Certified Nursing Assistant (CNA) assignments. The document further indicated which assigned residents were feeders. During an interview with CNA21 on 8/20/26 at 1:10 P.M., CNA21 stated, in reference to resident 45, She's a feeder. During an interview on 8/21/26 at 9:35 A.M. with the Director of Nursing (DON), the DON stated we do not use the term 'feeder,' the term impacts the dignity of the residents . During a review of the facility's policy and procedure titled, Resident Rights, revised 2/2021, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence

Based on interview, and record review, the facility did not provide Advanced Directive (a legal document that lets you state your choices for medical care ahead of time if you become unable to speak or make decisions for yourself ) information for two of seven sampled residents, Residents 113 and 115, in a timely manner. This delay had the impact of the residents not being fully informed of treatment options.Findings: Per the facility's admission Record, resident 113 was admitted on [DATE] with diagnoses of Morbid (severe) obesity with alveolar hypoventilation (carbon dioxide and too little oxygen in the blood during the day), obstructive sleep apnea (a sleep disorder where throat muscles relax and repeatedly block the airway during sleep), acute respiratory failure with hypercapnia (a medical emergency where carbon dioxide builds up rapidly in the blood because the lungs cannot remove the waste gas effectively), and acute respiratory failure with hypoxia (a sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the bloodstream). Per the facility's admission record, resident 115 was admitted on [DATE] with diagnoses of pneumonitis (lung inflammation) due to inhalation of food and vomit, and chronic respiratory failure (a long term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide). During an interview with Resident 115 on 8/20/26 at 8:15 A.M., Resident 115 stated No one spoke to me about Advanced Directives. I think someone should have, I'm young but I'd like to know. During an interview with Resident 113 on 8/20/26 at 9:45 A.M., Resident 113 stated I just got information a couple of days ago. I came here on the 4th. During an interview with the Social Services Director (SSD) on 8/20/26 at 1:56 P.M., the SSD stated I do a basic hello the day after admission. I do the Social History and Discharge Planning two to three days after that. The SSD further stated, That is when I discuss Advanced Directives. During an interview with the Director of Nursing (DON) on 8/21/26 at 9:40 A.M., the DON stated the expectation is if something is to be done upon admission that it is done when the person is admitted . If the admission is at night, then I think the next day is appropriate but not after that. The DON continued Six days later is too long, especially for a discussion on Advanced Directives. During a review of the facility's policy titled Advanced Directives Revised November 2025 indicated .Providing the Resident with Written Information Concerning Advance Directives .1. Upon admission, the resident or representative is provided information concerning their rights .

Based on observation, interview and record review, the facility failed to notify a resident and/or the resident's representative notices of transfer/discharge and/or bed hold for two of three residents reviewed for hospitalization. (Resident 6 and 17) This failure had the potential for the resident and/or the resident's representative not to have information regarding the transfer/discharge and bed hold rights.Findings: 1. Resident 6 was readmitted to the facility on [DATE] with diagnoses including fracture of right radius (main bone of forearm on thumb side), intertrochanteric (a type of hip fracture involving the thigh bone) fracture of right femur (thigh bone) and fracture of right ulna(inner longer bone of forearm located on same side as the pinky finger) according to the facility's admission Record. During an observation and interview on 8/18/26 at 9:52 A.M., Resident 6 was in a wheelchair in the hall then propelled the wheelchair into her room. Resident 6 stated she fell and hurt her left leg (touching left thigh). An interview and joint record review was conducted with the charge nurse (CN) on 8/20/26 at 10:40 A.M. The CN reviewed Resident 6's electronic medical record (EMR). The CN stated Resident 6 had a change of condition on 6/5/26 due to being found on the floor with moderate bleeding on the right wrist. The CN stated Resident 6's physician ordered Resident 6 to be sent to the hospital via 911. The CN stated the Notice of Proposed Transfer/Discharge indicated Resident 6 was notified of the transfer, but not Resident 6's responsible party. The Notice of Proposed Transfer/Discharge further indicated that the notice was not sent to Resident 6's responsible party. The CN also could not find a notice of bed hold in Resident 6's EMR. During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 6/17/26, section C0500 indicated Resident 1's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 3, severely impaired. During an interview on 8/20/26 at 1:50 P.M. with the Social Service Director (SSD), the SSD stated that the nursing staff was responsible for completing bed hold notices. The SSD stated it was important to complete the bed hold notice to know if the responsible party would like to hold a bed. 2. Resident 17 was readmitted to the facility on [DATE] with diagnoses including fracture of lumbar vertebra (lower back bone below rib cage and above tailbone) and respiratory failure (when lungs cannot get enough oxygen into the blood or remove waste gas) according to the facility's admission Record. During an observation and interview on 8/18/26 at 8:54 A.M., Resident 17 was in bed on a low air loss mattress (mattress designed to distribute the resident's body weight and help prevent skin breakdown). Resident stated he has been in and out of the hospital but could not remember the last transfer out to the hospital. An interview and joint record review was conducted with the CN on 8/21/26 at 8:43 A.M. The CN reviewed Resident 17's EMR. The CN stated Resident 17 had a change in condition on 2/19/26 due to shortness of breath with nausea and vomiting. The CN stated Resident 17's physician had ordered to send Resident 17 to the hospital. The CN reviewed Resident 17's Notice of Proposed Transfer/Discharge and stated the notice was left blank regarding providing the responsible party a written notice. The CN further stated there was no bed hold notice in Resident 17's EMR. The CN stated there should be a bed hold notice to ensure Resident 17 had a bed upon return to the facility. An interview was conducted on 8/21/26 at 1:52 P.M. with the Director of Nursing (DON). The DON stated the Notice of Proposed Transfer/Discharge should be completed and sent to the responsible party to be aware of the reason for transfer or discharge. The DON further stated the bed hold notification was needed to ensure that the resident can return to the facility. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, dated March 2025, the P&P indicated Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. The P&P did not provide guidance to staff regarding completion of the Notice of Proposed Transfer/Discharge form and providing a written copy to the resident and/or responsible party. During a review of the facility's P&P titled, Bed-Holds and Returns, dated October 2022, the P&P indicated, Policy Statement.Residents and/or representatives are informed [in writing] of the facility and stated [if applicable] bed-hold policies.Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer [e.g., in the admission packet]; and b. notice 2: at the time of transfer [or, if the transfer was an emergency, within 24 hours].

Based on interview and record review, the facility failed to ensure a written summary of the baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) was provided to the resident's representative for one of two residents (Resident 116) reviewed for baseline care planning. This failure had the potential for the resident and representative to not be informed of the initial plan of care, goals and services for the resident.Findings: Resident 116 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) and pneumonia (severe lung infection that causes air sacs inside the lungs to fill up with fluid or pus) according to the facility's admission Record. During an observation on 8/18/26 at 9:14 A.M., Resident 116 was lying in bed with his eyes closed and with oxygen. An intravenous (IV- into the vein) pump was observed with an IV medication infusing into Resident 116's right upper arm IV site. An interview on 8/19/26 at 3:54 P.M. was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 116 had physician's orders for IV medications and oxygen due to pneumonia. LN 3 stated the IV medications were administered to Resident 116 via a peripherally inserted central catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm used for intravenous medications) and the PICC site had to be checked for signs of infection. An interview and joint record review on 8/21/26 at 8:50 A.M. was conducted with the Charge Nurse (CN). The CN reviewed Resident 116's electronic medical record (EMR). The CN stated Resident 11 had a PICC line which required sterile procedure during weekly dressing changes and monitored for infection and bleeding. The CN checked Resident 116's EMR for baseline care planning. The CN stated the Baseline Care Plan Person-Centered Care Planning form was completed by nursing staff on 8/16/26 for Resident 116. The CN stated she was not sure who provided a written copy to residents' responsible party. During an interview on 8/21/26 at 9:21 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated baseline care plans were completed within 72 hours of a resident's admission. The MDSN stated the registered dietician, rehab staff, social services and nursing staff completed the form in the EMR and the form was printed and given to the resident or representative. A copy of the signed baseline care plan form was then given to medical records staff. On 8/21/26 at 9:26 A.M., the facility's medical records consultant stated Resident 116's baseline care plan was incomplete and there was no record of a written copy provided to Resident 116's representative. During an interview on 8/21/26 at 1:52 P.M. with the Director of Nursing (DON), the DON stated he expected the nursing staff to complete the baseline care plan for residents within 72 hours of admission. The DON stated the baseline care plan was a summary of care provided to residents which was a short version of the comprehensive care plan. A review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, revised December 2016 was conducted. The P&P indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident with forty-eight [48] hours of admission.The resident and their representative will be provided a summary of the baseline care plan.

Based on observation, interview, and record review, the facility failed to develop resident-centered care plan for one of nine residents reviewed for care planning when Resident 7's wound was not care planned. This failure had the potential for staff to not have knowledge about the wound resulting in lack of appropriate care and treatment of Resident 7's wound.Findings: Resident 7 was admitted to the facility on [DATE] with diagnoses including chronic venous hypertension (high blood pressure inside the veins) with ulcer of bilateral lower extremity according to the facility's admission Record. During an observation and interview on 8/18/26 at 8:45 A.M., Resident 7 was in sitting up in bed with oxygen on. Resident stated he cannot walk and had wounds on his legs. A review of physician's orders for Resident 7 was conducted on 8/18/26 at 11:33 A.M. The physician's orders in the electronic medical record (EMR) indicated treatments for Resident 7's left lower leg venous ulcer (slow healing open sore on the lower leg) and wound on perineum (area located between genitals and anus). During a review of the nurse practitioner's wound progress notes (PN) for Resident 7 the PN indicated a wound on Resident 7's left lateral (outer part of leg) lower leg which measured 6.0 x 2.0 x 0.1 cm (centimeter) with treatment start date of 8/5/26. An interview and joint record review was conducted on 8/19/26, at 2:45 P.M. with treatment nurse (TN) 1. TN 1 reviewed Resident 7's EMR and skin sheets. TN 1 stated Resident 7 was admitted with left lower leg redness with a scab which became a non-pressure chronic venous ulcer. The TN nurse stated she was unsure of the date the scab opened and became an ulcer. The TN reviewed care plans for Resident 7. The TN stated she could not find care plan for Resident 7's left lower leg redness with scab and stated there should be a care plan to follow up on the wound and for nursing staff to be aware. An interview on 8/21/26 at 1:52 P.M. was conducted with the Director of Nursing (DON). The DON stated the care plan was the bible of care for residents and should be followed. The DON stated residents' preferences and diseases should be care planned. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022 was conducted. The P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [influence of social factors on a person's mind or behavior] and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview and record review, the facility did not ensure communication devices were provided for two of nine residents reviewed for activities of daily living (ADL- bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) (Resident 69 and Resident 62). This failure had the potential for residents to not have their needs met.Findings: 1. Resident 69 was readmitted to the facility on [DATE] with diagnoses including aphasia (language disorder affecting how to communicate) following cerebral infarction (disrupted blood flow to the brain) according to the facility's admission Record. An observation and interview on 8/18/26, at 9:39 A.M. was conducted with Resident 69. Resident 69 was in his room, sitting up in a wheelchair next to his bed. Resident 69 could not speak and only moaned to respond. There was no communication board or other devices observed in resident's room to assist with communication. During an interview and joint record review on 8/19/26, at 12:52 P.M. with Licensed Nurse (LN) 1, LN 1 stated Resident 69 only spoke Spanish. LN 1 reviewed Resident 69's care plans in the electronic medical record (EMR). LN 1 stated Resident 69 had a care plan which indicated, communication related to.APHASIA FOLLOWING CEREBRAL INFARCTION.impaired ability to make self understood -impaired ability to understand others, date initiated 7/12/23. The care plan intervention did not include use of a communication device. On 8/20/26 at 1:59 P.M. a joint observation of Resident 69's room was conducted with the Social Service Director (SSD). The SSD confirmed that there was no communication device in Resident 69's room. The SSD stated pictures of basic needs would help with communicating resident's needs. 2.Resident 62 was readmitted to the facility on [DATE] with diagnoses including aphasia and unspecified speech disturbances according to the facility's admission Record. During an observation on 8/18/26, at 3:54 P.M., Resident 62 was lying on his right side in bed with good eye contact. Resident 62 did not respond verbally. No communication board or device observed in Resident 62's room. An interview on 8/20/26, at 10:31 A.M. was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated Resident 62 was Spanish speaking, can only mumble and cannot talk. An interview and joint record review on 8/20/26, at 1:38 P.M. was conducted with the Social Service Director (SSD). The SSD stated residents who cannot speak or non-English speaking would have communication device with pictures of basic needs in their rooms. The SSD stated either the activity staff or social service staff would initiate and place the communication device in residents' rooms. The SSD reviewed Resident 62's care plans in the EMR. The SSD stated Resident 62 had a care plan for altered communication, but the communication device was not in the interventions. The SSD stated pictures of basic needs would help with communication. On 8/20/26 at 1:59 P.M. a joint observation of Resident 62's room was conducted with the SSD. The SSD confirmed that there was no communication device in Resident 62's room. An interview on 8/21/26, at 1:52 P.M. was conducted with the Director of Nursing (DON). The DON stated It was important for residents to be able to express their needs to staff and for staff to understand residents' needs the best way possible to provide quality of care. A review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised July 2026 was conducted. The P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency [LEP] shall have meaningful access to information and services provided by the facility. The facility did not provide policies and procedures regarding communication assistance for residents who cannot communicate verbally.

Based on interview and record review, the facility failed to ensure the controlled drug record (CDR- an accounting of controlled medications, drugs with a high abuse potential) reconciled with the medication administration record (MAR- documentation that a resident received a medication) for one of three residents (Resident 113). This failure had the potential for the facility to be unable to readily identify loss and drug diversion (illegal distribution or abuse of prescription drugs) of controlled medications.Findings: Per the facility's admission Record, Resident 113 was admitted on [DATE] with diagnoses of Morbid (severe) obesity with alveolar hypoventilation (carbon dioxide and too little oxygen in the blood during the day), obstructive sleep apnea (a sleep disorder where throat muscles relax and repeatedly block the airway during sleep), acute respiratory failure with hypercapnia (a medical emergency where carbon dioxide builds up rapidly in the blood because the lungs cannot remove the waste gas effectively), and acute respiratory failure with hypoxia (a sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the bloodstream). On 8/20/26 1:33 P.M., a joint interview and record review was conducted with the Licensed Nurse (LN11). LN11 reviewed Resident 113's physician's order, CDR, and MAR. Resident 113's physician's order dated 8/6/26, indicated the resident was to receive hydrocodone-APAP 5/325 (medication used to relieve pain) milligrams (mg-unit of measure) one tab every four hours as needed for moderate to severe pain. LN11 reviewed Resident 113's CDR indicated a dose of the resident's hydrocodone-APAP 5/325 mg had been removed from the locked supply on 8/12/26 at 9 A.M. and on 8/13/26 at 11 A.M. LN11 reviewed Resident 113's MAR for hydrocodone-APAP 5/325 mg had no entry on 8/12/26 at 9 A.M. and no entry on 8/13/26 at 11 A.M. LN11 stated Resident 113's hydrocodone- APAP 5/325 mg could not be determined if the medication had been given to the resident. LN11 stated when a narcotic (a strong potentially addictive drug used to numb the senses, dull severe pain) medication was given the licensed nurse must document on the CDR and the MAR. LN11 stated it was important to document in the CDR and the MAR when the medication was given so other nurses would know when the dose had been given and for patient safety. On 8/21/26 at 1:38 PM., an interview was conducted with the Director of Nursing (DON). The DON stated his expectation was for the LN to sign the CDR when controlled medications were removed from the locked drawer and then for the LN to document in the resident's MAR once the medication was given to the resident. Per facility's policy and procedure titled Controlled Substances, revised November 2023, indicated, .2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following.b. medication administration records.

Based on observation, interview and record review, the facility did not ensure an assistive device was set up appropriately for one of four residents reviewed for assistive devices with meals (Resident 40). This deficient practice had the potential for decreased nutritional intake and independence with the potential for weight loss.Findings: Resident 40 was readmitted to the facility on [DATE] with diagnoses including muscle weakness and dysphagia (difficulty in swallowing) according to the facility's admission Record. A dining room observation was conducted on 8/18/26, at 12:07 P.M. Treatment Nurse (TN) 1 served Resident 40's meal tray. TN 1 placed a white plastic plate guard (a curved rim that clips onto the edge of a standard plate to prevent food from falling off during meals) at nine and three o'clock position, at the top rim of the plate. Resident 40 started eating the chopped broccoli which fell off the plate and onto Resident 40's lap and on the floor. Resident 40 continued to attempt to pick up the broccoli using a fork but multiple pieces continued to fall off the plate. On 818/26, at 12:30 P.M., Certified Nurse Assistant (CNA) 4 came to Resident 40's table and adjusted Resident 40's plate guard at three o'clock and nine o'clock position, at the bottom rim of the plate. CNA 4 stated the plate guard was placed incorrectly on the plate which caused multiple food items to fall off the plate and Resident 40 could not eat all of the food items on the plate. During a review of Resident 40's care plan, the care plan indicated, Resident.is at risk for further decline in functional abilities [self-care and mobility] and requires assistance related to weakness.Interventions.Adaptive Feeding Equipment: Plate guard to be provided during all meals to facilitated independence with self-feeding. An interview and joint observation on 8/20/26, at 2:50 P.M. was conducted with the Restorative Nurse Assistant (RNA- a CNA who work alongside rehab staff to provide exercises for residents with limited mobility). The RNA return demonstrated using an empty plate, how to apply the plate guard during meals for Resident 40. The RNA placed the plate guard on the plate on the left side of the plate at six o'clock and 12 o'clock position. The RNA stated it was how the plate guard should be positioned to prevent food from spilling and prevent weight loss. During an interview on 8/21/2026, at 1:52 P.M. with the Director of Nursing (DON), the DON stated the plate guard should be positioned properly to prevent spillage, to receive the nutrition Resident 40 needed and promote independence. A review of the facility's undated policy and procedure (P&P) titled, Adaptive Feeding Equipment was conducted. The P&P indicated, The purpose of Adaptive Feeding Equipment is to improve or maintain independence when eating and consuming food.The goal of the Adaptive Feeding Equipment Best Practice is to facilitate interdisciplinary [team members with various areas of expertise who work together toward the goals of their residents] communication to ensure that the appropriate adaptive feeding devices are utilized as recommended to improve or maintain independence.

Based on observation, interview, and record review, the facility failed to ensure complete resident record for one of nine residents reviewed for medical records regarding appointments (Resident 3). This failure did not facilitate communication to facility staff regarding Resident 3's appointments. In addition, this failure had the potential to miss a change in resident's condition. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of bladder and secondary malignant neoplasm of bone according to the facility's admission Record. During an interview and observation on 8/18/26 at 9 A.M., Resident 3 was lying in bed with a family member visiting. The family member stated Resident 3 had cancer of the bladder which had spread to Resident 3's bone. The family member stated Resident 3 had multiple appointments for radiation (medical procedure that uses high-energy rays or particles to destroy cancer cells and shrink tumors) and for orthopedic doctor (bone doctor). Resident 3's family member showed five notes posted on the wall with dates and time of Resident 3's appointments. Resident 3's family member stated she had notified facility staff regarding the appointments. The posted notes indicated the following appointments:8/4/26- orthopedic appointment8/6/26, 8/7/26, 8/10/26, 8/11/26 and 8/12/26- radiation treatments An interview and joint record review on 8/19/26, at 11:14 A.M. was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 3's electronic medical records (EMR). LN 1 checked physician's orders for Resident 3 and stated there was an order for orthopedic appointment on 8/4/26 but none for the radiation treatments. LN 1 reviewed progress notes (PN) for Resident 3. LN 1 stated a PN dated 8/4/26 indicated Resident 3 returned from an orthopedic appointment at 4:40 P.M. but there was no PN regarding what time Resident 3 left for the appointment. LN 1 stated the PN had documentation that Resident 3 left for radiation appointment on 8/6/26, but no documentation when Resident 3 returned from the appointment. LN 1 stated there was no PN regarding radiation appointment on 8/7/26. LN 1 stated the PN indicated Resident 3 returned from radiation appointment on 8/10/26 at 10:08 A.M. but there was no documentation when Resident 3 left the facility for the appointment. LN 1 stated PN documentation indicated Resident 3 refused radiation appointments on 8/11/26 and on 8/12/26. LN 1 stated PN should have documentation of when residents leave for appointments and upon return to the facility to check their condition for any changes. An interview on 8/21/26, at 1:52 P.M. was conducted with the Director of Nursing (DON). The DON stated nursing staff should document when residents leave the facility and upon return to the facility to monitor residents' condition. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017 was conducted. The P&P indicated, Policy Statement.All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record.Objective observations.Events, incidents .3. Documentation in the medical record will be objective,.complete, and accurate.

Based on interview, and record review the facility failed to ensure that a one of five sampled resident (Resident 4) tuberculosis (TB-contagious airborne bacterial infection that mainly infect the lungs) test was completed in accordance with the facility's infection prevention and control program. This failure to ensure an annual TB test was completed, increased the potential for an unidentified TB infection to be introduced into the facility and transmitted to other residents, staff and visitors.Findings: A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility with original date 4/28/23 and readmit date [DATE] with a diagnosis of chronic kidney disease (CKD- a condition where the kidneys are damaged over time and cannot filter blood the way they should.) On 8/21/26 at 9:38 A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP reviewed Resident 4's immunization record. The IP stated the last date Resident 4 had a TB test was on 7/30/25. The IP stated there was no documentation that Resident 4 had a TB test after 7/30/25 and no documentation of a chest x-ray. The IP stated Resident 4 should have had an annual TB test on 7/30/26. The IP stated it was important for all residents to have an annual TB test to be able to identify if any residents tested positive for TB and should be treated. The IP stated TB was contagious and if left unidentified could put Resident 4 untreated and other resident at risk to contract TB. On 8/21/26 at 1:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 4 was due for a TB test on 7/30/25. The DON stated the long-term residents should get a TB test annually. The DON stated it was important for TB testing since residents lived in a congruent living space. The DON stated Resident 4 should have had an annual TB test done. According to the CDC recommendations: Titled Clinical Testing and Diagnosis for Tuberculosis, dated April 17,2025, indicated higher risk of being infected with TB germs, you should get tested. You have a higher risk of being exposed to TB germs if you. People who currently live or used to live in large group settings where TB is more common. or nursing homes. People with diabetes mellitus. A review of the facility's policy titled Tuberculosis Infection Control Program, revised January 2026, indicated .All residents are screened for exposure to tuberculosis (TB) disease and tested appropriately.

Based on interview and record review the facility failed to ensure one of three residents sampled (Resident 14) reviewed for pneumococcal immunization (a shot that protects against serious infections caused by Streptococcus pneumoniae bacteria) was provided education and offered pneumococcal immunization. This failure had the potential to place Resident 14 at risk for acquiring, transmitting, or experiencing complications from pneumococcal disease.Findings: A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of Metabolic Encephalopathy (a temporary brain malfunction caused by chemical imbalances or toxins in the blood when the body's organs are sick or failing). On 8/21/26 at 9:38 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IP). The IP reviewed Resident 14's immunization record. The IP stated there was no documentation of pneumococcal vaccine being offered or declined and there should have. The IP stated residents living in a skilled nursing facility could expose residents to the diseases and the pneumococcal vaccine could offer protection against pneumococcal infections. On 8/21/26 at 1:30 P.M., an interview was conducted with the Director of Nursing. The DON stated residents should be offered and educated about the pneumococcal vaccine. The DON stated vaccination record should be documented that the resident/and or the resident's representative accepted or refused the pneumococcal vaccine. A review of the facility's policy titled Pneumococcal Vaccine, revised October 2023, indicated All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.3. Provision of such education is documented in the resident's medical record. 5. Residents/representative have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medication record indication the date of the refusal of the pneumococcal vaccination.

Based on observation, interview and record review, the facility failed to implement a 30-minute visual monitoring intervention for one sampled resident (1) reviewed for elopement and wandering after the resident previously eloped from the facility. As a result, Resident 1 was placed at increased risk of another potential elopement.Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a chronic mental health condition with symptoms of hallucinations, delusions and mood alterations) per the facility admission record. A review of the facility's elopement and wandering risk assessment, dated 4/10/26, indicated Resident 1 was assessed as at risk for wandering or elopement. A review of the facility's progress notes for Resident 1 indicated Resident 1 eloped from the facility on 4/16/26 sometime around 8:00 P.M. and returned to the facility the next morning on 4/17/26 at 8:45 A.M. During an observation on 4/21/26 at 2:20 P.M., Resident 1 was sitting in his wheelchair in his room near the door with multiple packed bags sitting at the foot of the bed. A binder titled, Visual observation, Q-30 minutes was labeled with Resident 1's room number and was placed on the handrail directly outside Resident 1's door. During an interview and record review on 4/21/26 at 2:32 P.M., certified nursing assistant (CNA) 1 stated he was Resident 1's CNA for the 7AM-3PM shift. CNA 1 stated Resident 1 needed to be supervised because the resident likes to leave and had previously eloped from the facility. CNA 1 stated staff was instructed to monitor and document Resident 1's whereabouts and activities every 30 minutes in Resident 1's visual observation binder (VOB). A review of Resident 1's VOB documentation for CNA 1's 7AM-3PM shift indicated CNA 1 made zero entries for the 30-minute intervals from 10:30 A.M. to 2:30 P.M. CNA 1 stated he got busy and did not fill out the 30-minute documentation for between 10:30 A.M. and 2:30 P.M. monitoring intervention. CNA 1 stated if the VOB documentation was not complete there was no way to know if anyone checked on the resident. Further review of the 30-minute visual monitoring forms in Resident 1's VOB indicated the forms included a space for the date, time, staff monitoring and the resident's activity and behavior for that period. The 30-minute visual monitoring forms in Resident 1's VOB indicated the facility had not documented monitoring entries for over two consecutive hours or more on the following dates and times: 4/17/26: 12 A.M.-2:30 A.M. (2.5 hours(hrs.), 9:30 A.M - 9:30 P.M. (12 hrs.)4/18/26: 12 A.M.-10:00 A.M (10 hrs.)4/20/26: 10 A.M. - 12 P.M. (2 hrs.) 5:30 P.M.-11:30 P.M. (6 hrs.)4/21/26: 12: A.M. - 6:30 A.M. (6.5 hrs.) 10:30 A.M.-2:30 P.M. (4 hrs.) During an interview on 4/21/26 at 2:50 P.M., licensed nurse (LN) 1 stated he was working on the evening of 4/16/26 when Resident 1 eloped from the facility. LN 1 stated Resident 1 was independent and ambulatory and was believed to have walked out of the facility unnoticed. LN 1 stated Resident 1's location should be monitored by CNA's every 30 minutes and documented in Resident 1's VOB. LN 1 stated the VOB should be filled out every 30 minutes and CNAs should not wait until the end of the shift to document because that would not be considered monitoring the resident every 30 minutes. LN 1 stated licensed nurses should be checking that CNA's fill out the VOB every 30 minutes at the end of each shift. During an interview and record review of Resident 1's VOB monitoring forms with the director of staff development (DSD) on 4/21/26 at 3:30 P.M., the DSD acknowledged the missing 30-minute visual monitoring entries for Resident 1 from 4/17/26 through 4/21/26. The DSD stated facility were expected to fill out the monitoring forms and document Resident 1's activity every 30 minutes and should know the importance of completing the task right after each observation. During an interview and record review of Resident 1's VOB monitoring forms with the director of nursing (DON) on 4/21/26 at 3:30 P.M., the DSD acknowledged the missing 30-minute visual monitoring entries for Resident 1 from 4/17/26 through 4/21/26. The DON stated staff were expected to complete visual monitoring of Resident 1 and document in the VOB every 30 minutes. The DON stated it was not ok for staff to wait until the end of their shift to document. The DON stated he was disappointed to see that monitoring checks were not completed because it placed the resident's safety at risk. A review of Resident 1's care plan for elopement, revised 4/17/26, indicated, Focus. Resident is at risk for elopement/exit seeking/wandering related to mood or behavior disorders, psychotropic/mood altering medications. Interventions. Location/safety checks. until appropriate placement or safety risk is no longer identified. A review of the facility in-service titled, Elopement vs Wandering: Code Yellow, dated 4/17/26, given to all staff by the DSD indicated, . Objective: Staff will demonstrate understanding of wandering and elopement risks, identify residents at risk and correctly implement prevention strategies. in order to maintain resident safety. Course Content. 3. Prevention. Staff awareness. Supervision at all times (q30 rounds). 6. Post elopement Care. Documentation. 8. Conclusion. Prevention is everyone's job; Early intervention is key. A review of the facility policy titled, Wandering, Unsafe Resident, revised August 2014, indicated, Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.

Based on interview and record review, the facility failed to explain the discharge plan to one of two sampled residents (1). As a result, Resident 1 may not have been aware of the scheduled post-discharge appointment with his physician.Findings: Per the facility's admission Record, Resident 1 was admitted on [DATE] with diagnoses to include heart failure, and discharged from the facility on 4/3/26. Per the facility's Discharge Summary and Post-Care Instructions V2.0 dated 4/2/26, Resident 1 was to be discharged to home on 4/3/26 with a scheduled appointment with his primary care physician (PCP) on 4/7/26. On 4/16/26 at 10:05 A.M., an interview was conducted with the Case Manager (CM). The CM stated that she scheduled the appointment with Resident 1's PCP, but did not discuss the PCP appointment with Resident 1 or his family because that was the responsibility of the Licensed Nurse (LN) at the time of discharge. On 4/16/26 at 10:14 A.M., an interview was conducted with LN 3. LN 3 stated, she conducted the discharge for Resident 1, but she did not discuss the scheduled PCP appointment with Resident 1 or his family because that was the responsibility of the CM prior to discharge. On 4/16/26 at 10:21 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, for Resident 1, the CM should have discussed the scheduled PCP appointment with Resident 1 during discharge planning, and LN 3 should have discussed the scheduled PCP appointment with Resident 1 at the time of discharge. The facility's policy, titled Transfer or Discharge, revised March 2025, did not contain instructions on discharge planning, or communicating the discharge plan to the resident.

Based on interview and record review, the facility failed to administer medications as ordered for one of four sampled residents (1). As a result, Resident 1 was placed at an increased risk of medication side effects.Findings: Per the facility's admission Record, Resident 1 was admitted on [DATE] with diagnoses to include heart failure, and discharged from the facility on 4/3/26. Per the facility's Medication administration Record for March 2026, Resident 1 had orders for Amlodipine (a medication to lower blood pressure) 5 milligrams (MG), isosorbide mononitrate (a medication to lower blood pressure) extended release 30 MG, and lisinopril (a medication to lower blood pressure) 5 MG. All three medications were ordered to be given every day, but not to administer if Resident 1's systolic blood pressure was less than 110. On 3/1/26 Licensed Nurse (LN) 2 documented that they administered all three medications and that his systolic blood pressure was 106 at the time of administration. On 4/28/26 at 9:04 A.M., a telephone interview was conducted with LN 2. LN 2 stated, she did not remember giving Resident 1 his blood pressure medications while his systolic blood pressure was less than 110. On 4/28/26 at 9:50 A.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, LN 2 should have held Resident 1's blood pressure medications when his systolic blood pressure was less than 110. Per the facility's policy, titled Administering Medications dated 2001, 4. Medications are administered in accordance with prescriber orders.6. Medication errors are documented, reported, and reviewed

Based on observation, interview and record review, the facility failed to ensure medications were not left unattended at Resident 1's bedside table for 1 out of 3 sampled residents reviewed for medication administration. This failure had the potential to place residents at risk for ingestion of the medications. Findings.An unannounced visit to the facility was conducted on 2/17/26 relative to an anonymous complaint regarding the quality of care the facility provides. A review of the facility's undated admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included encounter attention to gastrostomy (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medication) and seizures (a sudden uncontrolled surge of electrical activity in the brain). During a tour of the facility on 2/17/26 at 10:15 A.M., Resident 1 was observed lying in bed with his eyes closed. A clear plastic cup was observed with medications crushed mixed in a tea colored liquid on Resident 1's bedside table. A review of Resident 1's minimum data set (MDS - a federally mandated assessment tool) dated 1/7/26 indicated Resident 1's brief interview for mental status (BIMS) cognition- (thought process) was blank. A review of Resident 1's physician orders dated 6/16/24 indicated Resident 1 was on the following medications:Ascorbic acid (Vitamin C) tablet 500 mg (unit of measurement), give 1 tablet via g-tube in the morning for immune support.Furosemide oral tablet 40 mg, give 1 tablet via g-tube in the morning for diuretic. Hold dose if systolic blood pressure -top number in a reading) sbp <100. Multivitamin with minerals oral tablet (multiple vitamins with minerals), give 1 tablet via g-tube in the morning for dietary supplement. A review of the Medication Administration Record (MAR) dated 2/17/26 indicated the above medications were administered and signed off by the licensed nurse (LN) as being given. On 2/17/26 at 11 A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated she left Resident 1's medications on Resident 1's bedside table to further dissolve in water. LN 1 stated she should not have left the medications in a clear cup on Resident 1's bedside table for safety, since some residents or someone might picked up the medications, take them and swallow them. On 2/17/26 at 11:15 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated medications should not be left anywhere in any resident rooms unattended. The DON stated it was important to not leave medications unattended for residents' safety . A review of the facility's policy titled, Storage of Medications dated April 2007 indicated, #2.The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. #7. Compartments (including but not limited to drawers, cabinets, rooms, ) containing biologicals shall be locked when not in use.items shall not be left unattended .

Based on Observation, interview and record review, the facility failed to maintain accurate documentation for one of three sampled residents (Resident 1). when Resident 1's medication left unattended at Resident 1's bedside was documented as being given. This failure created inaccurate information which could affect Resident 1's plan of care. Findings. An unannounced visit to the facility was conducted on 2/17/26 relative to an anonymous complaint regarding the quality of care the facility provides. A review of the facility's undated admission record indicated resident 1 was admitted to the facility on [DATE] with diagnoses that included encounter attention to gastrostomy (GT- a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medication) and seizures (a sudden uncontrolled surge of electrical activity in the brain). During a tour of the facility on 2/17/26 at 10:15 A.M., Resident 1 was observed lying in bed with his eyes closed. A clear plastic cup was observed with medications crushed mixed in a tea-colored liquid on Resident 1's bedside table. A review of Resident 1's minimum data set (MDS - a federally mandated assessment tool) dated 1/7/26 indicated Resident 1's brief interview for mental status (BIMS) cognition- (thought process) was blank. A review of Resident 1's physician orders dated 6/16/2024 indicated Resident 1 was on the following medications.Ascorbic acid (Vitamin C) tablet 500 mg (unit of measurement), give 1 tablet via g-tube in the morning for immune support.Furosemide oral tablet 40 mg , give 1 tablet via g-tube in the morning for diuretic. hold dose if systolic blood pressure -top number in a reading) sbp <100.Multivitamin with minerals oral tablet( multiple vitamins with minerals) , give 1 tablet via g-tube in the morning for dietary supplement. A review of the Medication Administration Record (MAR) dated 2/17/25 at 9 A.M. indicated the above medications were administered and signed off by the licensed nurse (LN) as being given. On 2/17/26 at 11 A.M., an interview with the Licensed Nurse (LN) 1 was conducted. LN 1 stated she left Resident 1's medications on Resident 1's bedside table to further dissolve in water she had administered earlier and had already documented in the MAR. On 2/17/26 at 11:15 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated medications should not be left anywhere in any resident rooms unattended. The DON stated LN 1 had documented in the MAR she had administered Resident 1's medications via GT. A review of the facility's policy titled Administering Medications dated April 2029 , indicated Policy & Implementation #1. Only licensed or permitted by the state to prepare, administer and document the administration of medications.#4. Medications are administered in accordance with prescribers orders . #21. If a drug is withheld, refused , or given at a time other than the scheduled time, the individual administering the medication .

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for one of 24 sampled residents (41) and four unsampled residents (63,80, 191, 36) reviewed for pharmacy services when: 1. Resident 63's Aspirin 81 mg chewable (a prescribed medication as a stroke prophylaxis) was administered over the one hour allotted time frame. 2. The manufacturer's instructions for Fluticasone nasal spray (a nasal spray for allergies) was not followed when the medication was administered to Resident 191. 3. Resident 41's G-tube (a surgical opening fitted with a device to allow feedings or medications to be administered directly to the stomach) was not properly auscultated for placement before medication administration. In addition, the Licensed Nurse (LN 35) did not administer the resident's medication by gravity. 4. Controlled medications (drugs with high abuse potential) prescribed to Resident 80 and Resident 36 could not be accounted for. As a result, the facility could not ensure pharmaceutical services were safely provided to its residents. In addition, the facility was unable to readily identify potential loss and/or drug diversion (illegal distribution or abuse of prescription drugs). Findings: 1. A review of Resident 63's admission Record indicated the resident was admitted to the facility on [DATE]. On 5/29/25 9:15 A.M., a medication administration observation was conducted with Licensed nurse (LN) 33. LN 33 was observed preparing, dispensing, and then administering the aspirin to Resident 63. A review of Resident 63's physician orders dated 3/19/25, indicated the resident was to receive aspirin 81 milligrams once a day. The medication was scheduled to be administered at 7:00 A.M. A review of Resident 63's medication administration record (MAR) indicated the resident's aspirin was documented as administered to the resident on 5/29/25 at 9:39 A.M. On 5/30/25 at 8:56 A.M., an interview and record review was conducted with LN 32. LN 32 reviewed Resident 63's MAR dated 5/29/25 and stated administration for Aspirin order time is 7:00 A.M. daily. LN 32 stated Resident 63's aspirin administration occurred at 9:39 A.M. LN 32 stated, it was late. LN 32 stated it was important to follow physician's order. On 5/30/25 at 3:25 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 63's aspirin was not administered timely. The DON stated it was her expectation for all nursing staff to follow the physician's orders. A review of the facility's policy titled Administering Medications, revised 4/2019, indicated, .4. Medications are administered in accordance with prescriber orders, including any required timeframe 2. A review of Resident 191's admission Record indicated the resident was admitted on [DATE]. On 5/29/25 at 10:05 A.M., a medication administration observation was conducted with licensed nurse (LN) 34. LN 34 was observed preparing and dispensing medications for Resident 191. LN 34 was observed administering Fluticasone nasal spray to Resident 191. LN 34 instructed Resident 191 to tilt her head back as LN 34 assisted with administering nasal spray in Resident 191's nostrils. A review of the Fluticasone packaging insert indicated, .Instructions for using Fluticasone nasal spray .Step 2. Close one nostril. Tilt your head forward slightly and keeping the bottle upright .Step 7. Wipe the nasal applicator with a clean tissue and replace the translucent cap On 5/30/25 at 8:56 A.M., an interview was conducted with LN 32. LN 32 stated it was important to follow manufacturer guidelines for the medication to be effective. On 5/30/25 at 9:12 A.M., an interview and record review was conducted with LN 34. LN 34 reviewed the Fluticasone nasal spray packaging insert (for Resident 191's Fluticasone). LN 34 stated she did not follow the manufactures instructions when administrating the Fluticasone nasal spray to Resident 191. LN 34 stated she should have instructed the resident to tilt her head forward. LN 34 stated it was important to follow manufacture guidelines for the medication to be effective. On 5/30/25 at 3:25 P.M., an interview was conducted with the DON. The DON stated her expectation was for all nursing staff to follow manufactures guidelines when administering medications for the medication to be effective. The DON stated LN 34 should have instructed Resident 191 to tilt her head forward. 3. A review of Resident 41's admission Record indicated the resident was admitted on [DATE]. On 5/29/25 at 8:15 A.M., a medication administration observation was conducted with licensed nurse (LN) 35. LN 35 was observed preparing a medication to be administered via G-tube for Resident 41. LN 35 was observed auscultating Resident 41's G-tube with 10 cc of water to check for placement before administering medication. LN 35 stated Its good. LN 35 was observed using the syringe/plunger to push the medication and a water flush into the resident's G-tube. LN 35 did not attempt to administer the medication or water flush via gravity. On 5/30/25 at 8:56 A.M., an interview was conducted with LN 32. LN 32 stated to verify placement of a G-tube before medication administration, the LN had to push a syringe filled with air into the G-tube while auscultating the resident's abdomen. LN 32 stated medication administered via G-tube had to be given via gravity. On 5/30/25 at 9:23 A.M., an interview was conducted with LN 35. LN 35's observed medication administration for Resident 41 on 5/29/25 was discussed. LN 35 acknowledged she had auscultated the water flush to verify placement and did not attempt to administer the resident's medication via gravity. LN 35 stated, That is my practice. On 5/30/25 at 3:25 P.M., an interview was conducted with the DON. The DON stated it was important to know the placement of a G-tube to ensure medication or feeding is going into the stomach and not the lungs. The DON stated placement was verified by auscultating air injected into the G-tube and listening with a stethoscope for placement. The DON stated medication and water flush should be administered by gravity as per policy. The DON stated her expectation was for all nursing staff to follow facility policy. Per facility policy and procedure titled Administering Medication through and Enteral Tube, revised November 2018, indicated, .6. Verify placement of feeding tube 12. Administer medication by gravity flow: A. pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. B. Open the clamp and deliver medication slowly 4a. A review of Resident 80's admission Record indicated the resident was admitted on [DATE]. Resident 80's physician's order, controlled drug record (CDR), and electronic medication administration record (EMAR) was reviewed. Resident 80's physician's order dated 3/23/25, indicated the resident was to receive oxycodone 2.5 mg (medication used to relieve pain) one tab every four hours as needed for pain level of 4-6 (self-rated pain score indicating moderate pain) and oxycodone 5 mg one tab every six hours as needed for pain level of 7-10 (self-rated pain score indicating severe pain). A review of Resident 80's EMAR indicated on 5/13/25 and 5/15/25, the resident's oxycodone 5 mg was signed out on the CDR but was not documented on the EMAR. Resident 80's oxycodone 5 mg had been removed again from the locked supply on 5/13/25 and 5/24/25. Resident 80's EMAR for oxycodone 5 mg had blank entries on 5/13/25 and 5/24/25 and it could not be determined if the medication had been given to the resident. 4b. A review of Resident 36's admission Record indicated the resident was admitted on [DATE]. A review of Resident 36's physician's order, CDR, and EMAR was conducted. Resident 36's order dated 4/19/25, indicated the resident was to receive Norco oral tab 10-325 mg (medication used to relieve pain) one tab every four hours as needed for moderate to severe pain. A review of Resident 36's CDR indicated the resident's Norco10/325mg was removed from locked storage on 5/27/25 and 5/28/25 but was not documented on the EMAR. It could not be determined if the medication had been given to the resident. On 5/30/25 at 1:58 P.M., an interview and record review was conducted with LN 35. LN 35 stated she had to sign controlled medications out on the CDR and document on the EMAR when the medication was given to the resident. LN 35 stated that it was important to keep track of controlled medications so that other LNs knew when the medication was given. LN 35 reviewed Resident 36's CDR and EMAR for Norco 10/325 on 5/27/25 and 5/28/25. LN 35 stated she should have documented when she administered the medication in the resident's EMAR. On 5/30/25 at 2:12 P.M., an interview with record review was conducted with the Assistant Director of Nursing (ADON). The ADON reviewed Resident 80's CDR and EMAR for oxycodone 5 mg on 5/13/25 and 5/24/25. The ADON stated the administration of the resident's oxycodone was not documented on the EMAR. The ADON reviewed Resident 36's CDR and EMAR for Norco 10/325mg on 5/27/25 and 5/28/25. The ADON stated the resident's Norco administration was not documented on EMAR. The ADON stated when a controlled medication was given to a resident, nurses were required to document the medication administration right away. The ADON stated she did not audit the CDR or EMAR. On 5/30/25 at 3:25 P.M., an interview was conducted with the DON. The DON stated the importance of reconciling controlled medications was to ensure accurate accounting of controlled drug medication and to prevent drug diversion. The DON stated her expectation was for the EMAR and CDR to match. The facility's policy and procedure, titled Controlled Substance, revised November 2022, indicated, .Dispensing and reconciling controlled substances 1. Controlled substances inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection/follow-up

Based on observation, interview, record review, the facility failed to ensure medications were stored and labeled according to acceptable standard of practice during an inspection of two of three medication carts, and one of two medication rooms when: 1. Expired insulin (medication to lower blood sugar levels) was stored in a medication cart. 2. Ipratropium/albuterol inhalation (breathing medication) was stored unprotected from light in the medication cart. 3. A box of Ampicillin 3 grams vials was stored inside a drawer in the medication room without the medication label. These failures had the potential for medications to have reduced effectiveness and/or medication misuse. Findings: On [DATE] at 2:34 P.M., an observation and interview was conducted with Licensed Nurse (LN) 35. LN 35's assigned medication cart was inspected. Ipratropium/albuterol inhalation vials were kept in a foil packing in a box that had the lid open. The medication was exposed to light when the medication cart was opened. LN 35 stated the lid should have been closed to protect the medication from light. A review of patient information for Ipratropium/albuterol inhalation from (manufacture name) dated [DATE], indicated, .Protect from light. Keep unused vials in the foil pouch or carton On [DATE] at 2:35 P.M., an observation and interview was conducted with LN 33. LN 33's medication cart was inspected. A vial of Humalog 100 units (insulin) had an opened date of [DATE]. LN 33 stated it should have been discarded because it may lose it potency after 28 days. On [DATE] at 2:45 P.M., an observation and interview was conducted with LN 36 while inside the medication room. An unlabeled box of Ampicillin 3 gram vials (8 vials) was kept inside a drawer. The drawer also contained a plastic bag and a pen. LN 36 stated she did not know why the medication was kept in the drawer with no label. On [DATE] at 2:12 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the box of Ampicillin should have been in a plastic bag with a label of the resident's name and other information on it from the pharmacy. The ADON stated the medication should have been discarded. On [DATE] at 3:25 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated expired insulin could lose its potency. The DON stated her expectation was for all nurses to take expired medication out of cart and discard them. The DON stated the box of Ipratropium/albuterol inhalation should have been closed at all times to protect the medication from the light. The DON stated the Ampicillin should have been discarded. A review of facility's policy titled Medication Labeling and Storage, revised February 2023, indicated, .Medication Labeling . 2. The medication label includes at a minimum; a. medication name prescribed dose . e. Resident's name . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days According to the FDA's online document titled Information Regarding Insulin Storage and Switching Between Products in an Emergency dated [DATE], indicated, .insulin products in vials or cartridges supply by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 [degrees Fahrenheit] and 86 [degrees Fahrenheit] for up to 28 days and continue to work

Based on observation and interview the facility failed to cook food in a way to preserve the palatability of the food. As a result, residents may not want to eat the food served to them and have the potential for weight loss. Findings: 1. After the initial resident screening and confidential group interview it was determined there were resident complaints about the food served at the facility. The resident complaints included the food was served cold and did not taste good. During initial tour from 5/27/25 to 5/28/25 the following resident comments regarding food complaints were: On 5/27/25 at 08:28 A.M., during the initial screening Resident 36 stated the food does not taste good and looks cheap. Resident 56 stated food needs more variety food looks thrown together and worse on weekends the food issue has been brought up in resident council, but still feels food has not changed. On 5/27/25 at 8:47 A.M., Resident 6 stated the food was served cold at times. On 5/27/25 at 9:12 A.M., Resident 291 stated she did not eat the food served, the food tasted horrible, the presentation was horrible. Resident 291 stated she had thrown food away. Family brings her food in. On 5/27/25 at 9:27 A.M., Resident 38 stated the food was Disgusting, he doesn't eat the food, he gets something else. On 5/27/25 at 9:50 A.M., Resident 15 stated breakfast is always cold. The food combinations are weird. She stated she eats a lot of sandwiches. She stated her Diabetic doctor told her the biggest meal of the day should be breakfast, but here they just give her eggs. She complained the give her things she doesn't eat. On 5/27/25 at 10:24 A.M., Resident 23 stated the food is okay, but the portions to small, and the food can be cold when they get it. On 5/27/25 at 3:18 P.M., Resident 81 stated the food is not that great and he gets alternatives like a burger. On 5/28/25 at 08:15 A.M., Resident 20 stated food does not taste good and is cheap maybe they get the food from 99 cent store stated she gets a veggie or fruit plates due to food tasting bad During the confidential group interview on 5/28/25 at 8:52 A.M., the residents stated we had issues about the food. The main issue was on the weekends when the Supervisor is not there. The sausage was cold, and cottage cheese not available. These resident complaints determined to the Survey team a test tray was needed to verify the temperatures and the taste of the food. On 2/28/25 a test tray was requested during the lunch tray line. According to the Menu, lunch was Roast Turkey with Savory Cream Sauce, Herb Roasted Red Potatoes, [NAME] Cauliflower and Peas, Fresh [NAME] Salad and [NAME]. The test tray was brought to the floor at 12:51 P.M., the temperatures were tested, and all meal items were tasted by the surveyor and the DSS for temperature and taste. The temperature of the food items was palatable, the Roast Turkey was tasteless the DSS agreed.

Based on observation, interview, and record review the facility failed to provide care and services according to professional standards of practice to one (Resident 6) of four residents reviewed for quality of care when: 1. The facility did not assess Resident 6's change in condition and, 2. The facility did not notify the physician of Resident 6's change in condition. As a result, the physician was not aware of Resident 6's change of condition and Resident 6 expired. Findings: Resident 6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) and ischemic cardiomyopathy (damaged heart muscle from lack of blood flow) according to the facility's Admission Record. During a review of progress notes (PN) written by the assigned night shift nurse for Resident 6 dated [DATE] at 5:20 A.M., the PN indicated the certified nurse assistant (CNA) reported to the charge nurse that resident was not responding. The PN indicated cardiopulmonary resuscitation (CPR-a lifesaving technique used when someone's heart was not beating) was initiated for Resident 6 and 911 (emergency telephone number) was called. The PN further indicated, Paramedics arrived after 5 minutes after the call was made. Paramedics pronounced resident expired. An interview was conducted on [DATE] at 2:50 P.M., with certified nurse assistant (CNA) 3. CNA 3 stated she was assigned to Resident 6 on [DATE], night shift which started at 10:30 P.M. until 7 A.M. CNA 3 stated during rounds at approximately 4 A.M. to 5 A.M., she found Resident 6 unresponsive. CNA 3 stated she called out, Hello, hello, then shook Resident 6, but did not wake up. CNA 3 stated she notified licensed nurse (LN) 4 right away. CNA 3 further stated Resident 6 was asleep when she checked Resident 6 at 10:30 P.M., 12 A.M., and at 2 A.M. An interview was conducted on [DATE] at 1:52 P.M., with LN 3. LN 3 stated he was assigned to Resident 6 on [DATE], night shift which started at 11 P.M. LN 3 stated there was no report of any change in condition from the afternoon LN regarding Resident 6. LN 3 stated he saw Resident 6 at approximately 12 A.M. to 1 A.M. and Resident 6 was sitting up at the edge of his bed, watching TV without any changes. LN 3 stated at approximately 5 A.M., the CNA notified him that Resident 6 was unresponsive. LN 3 stated he ran to the room and called another LN. LN 3 stated he and the other LN placed Resident 6 on the floor and initiated CPR until the paramedics (health care professionals who responds to emergency calls) arrived. An interview was conducted on [DATE] at 2:06 P.M., with LN 4. LN 4 stated he was assigned to Resident 6 on [DATE] 2:30 P.M. until 11 P.M. LN 4 stated CNA 6 notified him at around 9:30 P.M. to 10 P.M. that Resident 6 refused to take a shower because Resident 6 was not feeling well. LN 4 stated he requested for Resident 6's vital signs (VS- temperature, heart rate, breathing), but CNA 6 did not provide Resident 6's VS. LN 4 stated he did not follow up to take Resident 6's VS or check on Resident 6's condition because he was busy. LN 4 was asked when he would check on a resident and replied, It depended on the needs of the resident. If there was a change in condition it would be a priority. During an interview on [DATE] at 2:57 P.M., with CNA 6, CNA 6 stated she worked on the [DATE] afternoon shift and was assigned to provide a shower for Resident 6. CNA 6 stated CNA 3 was assigned to Resident 6 for the afternoon shift. CNA 6 stated Resident 6 was offered a shower at 3:30 P.M. and Resident 6 refused because he was not feeling well. CNA 6 stated Resident 6 requested to return later. CNA 6 stated she offered a shower again to Resident 6 at 4:30 P.M., and Resident 6 stated he still did not feel well and looked pale and sweaty. CNA 6 stated she reported to LN 4 that Resident 6 refused shower and did not feel well. CNA 6 stated LN 4 instructed her to have the assigned CNA take Resident 6's VS. CNA 6 stated LN 4 got upset because CNA 3 brought the VS machine to LN 4 with Resident 6's VS instead of writing them on a piece of paper. After dinner, CNA 6 stated she offered the shower to Resident 6 again with CNA 3 as the witness, but Resident 6 was still pale and sweaty. CNA 6 stated she notified LN 4 again and LN 4 asked how Resident 6 looked. CNA 6 stated she reported that Resident 6 looked like he had flu symptoms. CNA 6 further stated LN 4 did not check on Resident 6. During a review of Weights and Vitals Summary for Resident 6, there was no documentation of Resident 6's temperature and respirations on [DATE] afternoon shift. An interview was conducted on [DATE] at 3:50 P.M., with the director of nurses (DON). The DON confirmed CNA 3 was assigned to Resident 7 on [DATE] afternoon shift. The DON stated if she was the licensed nurse and a CNA did not take a resident's VS per her instruction, she then would take the VS herself and complete an assessment prior to physician notification. An interview was conducted on [DATE] at 3:06 P.M., with LN 7 regarding a resident's change in condition. LN 7 stated she would assess the resident, take the resident's VS, and notify the physician. The facility's director of staff development (DSD- a licensed nurse certified for staff training) was interviewed on [DATE] at 3:14 P.M. The DSD stated she had conducted an in-service for the facility's licensed nurses regarding resident change in condition. The DSD stated licensed nurses were taught to complete the e-Interact (Interventions to Reduce Acute Care Transfers- an electronic quality improvement program designed to improve identification, evaluation, and communication about changes in resident status) form which triggered staff to notify the physician. The DSD further stated assessment of a resident with a change in condition should be performed prior to physician notification. During a review of an In-service Attendance Record, dated [DATE] titled, COC (change of condition) documentation and Processes ., the in-service attendance record did not have LN 4's signature under Attendance. Resident 6's physician was interviewed on [DATE] at 9 A.M. The physician stated Resident 6 had diagnoses including CHF, ischemic cardiomyopathy, and a history of myocardial infarction (MI- a heart attack). The physician stated he was not aware that Resident 6 had symptoms of sweating and being pale. The physician stated symptoms of being sweaty and pale were signs of ischemia (lack of blood flow to a part of the body). The physician further stated he expected the facility staff to assess (evaluate) Resident 6 and to notify him of the change in condition. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .