Every finding on record at Rancho Mirage Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the licensed nurse appropriately assessed and monitored the combative behavior incident resulting in multiple areas of skin discoloration for one of three residents evaluated for quality of care (Resident 1). In addition, the licensed nurse did not promptly inform the physician or responsible party after Resident 1's combative incident identified on July 5, 2026.This failure placed Resident 1 at risk for delayed medical intervention and increased the likelihood of complications related to the combative incident. On July 16, 2026, an unannounced visit was conducted at the facility to investigate a complaint about lack of notification regarding an incident involving Resident 1.On July 16, 2026, at 9:10 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was in bed, alert, interviewable, and appeared confused. Resident 1 was observed with fading purplish yellow skin discolorations, variable in size, on the left side of the forehead, left and right inner periorbital area (area surrounding the eyes), bridge of nose, both arms and anterior hands. Resident 1 stated she did not know how she got her skin discolorations. On July 16, 2026, at 9:45 am, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated he was assigned to Resident 1 on the morning shift of July 6, 2026. CNA 1 stated he noticed the multiple skin discolorations on Resident 1's face and arms and informed both the night and morning Licensed Nurses (LN) between 7:00 am and 8:00 am that day. CNA 1 stated he did not know what happened to Resident 1 since he did not receive a report from the night shift of any incident involving Resident 1. On July 16, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (memory loss). The Nursing Progress Notes, completed by a LN, dated July 6, 2026, 9:22 a.m., indicated, .This writer was called by the charge nurse to assess discoloration to arms for resident. During assessment notes skin discoloration to nose bridge that extend to bilateral inner canthus (the area around the eye next to the nose) of the eye and left temporal site. There is multiple skin discoloration to upper extremities with different marks to skin.Advise calling the nurses from previous shift to ask if resident had a behavior of aggressiveness due to previous history.The Nursing Progress, completed by Licensed Vocational Nurse (LVN) 1, dated July 6, 2026, at 11:31 a.m., indicated, .Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Other change in condition.Outcomes of Physical assessment .Mental Status Evaluation: No changes observed.Functional Status Evaluation: No changes observed: Behavioral Status Evaluation (No response entered by LVN 1).Neurological Status Evaluation (No response entered by LVN 1).Primary Care Provider Feedback.Recommendations: New order for Ativan (medication used to treat anxiety). The ADL (Assisted Daily Living) CNA notes, completed by CNA 2, dated July 5, 2026, at 7:59 p.m., indicated, After Dinner, brief change, pt (patient) became increasingly agitated and extremely combative, hitting, scratching, biting, kicking, when performing care, 4 eyes/2 people are strongly recommended for pt and staff safety.The Nursing Progress notes for the evening shift on July 5, 2026, did not indicate that an incident was reported by CNA 2 and/or that a LN conducted an assessment following Resident 1's combative and striking behavior toward CNA 2 during care. Furthermore, there is no indication in the record that the physician or Resident 1's responsible party were notified of Resident 1's combative incident prior to July 6, 2026.On July 16, 2026, at 2:02 pm, an interview was conducted with LVN 1. LVN 1 stated:- She was the licensed nurse assigned to Resident 1 on July 6, 2026, during the morning shift;- CNA 1 reported to her during change of shift that Resident 1 had multiple discolorations on her face and bilateral arms around between 7:00 a.m. to 8 a.m.; - She asked the night shift LN what happened to Resident 1 during their shift and the night shift LN told her she did not know; - She and the night shift LN checked Resident 1, but neither knew what happened or received an incident report for the previous day's event (July 5, 2026);- Resident 1 had a behavior of striking out and combative during care; - Resident 1's physician was not notified of the combative incident that occurred on July 5, 2026, until she reported to the physician on July 6, 2026.On July 20, 2026, at 2:18 p.m., an interview with a concurrent record review on Resident 1's CNA ADL notes was conducted with Registered Nurse (RN) 1 and LVN 2. Bothe RN 1 and LVN 2 stated:- CNA 2 documented on Resident 1's ADL notes on July 5, 2026, at 7:59 p.m., that Resident 1 was, .increasingly agitated and extremely combative, hitting, scratching, biting, kicking, when performing care.;- CNA 2 did not indicate if the LN was notified of Resident 1's combative behavior and there was no documentation CNA 2 notified the LN about Resident 1's combative behavior on July 5, 2026, at 7:59 p.m; and- There was no documentation from the LN on July 5, 2026, during the p.m. shift, that Resident 1 was reported combative during the care with CNA 2, and/or the LN assessed, evaluated the resident, and notified the physician and family. On July 20, 2026, at 2:40 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated:- Resident 1 had a history of combative behavior and striking out. Resident 1 had an incident of combative behavior with CNA 2 on July 5, 2026, during the p.m. shift;- Resident 1's hands can be everywhere when she gets combative. She hits, spits, and kicks and her skin discolorations may have been caused by that;- The LN, LVN 3, assigned to Resident 1 during that shift should have reported to the physician and notified Resident 1's family of her combative and striking out behavior on July 5, 2026, during the p.m., shift;- LVN 3 should have documented what had happened and started a Change in Condition (COC) monitoring on Resident 1 during her shift on July 5, 2026. The facility's policy and procedure titled, Resident Examination and Assessment, dated December 2011, indicated, .The purpose of this procedure is to examine and assess the resident for any abnormalities in health status.Review the resident's admission assessment and/or preliminary care plan to assess for any special situations regarding resident care.Examine and note the following.Vital Signs.Cardiovascular.Respiratory.Neurological.Musculoskeletal.Skin.Activity Level.Psychiatric/Behavioral.oriented to time, place, person.affect.attention span.appropriate response to questions.combativeness.Pain.The following information should be recorded in the resident's medical record.The date and time the procedure was performed.The name and title of individual (s) who performed the procedure.All assessment data obtained during the procedure.Reporting.Notify the physician of any abnormalities such as, but not limited to.change in cognitive, behavioral or neurological status from baseline.Report other information in accordance with the facility policy and professional standards of practice.The facility's policy and procedure titled, Change in a Resident's Condition or Status, dated April 2011, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) or changes in the resident's medical/mental condition.The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review for one of three residents reviewed for quality of care (Resident 1), the facility failed to ensure:1. An appropriate assessment and evaluation were conducted prior to obtaining an order for Lorazepam (generic name for Ativan, a medication used to treat anxiety) as needed (PRN) for 14 days on June 21, 2026; and2. An appropriate assessment, monitoring, and evaluation were conducted prior to obtaining an order for Lorazepam 0.5 milligram (mg- unit of measurement) give one tablet by mouth every 12 hours for anxiety manifested by striking out, on July 6, 2021. This failure placed Resident 1 at high risk for unnecessary medication use without proper assessment. Findings:1. On July 16, 2026, at 9:10 a.m., an observation with concurrent interview was conducted with Resident 1. Resident 1 was in bed, alert, interviewable, and appeared to be confused. Resident 1 was observed with multiple fading purplish yellow skin discolorations, variable in size, on the left side of the forehead, left and right inner periorbital area (area surrounding the eyes), bridge of nose, both arms and anterior hands. Resident 1 stated she did not know how she got her skin discolorations.On July 16, 2026, at 9:45 am, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated Resident 1 was confused, exhibits combative behavior during care, and sometimes physically strikes staff.On July 20, 2026, at 2:18 p.m., a record review with a concurrent interview was conducted with Registered Nurse (RN) 1.Resident 1 was admitted to the facility on [DATE], with diagnoses including anxiety.The document titled, HISTORY AND PHYSICAL, dated January 26, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.The physician's order indicated to give Lorazepam 0.5 mg to give one tablet by mouth every 12 hours as needed for anxiety for 14 days (ordered June 21, 2026, and discontinued July 5, 2026).The PRN Lorazepam order did not specify a target behavior for its use. In addition, there was no documented assessment or evaluation conducted by the Licensed Nurse (LN) and/or physician, to justify the use of PRN Lorazepam for Resident 1, and there was no documentation explaining why the LN obtained the PRN lorazepam order on June 21, 2026.In a concurrent interview, RN 1 stated the LN who carried out the order for the PRN Lorazepam 0.5 mg for anxiety for 14 days, on June 21, 2026, did not document the reason why the order was obtained and there was no documentation of an assessment or evaluation conducted prior to obtaining the order. RN 1 stated the PRN Lorazepam did not indicate a specific target behavior for use. RN 1 stated there should have been documentation by the licensed nurse why the Lorazepam PRN order was obtained and carried out.2. On July 16, 2026, at 9:32 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 1 was confused, exhibits combative behavior during care, and sometimes physically strikes staff.On July 20, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including anxiety.The document titled, HISTORY AND PHYSICAL, dated January 26, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.The CNA ADL (Assisted Daily Living) notes indicated: (Name of Resident).7/5/2026 19:59.increasingly agitated and extremely combative, hitting, scratching, biting, kicking, when performing care, 4 eyes/2 people are strongly recommended for Pt (abbreviation to indicate 'patient') and staff safety.06/24/2026 21:47.Resident was being combative, which made it really hard to take blood pressure tried more than 6x throughout the day.06/24/2026 11:44.Pt was showing signs of agitation, was punching, bitting (sic.) and kicking CNAs nurse informed.There was no documented evidence Resident 1's combative behavior identified on June 24, 2026, and July 5, 2026, were reported, monitored, and/or addressed by the Licensed Nurse (LN).Resident 1 had the following physician's orders:- Lorazepam 0.5 milligrams (mg- unit of measurement) give one tablet by mouth every 12 hours as needed for anxiety for 14 days, ordered June 21, 2026, and discontinued July 5, 2026;- Lorazepam 0.5 mg give one tablet by mouth every 12 hours for anxiety manifested by striking out, ordered July 6, 2026;- Monitor episodes of anxiety manifested by striking out, ordered July 6, 2026;- .Intervention(s) that best works to alleviate behavior. Key: 0-No intervention attempted.2-Redirect 3- Remove from situation/Ensure resident Safety 4- Calm Environment.12-Resident refused. Every shift for intervention Document the corresponding number of interventions attempted. Document effectiveness of interventions. ordered December 1, 2025; and,- Monitor anxiety manifested by inability to relax, ordered December 2, 2025, and discontinued July 6, 2026.The document titled, Care Plan Report, dated November 9, 2022, indicated, .Behavioral symptoms.physically abusive hitting, striking out, grabs, scratches.resists care: hits out, yells and kicks.R/T (related to) Dementia.Interventions.Assess for pain. Provide interventions as deemed necessary.attempt to determine the cause of upset and resolve if possible.monitor behavior q shift and record. Notify MD (Medical Doctor) if behavior interferes with functioning.Nursing staff to leave resident when combative and return when she is calm to provide care.The document titled, Care Plan Report, dated September 9, 2022, indicated, .Focus.The resident uses anti-anxiety medications Lorazepam 0.5mg by mouth two times a day for anxiety M/B (manifest by) striking out r/t anxiety disorder.Intervention.Monitor/record occurrence of for target behavior symptoms.Specify.violence/aggression towards staff/others. and document per facility protocol.The electronic medication Administration Record (eMAR) dated July 1 to 31, 2026, indicated the following:- The PRN Lorazepam order to give 0.5 mg by mouth every 12 hours as needed for anxiety was administered to Resident 1 on the following dates:- July 1, 2026, at 12:49 pm;- July 2, 2026, at 5:28 p.m.;- July 3, 2026, at 3:07 p.m.; and- July 4, 2026, at 8:19 a.m., and 8:57 p.m.The eMAR did not indicate the target behavior intended for the PRN Lorazepam use prior to administering the medication on those dates;- Resident 1 had two episodes of anxiety manifested by inability to relax (July 3 and 4, 2026) during the period from July 1 to 6, 2026;- There were no non-pharmacological interventions attempted or offered to Resident 1 to address the anxiety behaviors from July 1 to 6, 2026; and-The monitoring of Resident 1 for aggressive or combative behavior did not begin until July 6, 2026.The document titled, MONTHLY PSYCHOTROPIC SUMMARY, indicated Resident 1 had 25 episodes of inability to relax behavior for the month of June 2026. The document did not indicate Resident 1 was being monitored for combative or striking out behavior for the month of June 2026.The document titled, .Change in Condition Evaluation. completed by LVN 1 and dated July 6, 2026, indicated, .Signs and Symptoms Identified.Multiple discolorations to face and to bilateral upper extremities. Increased combativeness.This condition, symptom or sign has occurred before.Unknown.Mental Status Evaluation.No changes observed.Date and time of clinician notification.07/06/26 12:50.Recommendation of Primary Clinician.new order for Ativan (brand name for Lorazepam).Is the behavioral assessment relevant to the change in condition been reported .Not clinically applicable to the change in condition being reported.Describe behavioral changes: (no entered response by LVN 1).Is the resident/patient displaying any of the following signs and symptoms? (No entered response by LVN 1) . The Change of Condition Evaluation notes did not indicate an assessment, monitoring, or evaluation conducted to address Resident 1's combative and striking out behavior from July 1 to 6, 2026, prior to obtaining the order for Lorazepam 0.5 mg by mouth every 12 hours for anxiety manifested by striking out on July 6, 2026.On July 16, 2026, at 1:25 p.m., an interview with a concurrent record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated:- Resident 1's previous Lorazepam order was .Lorazepam.Give 0.5 mg by mouth every 12 hours as needed for anxiety . ordered June 21, 2026, and discontinued July 5, 2026;- On July 5, 2026, Resident 1 had an incident of increased combative behavior with staff. LVN 1 notified the physician on July 6, 2026 and received an order for routine Lorazepam 0.5 mg orally every 12 hours for anxiety with striking out.- He did not see a recorded or documented increased combative or striking out behavior documentation in Resident 1's record prior to obtaining the routine Lorazepam order on July 6, 2026;- The licensed nurses should have documented, monitored, assessed, evaluated, and determined the cause of the increased combative and striking out behavior prior to obtaining the routine Lorazepam order on July 6, 2026; and- There was no adequate monitoring and evaluation conducted on Resident 1's increased combative and striking out behavior prior to obtaining the routine Lorazepam order on July 6, 2026.The facility's policy and procedure titled, Psychotropic Medication Use, dated July 2022, indicated, .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying cause.Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications.Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.For psychotropics that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.Resident Evaluations.Situations which may prompt an evaluation or re-evaluation of the resident include.a new, persistent, or recurrent clinically significant symptom or problem.a worsening of an existing problem or condition.The evaluation may include.an evaluation of resident status (co-morbid conditions, symptoms, psychiatric diagnosis, etc.).resident goals and preferences.history or medication use.When determining whether to initiate, modify, or discontinue medication therapy, the IDT (Inter Disciplinary Team) conducts an evaluation of the resident. The evaluation will attempt to clarify whether.other causes for symptoms (including symptoms that mimic psychiatric disorder have been ruled out.signs and symptoms are clinically significant to warrant medication therapy.

Based on observation and interview, the facility failed to meet professional standards when two of two toured medication rooms had expired COVID-19 (coronavirus disease 2019, contagious infection responsible for the death of over one million people in the United States) test kits. This failure had the potential for inaccurate test results which could cause missed COVID-19 infections and possible infection spread in the facility.Findings: 1. During a concurrent observation and interview on [DATE], at 2:29 p.m. with Licensed Vocational Nurse 2 (LVN 2), the Medication room [ROOM NUMBER] tour was conducted. There was one opened box of COVID-19 test kits in the room. LVN 2 stated the test kit expired on [DATE], and she would remove it from the room. 2. During a concurrent observation and interview on [DATE], at 2:46 p.m. with LVN 3, the Medication room [ROOM NUMBER] tour was conducted. There were six boxes of COVID-19 test kits in the room with an expiration date of [DATE]. There was also an opened box containing one combination flu and COVID-19 test kit with an expiration date of February 24, 2026. LVN 3 stated she would give the expired test kits to the Infection Preventionist (IP). During an interview on [DATE], at 2:25 p.m., the IP stated the test kits found in Medication rooms [ROOM NUMBERS] were expired. During a telephone interview on [DATE], at 10:50 a.m., the Consultant Pharmacist (CP) stated the expectation was expired COVID-19 test kits were discarded in the medication waste bin. The CP stated, anything expired shouldn't be on the shelf. During an interview on [DATE], at 12:07 p.m., the IP stated the facility did not have a policy addressing expired supplies. The IP stated the standard of practice was for expired COVID-19 test kits to be thrown away. The IP stated expired test kits were supposed to be discarded one week prior to the expiration date and confirmed this was not done. The IP stated there was a concern of inaccurate test results if the expired test kits were used. During an interview on [DATE], at 10:28 a.m., the Director of Nursing (DON) stated the expired COVID-19 test kits should not have been in the medication rooms. The DON stated if the expired test kits were accidentally used, there was a concern of false readings.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and manufacturer's specifications when:1. Inhaled medications were not labeled with an open date in two of four reviewed medication carts (Medication Carts 1 and 2), and2. One inhaled medication was not stored inside the foil pouch as required by the manufacturer in one of four reviewed medication carts (Medication Cart 2).These deficient practices had the potential to expose residents to deteriorated or ineffective medications, which could lead to the use of unsafe and ineffective medications for the residents.Findings: 1a. During a concurrent observation and interview on [DATE], at 10:49 a.m. with Licensed Vocational Nurse 5 (LVN 5), Medication Cart 1 was reviewed. The medication cart contained one opened box of generic DuoNeb (ipratropium bromide 0.5 milligrams [mg] and albuterol sulfate 3 mg inhalation solution for nebulizer, a machine that turns liquid inhaled medications into mist, to treat chronic obstructive pulmonary disease [COPD-a chronic lung disease causing difficulty in breathing]) for Resident 20 with an opened foil pouch of the medication inside. The pharmacy label on the box indicated, Fill Date: [DATE]. The box was also labeled, OD [open date]: [DATE], in black marker. LVN 5 stated the DuoNeb box was supposed to be labeled with the date opened. LVN 5 stated she did not know why the open date was before the medication was filled by the pharmacy. LVN 5 stated the medication needed to be discarded because there were too many dates on the box and she did not know when it was opened. LVN 5 stated all inhaled medications needed to be labeled with the open date because some medications expired after being opened. 1b. During a concurrent observation and interview on [DATE], at 11:04 a.m. with LVN 5, Medication Cart 2 was reviewed. The medication cart contained one opened box of generic DuoNeb 0.5-3 mg inhalation solution for Resident 101 with an opened foil pouch of the medication inside. LVN 5 acknowledged the box did not have a labeled open date. During an interview on [DATE], at 11:38 a.m., the Director of Staff Development (DSD) stated the nurses were supposed to label DuoNeb boxes with the open date. The DSD stated he did not know when Resident 20's DuoNeb was opened because the labeled open date was before the pharmacy fill date. 2. During a continued concurrent observation and interview on [DATE], at 11:04 a.m. with LVN 5, Medication Cart 2 was reviewed. The medication cart also contained a clear plastic bag with six doses of generic DuoNeb 0.5-3 mg inhalation solution. The bag was labeled for Resident 101 with a fill date of [DATE]. The bag had a yellow sticker which indicated, Once the product is removed from the pouch, discard unused medication. LVN 5 stated she did not know the meaning of the yellow sticker. During a telephone interview on [DATE], at 10:50 a.m., the Consultant Pharmacist (CP) stated DuoNeb was supposed to be stored in the foil pouch to protect from light. During a telephone interview on [DATE], at 11:18 a.m., the Consultant Pharmacist (CP) stated DuoNeb vials were supposed to be kept in the foil pouch after opening. The CP stated the medication needed to be used within 14 days after removing from the foil pouch because of light exposure. During an interview on [DATE], at 11:38 a.m., the DSD stated Resident 101's DuoNeb was supposed to be stored in the foil pouch, not a clear plastic bag. The DSD stated the facility would not know if the medication was expired without proper labeling and storage. The DSD stated if the open date or expiration date was unknown, the medication needed to be replaced. During an interview on [DATE], at 1:03 p.m., the Director of Nursing (DON) stated the expectation was for opened inhalers and nebulizer medications to be labeled with the open date. The DON stated DuoNeb was not supposed to be stored in a clear plastic bag. The DON stated if medications were not labeled or stored properly, the nursing staff were supposed to remove them from the medication carts so they were not used for residents. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for ipratropium and albuterol nebulizer solution (generic for DuoNeb), dated [DATE], retrieved from DailyMed, indicated: .PROTECT FROM LIGHT. The unit-dose vial should remain stored in the protective foil pouch until time of use. and .Once removed from the foil pouch, the individual vials should be used within one week. A review of the facility's policies and procedures (P&P), titled, Medication Labeling and Storage, undated and provided by the DON, indicated, 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 observation and interview, the facility failed to ensure food was served at a palatable temperature consistent with resident preferences for five of 91 sampled residents (Residents 19, 27, 68, 75, and 79)This failure had the potential to diminish resident satisfaction with meals and adversely affect residents' enjoyment of dining and food intake. Findings:On May 18, 2026, at 11:12 a.m., an interview was conducted with Resident 27. Resident 27 stated, hot foods were sometimes cold and cold foods were not cold as should be.On May 19, 2026, at 9:11 a.m., an interview was conducted with Resident 19. Resident 19 stated that hot food was cold during every meal. On May 19, 2026, at 11:10 a.m., an interview was conducted with Resident 68. Resident 68 stated that hot foods were cold.On May 20, 2026, at 12:47 p.m., an interview was conducted with Resident 79 and Resident 75. Resident 79 stated food temperatures were not as hot as expected. Resident 75 stated that food was cold and never served hot. On May 20, 2026, from 11:23 to 12:23 p.m., observations were conducted in the kitchen during meal service. Multiple meal items were removed from the steam table, plated three to four trays at a time, and held on a shelf above the steam table for approximately one to three minutes before being covered and placed into meal carts for service. On May 20, 2026, at 12:32 p.m., an observation and interview were conducted with Dietary Manager (DM 1), two sample meal trays were tested for temperature. Pureed meat sauce with noodles measured 115 degrees Fahrenheit ( F), and pureed green beans measured 105 F. DM 1 stated the temperatures did not meet the department's expected serving temperature of 120 F. DM 1 further stated temperatures below the department's expected standard could affect meal palatability and resident satisfaction. DM 1 stated residents should receive hot and cold foods at appropriate serving temperatures. On May 21, 2026, at 8:53 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated staff were expected to serve food directly from the steam table onto plates and cover them immediately, avoiding hold times greater than two minutes as a standard practice. The RD stated hot food should be maintained at temperatures that remain appealing to residents. The RD further stated meal quality and enjoyment depend on proper temperature control and timely delivery from the kitchen to the resident. The RD stated meals that did not meet resident expectations should be replaced with freshly prepared food. On May 21, 2026, at 12:30 p.m., follow up interview were conducted with Residents 19 and 68. Resident 19 stated the meal was not cold but needed to be warmer. Resident 68 stated the rice and vegetables were not hot enough. A review of the policy and procedure titled, Food Preparation and Service, dated November 2022, indicated, .food distribution.proper hot and cold temperatures are maintained during food distribution and service.A review of the culinary service group, a nationally recognized food service management company, article titled, Food safety 101 dated January 2021, indicated, .Food must be prepared by methods that conserve nutritive value, flavor, and appearance .Food and drink must be palatable, attractive, and at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for three of seven residents (Residents 4, 7, and 78) during the medication administration observation, when:1. Nursing staff failed to follow enhanced barrier precautions (EBP, infection control practice) for one resident (Resident 4),2. Nursing staff failed to properly clean and disinfect the prefilled insulin (medication for diabetes to treat high blood sugar) pen before use for one resident (Resident 7), and3. Nursing staff failed to properly clean and disinfect a shared glucometer (blood glucose [sugar] meter to measure the amount of sugar in the blood) for two residents (Residents 78 and 7). These failures had the potential to expose residents to infection and to compromise residents' health and safety in the facility.Findings: 1. During a medication pass observation on May 18, 2026, at 10:13 a.m., Licensed Vocational Nurse 6 (LVN 6) was observed preparing five medications for Resident 4. An orange flyer posted at Resident 4's doorway indicated STOP - ENHANCED BARRIER PRECAUTIONS. LVN 6 entered Resident 4's room and put on gloves before administering the medications through Resident 4's gastrotomy tube (G-tube, small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications). LVN 6 did not wear a gown while administering medications to Resident 4. A review of Resident 4's physician's orders, dated January 29, 2025, indicated Resident 4 had orders for Enhanced Barrier Precautions due to.g-tube. During an interview on May 18, 2026, at 2:29 p.m., LVN 2 stated nurses were supposed to wear a gown and gloves when handling a G-tube. During an interview on May 20, 2026, at 12:13 p.m., the Infection Preventionist (IP) stated nurses were supposed to wear a gown when giving medications through a G-tube. The IP stated he was aware LVN 6 did not wear a gown during Resident 4's morning medication pass on May 18, 2026. The IP stated Resident 4 had enhanced barrier precautions (EBP) in place. The IP stated, for residents with EBP, the gown acted as a barrier between the nurse and the resident to prevent the resident from getting an infection. The IP further stated for a resident with a serious infection, the nurse's gown also prevented the infection from spreading to other residents. During an interview on May 21, 2026, at 10:28 a.m., the Director of Nursing (DON) stated the nurse was supposed to wear a gown during Resident 4's morning medication pass to follow EBP. The DON stated the gown was a barrier to prevent infection transmission. A review of the facility's policies and procedures (P&P), titled, Enhanced Barrier Precautions, dated April 2024, indicated: .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDROs [infections that do not respond to antibiotics]) to residents. and .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use (.feeding tube.) 2. During a medication pass observation on May 18, 2026, at 4:29 p.m. in the hallway outside of Resident 7's room, LVN 4 was observed preparing one medication, Novolin R FlexPen (brand name of prefilled insulin pen), for Resident 7. LVN 4 removed the insulin cap and attached the needle to the pen tip. LVN 4 did not wipe the pen tip with anything before attaching the needle. LVN 4 then administered the medication to Resident 7. During an interview on May 18, 2026, at 4:39 p.m., LVN 4 stated he was supposed to wipe the insulin pen tip with an alcohol swab before attaching the needle and he forgot to do it for Resident 7. During an interview on May 19, 2026, at 2:18 p.m., the IP stated nurses were supposed to clean the insulin pen tip with an alcohol swab before attaching the needle. The IP stated the pen tip needed to be cleaned with an alcohol swab to prevent bloodborne pathogens (infections carried in and spread through blood). During an interview on May 21, 2026, at 10:28 a.m., the DON stated insulin pen tips were supposed to be wiped before attaching the needle. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Novolin R FlexPen, dated November 23, 2022, retrieved from DailyMed, indicated, .Pull off the pen cap.Wipe the rubber stopper with an alcohol swab. A review of the facility's P&P, titled, Prefilled Insulin Pen Device Prep & Administration, dated February 2026, indicated, Clean the rubber seal on the insulin cartridge with a sterile alcohol swab. 3. During a concurrent observation and interview on May 18, 2026, at 3:21 p.m. outside Resident 78's room, LVN 4 was observed exiting the room with a glucometer. LVN 4 stated he checked Resident 78's blood sugar. LVN 4 wiped the glucometer with an alcohol swab and put the glucometer away in the medication cart. During an observation on May 18, 2026, at 4:29 p.m. in Resident 7's room, LVN 4 was observed using the glucometer to check Resident 7's blood sugar. LVN 4 returned the glucometer to the medication cart without wiping it. During a concurrent observation and interview on May 18, 2026, at 4:39 p.m. outside Resident 7's room, LVN 4 stated nurses were supposed to wipe the shared glucometer with an alcohol swab before and after checking blood sugar for each resident for cleanliness. LVN 4 then used an alcohol swab to wipe the glucometer. During an interview on May 19, 2026, at 9:49 a.m., LVN 2 stated nurses were supposed to use the disinfecting wipes with the purple lid (brand name Sani-Cloth) to sanitize the glucometer between residents. During an interview on May 19, 2026, at 2:08 p.m., the IP stated nurses were supposed to use bleach wipes or the disinfecting wipes with the purple lid to sanitize the glucometer between residents. The IP stated alcohol swabs were not acceptable because the alcohol did not kill certain types of bacteria. The IP stated the glucometer was sanitized between residents to prevent bloodborne pathogens. During an interview on May 21, 2026, at 10:28 a.m., the DON stated the shared glucometer needed to be disinfected with the appropriate sanitizing wipes. The DON confirmed alcohol swabs were not sufficient to sanitize the glucometer. During a concurrent interview and record review on May 19, 2026, at 4:19 p.m. with the IP, the facility's P&P, titled, Cleaning and Disinfection of Environmental Surfaces, dated April 2025, was reviewed. The P&P indicated, Manufacturers' instructions will be followed for proper use of disinfecting.products. The IP stated there was no other facility policy to address the timing or selection of disinfecting wipes for the shared glucometer. A review of the manufacturer's instructions for cleaning and disinfecting the glucometer, titled, Guidelines for Cleaning and Disinfecting the Assure Platinum Meter [facility's glucometer], undated and provided by the IP, indicated: . To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended.The meter should be cleaned and disinfected after use on each patient. and .ARKRAY [manufacturer] recommends using these wipes to clean and disinfect the Assure Platinum meter.Clorox Healthcare Bleach Germicidal [kills bacteria and viruses] Wipes.Super Sani-Cloth Germicidal Disposable Wipes. A review of the facility's P&P, titled, Administering Medications, dated April 2019, indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of 11 residents reviewed for dignity (Resident 47) when Resident 47's meal tray was not provided at the same time as the other residents seated at her table. This failure had the potential to negatively affect Resident 47's sense of dignity, self-worth, and self-esteem.Findings: On May 18, 2026, at 11:54 a.m., an observation was conducted in the dining room with Resident 47. Resident 47 was seated at a table with two other residents. The other residents were served their meals and began eating. Resident 47 did not receive her meal until 12:05 p.m., approximately eleven minutes later, and was observed looking around while waiting for her meal to arrive. On May 18, 2026, at 12:15 p.m., a concurrent observation and interview were conducted with the Certified Nursing Assistant (CNA 1). CNA 1 stated Resident 47's meal tray had not been ready which had caused the delay in serving her meal with the other residents at the table. CNA 1 further stated that meal trays should be served to all residents at a table at the same time, so residents were not left waiting and watching other eat, in order to preserve resident's dignity. On May 20, 2026, at 10:55 a.m., an interview was conducted with Resident 47. Resident 47 stated she ate lunch in the dining room almost every day and preferred to receive her meal at the same time as the other residents seated at her table. On May 21, 2026, at 9:21 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated residents seated together were expected to receive their meals at the same time. The RD further stated serving meals separately could make residents feel left out and could negatively affect their sense of self-worth or self-esteem. A review of the facility's Policy and Procedure titled Quality of Life - Dignity, dated August 2009, indicated: .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.Residents are treated with dignity and respect at all times.

Based on interview and record review, the facility failed to ensure a resident received a prompt response and notification of the grievance investigation findings following submission of a grievance for one of four residents reviewed for grievances (Resident 9). This failure had the potential to leave Resident 9 unaware of whether her grievance had been investigated and addressed, which had the potential to contribute to ongoing dissatisfaction regarding her concerns. Findings:On May 18, 2026, at 3:31 p.m., an interview was conducted with Resident 9 in her room. Resident 9 stated staff and a physician referred to her as a troublemaker. Resident 9 stated she was upset by the comment. Resident 9 stated It's irritating. It makes me mad after a while. Resident 9 stated she had filed a grievance with the Social Services Director (SSD) regarding the physician's comment but had not received any follow-up. Resident 9 further stated the incident occurred a couple of weeks earlier at the nurses' station while she was with another resident. Resident stated she ignored the comment at that time but did not like being called that. A review of Resident 9's record showed she was admitted on [DATE], with diagnoses including depression (mood disorder that causes a persistent feeling of sadness). A review of Resident 9's Minimum Data Set (MDS- an assessment tool), dated April 6, 2026, indicated her Brief Interview for Mental Status (BIMS) score was 14, reflecting intact cognitive function. On May 20, 2026, at 9:15 a.m., an interview was conducted with the SSD. The SSD stated that Resident 9 filed a grievance approximately two months earlier regarding a comment made by the physician. The SSD further stated she informed the physician of the grievance and told him Resident 9 expected an apology. The SSD stated she was unsure whether the physician had apologized to Resident 9. The SSD further stated she did not follow-up on the grievance after speaking with the physician. A review of the Grievance Report Form and Follow Up/Investigation Report dated March 26, 2026, indicated multiple sections were incomplete including: - Department Manager Filing Follow Up Report: DON, F/U Report date: - Was the complaint/grievance addressed? - Date resident notified of report findings, - By, and Copy of report given to. -The form contained the SSD's signature but no date indicating the completion of the grievance investigation. Further review of Resident 9's medical record indicated no documented evidence that Resident 9 was notified of the findings or outcome of the investigation since the grievance was filed on March 26, 2026. On May 21, 2026, at 12:55 p.m., a follow-up interview was conducted with the SSD. The SSD stated the grievance form was incomplete and stated it was her responsibility to ensure the grievance investigation was completed and documented. The SSD further stated there should have been a follow-up with Resident 9 and that Resident 9 should have been informed of the outcome of the grievance. On May 21, 2026, at 12:58 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that she was not aware of the grievance and had not participated in the investigation. The DON stated the grievance remained unresolved and Resident 9 had not been informed of any findings or outcome. The DON stated the Social Services was responsible for following up with the resident regarding the physician's response and documenting the investigation. The DON further stated it was important to notify residents of grievance findings and result to ensure the resolution was acceptable to the complainant. The DON stated documentation of grievance investigations was necessary to demonstrate the grievance was investigated, addressed, communicated, and resolved. The DON further stated the facility did not follow its grievance process. The facility's policy titled Grievances/Complaints, Filing, dated 2017, indicated, .the Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is Social Services.Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings within 5 working days of receiving a grievance and/or complaint. The person filing the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation.

Based on observation, interview, and record review, the facility failed to administer one medication as ordered by the prescriber for one of seven residents (Resident 78) during the medication administration observation. This failure resulted in Resident 78 receiving a dose of metoprolol tartrate (generic for Lopressor, a medication to treat high blood pressure) without food which could cause hypotension (low blood pressure which can cause dizziness and fainting).Findings: During a medication pass observation on May 18, 2026, at 3:48 p.m. in the hallway outside of Resident 78's room, Licensed Vocational Nurse 4 (LVN 4) was observed administering four medications to Resident 78. The medications included one tablet of metoprolol tartrate 50 milligrams (mg). LVN 4 gave Resident 78 a cup of water to take with the medications. A review of Resident 78's physician's orders, dated October 13, 2022, indicated Resident 78 had orders for metoprolol tartrate 50 mg by mouth two times a day for hypertension (high blood pressure), take with food. During a concurrent interview and record review on May 18, 2026, at 4:48 p.m. with LVN 4, Resident 78's metoprolol tartrate orders were reviewed. LVN 4 stated Resident 78's metoprolol tartrate orders indicated to give the medication with food. LVN 4 stated he did not give Resident 78 food with the medication because it was too early for dinner. During a telephone interview on May 20, 2026, at 10:50 a.m., the Consultant Pharmacist (CP) stated metoprolol tartrate was recommended to give with food. The CP stated the concern was the blood pressure dropping too low if given without food. During an interview on May 20, 2026, at 11:51 a.m., the Director of Staff Development (DSD) stated if a medication was ordered to take with food, the expectation was the nurse would give the medication with food. The DSD stated Resident 78's metoprolol tartrate should have been given with dinner or with a snack. During an interview on May 21, 2026, at 10:28 a.m., the Director of Nursing (DON) stated Resident 78's metoprolol tartrate should have been given with food. The DON stated the physician's orders were supposed to be followed. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for metoprolol tartrate tablets, dated January 31, 2024, retrieved from DailyMed, indicated, Metoprolol tartrate tablets should be taken with or immediately following meals. A review of the facility's policies and procedures (P&P), titled, Administering Medications, dated April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure the personal belongings of one of three residents reviewed (Resident A) were protected when Resident A's hearing aid was not properly removed and stored. This failure resulted in damage to the device, which had the potential to cause impaired communication between Resident A, facility staff, and family. Findings: A review of Resident A's admission record indicated the resident was admitted to the facility on [DATE], with diagnosis of metabolic encephalopathy (brain dysfunction) and hearing loss. A review of Resident A's History and Physical dated February 19, 2026, indicated the resident did not have the capacity to make decisions. A review of Resident A's care plan dated February 19, 2026, indicated .The resident has an ADL (Activities of Daily Living) Self Care .wears bilateral hearing aids, one hearing aid missing .apply hearing aid Q am (every morning), collect hearing aids, open battery, and store Q HS (every bedtime) .A review of Resident A's Minimum Data Set (an assessment tool) dated February 22, 2026, indicated Resident A was highly impaired in hearing and utilized hearing aids. On March 9, 2026, at 5:30 p.m., during an interview with Resident A's Family Member (FM), the FM stated another family member visited the resident and noticed the resident's hearing aid was missing. The FM stated a staff member was notified, and the hearing aid was later found in the laundry, damaged. On March 12, 2026, at 11:15 p.m., during a concurrent observation and interview in Resident A's room with the FM present, the resident was lying in bed wearing only the right hearing aid. A Certified Nursing Assistant (CNA) asked Resident A if she was ready for lunch, the resident did not respond. When the FM repeated the question at a louder volume, the resident responded. The FM stated Resident A could hear with one hearing aid but not as well as when both hearing aids were in place. On March 12, 2026, at 12:30 p.m., during an interview with Laundry Supervisor (LS), the LS stated personal belongings should be checked in resident's clothing prior to laundering and any items found should be returned to the nursing station. The LS stated for Resident A's hearing aid, the laundry aid should have checked the clothing, and it was missed. On March 26, 2026, at 1:15 p.m., during an interview with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the resident's daughter reported the hearing aid missing. LVN 2 stated that after searching the room, staff located the hearing aid in the laundry area, where it was found damaged. LVN 2 further stated the daughter had previously instructed staff to remove the hearing aid prior to the resident's shower. On March 27, 2026, at 9:02 a.m., during an interview with the Director of Nursing (DON), the DON stated the CNA who placed clothes in the hamper should have checked to make sure no personal belongings were in the resident's clothing. The DON further stated laundry staff should have checked to make sure that the clothing placed in the washer did not contain any personal items such as phone, glasses, or hearing aids. On March 27, 2026, at 12:10 p.m., during an interview with CNA 2, CNA 2 stated hearing aids should be removed prior to showers and stored in a designated case or secured location to prevent loss or damage. A review of the facility undated policy and procedures titled Hearing Aid, Care of, indicated .The purpose of this procedure is to maintain the resident's hearing at the highest attainable level.Do not clean or immerse any part of the hearing aid in water.Do not expose a hearing aid to heat, moisture or aerosol vapor.The licensed nurses are responsible for removal and storage of hearing aid.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to one of three residents reviewed for accidents (Resident 1), who was wheelchair bound and cognitively impaired. Resident 1 was left unsupervised while outside the facility. In addition, there was no interventions developed by the facility to address the resident who was at risk for injury and accidents due to impaired cognition.This failure resulted in Resident 1 being hit by a moving vehicle while out in the parking lot of the facility, which has the potential to cause pain or injury to Resident 1.Findings:On January 12, 2026, at 10:51 a.m., an unannounced visit was conducted at the facility to investigate a complaint and facility reported incident involving an accident. On January 12, 2026, at 10:51 a.m., during an observation of the facility parking lot, front patio, and front entrance, the following were observed:a. The facility had a large parking lot with a smooth surface that connected directly to a u-shaped driveway and the facility entrance.b. There was no observed caution signage, patio seating, or safety barrier for pedestrians due to expected vehicle traffic on the u-shaped driveway near the facility entrance.c. The facility entrance had an automatic sliding door.d. Upon entering, the lobby was clean with seating available. The receptionist sat behind a desk with a tall countertop that had a box of facial masks and signage, obstructing the view of the entrance. On January 12, 2026, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (one-sided body weakness resulting in brain damage after a stroke).A review of the care plans for Resident 1 did not indicate interventions addressing the resident's risk for injury related to impaired cognition.A review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated November 10, 2025, indicated Resident 1 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 9 (moderate cognitive impairmentA review of Resident 1's eINTERACT Change in Condition Evaluation, dated January 2, 2026, indicated, .resident was hit by a SUV [sport utility vehicle - a larger car that sits higher off the ground than most regular cars] outside facility in the parking lot while she was propelling her wheelchair .But resident keeps on stating to feel left elbow discomfort .A review of Resident 1's COC (Change of Condition)/INTERACT ASSESSMENT FORM, dated January 2, 2026, at 1:49 p.m., indicated, .resident was propelling herself .outside left side parking lot .white little suv was backing out .resident was behind the vehicle .driver did not see resident .sitting in her wheelchair .hit resident on the left side of the wheelchair .resident was yelling .to stop the car .one eyewitness was honking .to stop the car .other witness ran .alerted the driver .MD (medical doctor) advice to send resident to ER (emergency room) .eval (evaluation) and treatment .A review of the hospital document titled Summary of Care Document, dated January 2, 2026, indicated .Encounter Diagnoses .pain in left elbow .On January 12, 2026, at 2:38 p.m., an interview was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 stated Resident 1 was oriented to self and place but not oriented to the situation. LVN 1 stated Resident 1 required increased supervision due to impaired judgement. LVN 1 stated residents were allowed in the activities room and dining room; and could go to the front or back patios only with supervision. LVN 1 stated all residents that sit outside on front patio should be supervised. LVN 1 stated Resident 1 should not have been on front patio unsupervised or alone due to impaired judgement and wandering risk. On January 12, 2026, at 4:14 p.m., an interview with concurrent record review of Resident 1's MDS dated [DATE], was conducted with the Director of Nursing (DON). The DON stated Resident 1's BIMS score indicated cognitive impairment. The DON stated the resident (Resident 1) should have been supervised while outside.On January 15, 2026, at 2:38 p.m., an interview was conducted with the DON. The DON stated the facility did not have staff or patrol assigned to monitor the facility exits or parking lot. The DON stated the facility exit doors did not have alarms. The DON stated there were no facility policy for resident designated areas.On January 15, 2026, at 3:35 p.m., LVN 2 stated in an interview that residents could access the back patio without restrictions unless the weather was unsafe. LVN 2 stated the facility door was unlocked and accessible 24/7. LVN 2 stated residents with cognitive impairment required supervision on the back patio and were only allowed on the front patio if accompanied by a CNA, licensed nurse, caregiver, or family member, to ensure safety.On January 16, 2026, at 12:22 p.m., an interview was conducted with Certified Nurse Assistant (CNA) 1. The CNA stated a resident with cognitive impairment cannot be in front of facility or parking lot without supervision.On January 16, 2026, at 1:45 p.m., an interview was conducted with the receptionist. She reported that on January 2, 2026, Resident 1 requested candy at her desk, then exited to the front patio unsupervised. The facility exit doors open automatically by sensor motion. She stated that monitoring and supervising residents was not part of her responsibilities.On January 16, 2026, at 3:41 p.m., an interview was conducted with Certified Occupational Therapist Assistant (COTA). The COTA stated Resident 1 was not ambulatory and required 1 person assist for transfers. The COTA stated a resident with cognitive impairment should not be outside of the facility without supervision. The COTA stated the incident could have been prevented by the facility.

Based on interview and record review, the facility failed to ensure that residents were treated with dignity and respect when staff awakened one resident in the middle of the night to ask if she wanted to be moved to another room, for one of three sampled residents (Resident A).This failure had the potential to cause unnecessary disruption, discomfort, and interfere with the resident's ability to attain her highest practicable physical, mental, and psychosocial well-being.On July 8, 2025 @ 11:09 a.m., an unannounced visit to the facility was conducted to investigate an allegation of resident rights issue.A review of Resident A's admission Record, indicated Resident A was admitted on [DATE], with diagnoses which included osteoarthritis (a chronic joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones in joints), and aftercare following joint replacement surgery.A review of facility document titled Notification of Room/Roommate Change Form, dated June 18, 2025, indicated, .Reason for Room Change .Resident Request-Prefers other room .Patient (Resident A) requested a room move on 6/18/25. She was offered a room on station 2 but declined at that time. She was then again offered that evening and stated she will move in the morning .On July 8, 2025, at 4:39 p.m., during an interview with the Certified Nurse Assistant (CNA), the CNA stated he worked night shift from 10:30 p.m. to 6:30 a.m. The CNA stated on June 18, 2025, earlier in the shift, the outgoing Registered Nurse (RN) instructed him to ask Resident A if she wanted to have room change to occur that night or the following day. The CNA stated he went to Resident A's room, around 11 p.m. to 11:15 p.m., and asked if she wanted to move that night or tomorrow.On July 8, 2025, at 4:55 p.m., during an interview with the Director of Nursing (DON), the DON stated the facility's practice is to discuss room changes with residents when they are awake and not to disturb them during sleep to ask such questions. A review of the facility's undated document titled Resident ‘s [NAME] of Rights , indicated .Resident has to be treated with consideration, respect and full recognition of dignity and individuality.A review of the facility's undated policy and procedure titled Transfer, Room To Room, indicated, .Unless Medically necessary or for the safety and wellbeing of the resident(s), a resident will be provided with an advance notice of the room transfer.

Based on observation, interview, and record review, the facility failed to implement a fall prevention intervention for one of three sampled residents (Resident 1), by not ensuring the tab monitor was attached while the resident was in a wheelchair, as sspecified in the resident's care plan. This failure had the potential to place Resident 1 at risk for further falls and potential injury. Findings: A review of Resident 1's medical record titled, Personal Information, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of a fracture (broken bone) to lower back, and muscle weakness. A review of Resident 1's care plan dated February 8, 2025, indicated, .Resident is at risk for falls r/t (related to) impaired mobility, hx (history) of falls .Intervention .apply tabs monitor in w/c (wheelchair) to remind resident to get assistance for ambulation (walking) and transfers . A review of Resident 1's, Brief Interview of Mental Status (a cognitive assessment), dated February 11, 2025, indicated a score of 14 (cognitively intact). A review of Resident 1's Progress Notes, dated February 22, 2025, at 2:00 p.m., indicated, . Resident had an unwitnessed fall . found resident sitting on the floor . (resident reported they) stood up and took unassisted steps . became unsteady . fell back and landed on her (butt). On February 25, 2025, at 1:39 p.m., a concurrent observation and interview with Resident 1 was conducted. Resident 1 was observed sitting in a wheelchair beside her bed, watching television. A tab monitor was observed hanging from the right side of the resident's bed rail, unattached to the resident. Resident 1 stated she had weakness and unsteady on her feet. Resident 1 further stated that she had a fall on February 22, 2025, because she did not use her call light to request for assistance before getting out of the wheelchair. On February 25, 2025, at 2:24 p.m., a concurrent interview and observation of Resident 1 with Certified Nursing Assistant (CNA1), CNA1 stated as part of her routine process, she checked to ensure residents are attached to their tab monitor and that the devices were functioning properly. CNA1 stated during the shift report, she was informed that Resident 1 had fallen over the weekend (February 22, 2025) and the fall intervention of a tab monitor was added to the resident's care plan for safety. CNA1 stated the tab monitor was not attached to Resident 1 while she was sitting in the wheelchair. CNA1 stated she should have checked that the tab monitor was attached to Resident 1. On February 25, 2025, at 4:10 p.m., an interview was conducted with RN 1, who stated, after a resident fall, the interdisciplinary team ({IDT}-Nursing, social services & department managers) would meet to identify the root cause of the fall and implement interventions to prevent further falls. RN1 stated after Resident 1's fall on February 22, 2025, the intervention of a tab monitor while sitting in a wheelchair was added to the resident's care plan for safety. On February 25, 2025, at 5:05 p.m., an interview was conducted with the Director of Nursing (DON), who stated a tab monitor was added to Resident 1's care plan after the resident's fall on February 22, 2025. The DON stated the tab monitor should have been attached to Resident 1 while she was sitting in her wheelchair. The DON stated, she expected Resident 1 to have the tab monitor attached while sitting in the wheelchair to ensure implementation of the care plan. A review of the facility Policy & Procedure (P&P), titled, Tab Alarms, Bed Alarms, Wanderguard System, undated, indicated, . Tab alarms . may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls . Policy Interpretation and Implementation . 2. A plan of care must be formulated with the Interdisciplinary Team ({IDT}-Nursing, Physical Therapy, Occupational Therapy, dietary, Activities, Social Worker, and Resident/Family) . to determine the need for tab . alarms . and documented in the Care Plan . 3. The tab alarm will be utilized on the resident when they are out of bed in a wheelchair or chair . 4. After applying the tab alarm . in place, a safety check to make sure they are in proper working condition must be done before leaving the resident. a) Documentation of the tab . alarm checks will be made in the resident record each shift daily. b) Before application of tab . alarms, they are dated on the date of application and documented in the resident record .

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters' lids were not closed, and the surrounding area was littered with trash. This failure had the potential to attract pests and rodents which could lead to contamination and food borne illness among residents. Findings: On February 3, 2025, at 9:40 a.m., during an observation of the dumpster storage outside the facility, three out of three dumpster lids were not closed, and trash was scattered around the dumpsters. On February 3, 2025, at 10:50 a.m., during a concurrent observation and interview with the Dietary Supervisor (DS) regarding the three dumpsters, the DS stated, the lids were open and trash was surrounding the area. The DS stated, the dumpsters should have been closed and free of trash to prevent pest infestations. On February 5, 2025, at 10:15 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MS), he stated he was responsible for keeping the dumpster lids closed and making sure the surrounding area was clean. The MS further stated, the dumpster should have been closed and that the surrounding area should have been free from trash to prevent rodent infestation, which could result in infection control problems. A review of the facility policy and procedure titled Food-Related Garbage and Refuse Disposal, dated October 2017, indicated, .Garbage and refuse containing food wastes shall be stored in a manner that is inaccessible to pests .outside dumpsters provided by garbage pickup services will be kept closed and free from surrounding litter .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food resident was found on the puree blender. 2. Spilled dry oatmeal was observed on the floor inside the dry storage room. 3. Two ovens had grime buildup and food residue. 4. A dietary staff's plastic cup was found on the bottom shelf of the tray line table. 5. The cook's beard and mustache were not covered with a beard net. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 86 out of 92 residents who received food prepared in the facility's kitchen. Findings: 1. On February 3, 2025, at 9:10 a.m., a concurrent observation and interview inside the walk-in preparation room were conducted with the Dietary Supervisor (DS). The puree blender was found with white and yellow food residue. The DS stated the puree blender had white and yellow food residue and it should be cleaned after each use to prevent cross-contamination. During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 2. On February 3, 2025, at 9:15 a.m., a concurrent observation and interview inside the dry storage room were conducted with the DS. Spilled dry oatmeal was observed on the floor. The DS stated the floor should be kept clean and free from any food residue to prevent pest infestation. During a review of the facility policy's titled Sanitation, revised October 2008, indicated Policy statement: The food service area shall be maintained in a clean and sanitary manner .1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils . 3. On February 3, 2025, at 9:20 a.m., a concurrent observation and interview were conducted with the DS. Two ovens had food crumbs, grease, yellow grime, and streaks of dark brown residue. The DS stated it is dirty and should be kept clean and sanitary to prevent food borne illness. During a review of the facility policy's titled Sanitation, revised October 2008, indicated Policy statement: The food service area shall be maintained in a clean and sanitary manner .1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils . 4. On February 3, 2025, at 9:25 a.m., a concurrent observation and interview were conducted with the DS. A dietary staff's plastic cup, dated January 29, 2025, was on the bottom shelf of the tray line table. The DS stated employee belongings should not be stored in the kitchen area to prevent cross-contamination. During a review of the facility policy's titled Sanitation, revised October 2008, indicated Policy statement: The food service area shall be maintained in a clean and sanitary manner .1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils . 5. On February 4, 2025, at 10:00 a.m., a concurrent observation and interview inside the kitchen were conducted with the DS. A cook was observed with an uncovered beard and mustache while preparing puree carrots. The DS stated the cook should cover his beard and mustache to prevent hair from falling into the pureed food. A review of the facility policy and procedure, titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised October 2017, indicated, .Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food . During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on observation, interview, and document review, the facility failed to ensure medications were properly labeled consistent with the policies and procedures and stored at appropriate temperature consistent with the drug manufacturer's instructions when: 1. Bisacodyl (medication to relieve constipation) 10 mg (milligram; unit of measurement) suppositories were stored in the medication room and the medication cart without proper pharmacy labels; 2. Multi-dose medications were not properly labeled with open dates; 3. One liquid medication bottle did not have a legible expiration date on the manufacturer's label; and 4. The room temperature in the Nursing Station 2 Medication Room was not maintained below the drug manufacturer's instruction for storage at room temperature. These failures had the potential for residents to received ineffective medication treatment. Findings: 1. During an inspection of the medication room located in Nursing Station 3 on February 3, 2025, at 11:30 a.m. with LVN 3, there were 13 bisacodyl 10 mg suppositories inside a plastic bag that did not have a pharmacy label to indicate who they belonged to. The plastic bag also contained smaller plastic bags containing bisacodyl suppositories that had resident-specific pharmacy labels. In a concurrent interview, LVN 3 was not able to tell who the suppositories belonged to. LVN 3 stated the facility usually kept them as house supply medications. LVN 3 acknowledged the plastic bag did not indicate they were house supply medications. During an inspection of Medication Cart 2A located in Nursing Station 2 with LVN 4, there were seven bisacodyl 10 mg suppositories in a plastic bag without a pharmacy label for specific residents In a concurrent interview, LVN 4 stated the plastic bag should have a label. LVN 4 acknowledged the plastic bag did not indicate it was a house supply medication or resident specific medications labeled by the pharmacy. The facility's policy and procedure titled, House-Supplied (Floor Stock) Medications, with the effective date, April 2008, was reviewed, and it indicated: .Floor stock medications are labeled as floor stock or house supply and kept in the original manufacturer's container. The manufacturer's or pharmacy's label should include the following: 1) Medication name 2) Medication strength 3) quantity 4) Accessory instructions 5) Lot number 6) Expiration date . The facility's policy and procedure titled, Medication Labeling and Storage, revised, February 2023, was reviewed, and it indicated: .Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable fedreal and state requirements and currently accepted pharmaceutical practices . The medication label includes, at a minimum: a. medication name .b. prescribed dose; c. strength; d. expiration date .e. resident's name; f. route of administration; and g. appropriate instructions and precautions . 2. During an inspection of the 8400 Floor Medication Cart located in Nursing Station 3 on February 3, 2025, at 12:10 p.m. with LVN 3, there were two medications in the cart with no open date as follows: One latanoprost (medication for treat increased pressure in the eye leading to vision loss) 0.005% eye drop that had a label that indicated: Discard unused portion after 28 days and was stored at room temperature; and One vial of cyanocobalamin (injectable vitamin B12 supplement) 1000 mcg/ml (microgram per milliliter; unit of measurement) 1 ml with the plastic cap removed and no open date on the vial. In a concurrent interview, LVN 3 agreed there was no open date on either medication. The facility's policy and procedure titled, Medication Labeling and Storage, revised, February 2023, was reviewed, and it indicated: .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial . According to the prescribing information for latanoprost eye drop, .Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks . 3. During an inspection of the 8400 Floor Medication Cart located in Nursing Station 3 on February 3, 2025, at 12:10 p.m. with LVN 100, there was a 16-ounce bottle of ferrous sulfate (iron supplement) 220 mg/5 ml (milligram per milliliter; unit of measurement) solution with the smudged manufacturer's expiration date. In a concurrent interview, LVN 3 stated the expiration date was faded and LVN 3 was not able to tell the expiration date of the ferrous sulfate solution. The facility's policy and procedure titled, Medication Labeling and Storage, revised, February 2023, was reviewed, and it indicated: .If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items . 4. During an inspection of the medication room located in Nursing Station 2 on February 3, 2025, at 2:40 p.m. with LVN 4, it was noted the temperature of the room was 82 degree Fahrenheit (F) according to the room thermometer. It was also noted the medication room stored residents' medications brought into the facility. In a concurrent interview, LVN 4 confirmed the room temperature was 82 F according to the thermometer. The United States Pharmacopeia (USP) is an independent organization that sets standards for the quality of medicines and drug manufacturers must comply with the USP standards. According to USP Chapter <659>: .Controlled room temperature: The temperature maintained thermostatically that encompasses the usual and customary working environment of 20 -25 (68 -77 F). The following conditions also apply. Mean kinetic temperature not to exceed 25 . The facility's policy and procedure titled, Medication Labeling and Storage, revised, February 2023, was reviewed, and it indicated: .The facility stores all medications and biologicals in locked compartments under proper temperature .

Based on observation, interview, and record review, the facility failed to ensure the physician's order for oxygen was transcribed into the electronic medical record after the order was received. This failure resulted in an incomplete and inaccurate medical record, which could have led to miscommunication among staff regarding Resident 189's prescribed oxygen therapy, potentially affecting the resident's respiratory care. Findings: On February 3, 2025, at 9:58 a.m., Resident 189 was observed lying in bed receiving oxygen at 2 liters per minute via nasal cannula (a medical device used to deliver supplemental oxygen to resident who has difficulty breathing or require oxygen therapy). A review of Resident 189's Admission Record indicated Resident 189 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) and dementia (memory loss). Resident 189 was under hospice care. A further review of Resident 189's record indicated Resident 189 did not have a physician order for the oxygen therapy in the electronic medical record. On February 6, 2025, at 1:35 p.m., during a concurrent interview and record review of the electronic physician order with Licensed Vocational Nurse (LVN) 1, she stated the oxygen order was placed on January 21, 2025 in Resident 189's physical chart by the hospice nurse upon admission and it was not transcribed into the electronic medical record. She further stated all physician orders should be transcribed at the time of admission to make sure all staff are aware of the prescribed treatment. On February 6, 2025, at 1: 56 p. m., during an interview with the Medical Records Director (MRD), she stated that the licensed nurse who received the physician's order was responsible for transcribing it into the electronic medical record. On February 6, 2025, at 3 p.m., in an interview with the Director of Nursing (DON), she stated the physician order should have been transcribed as soon as the nurse received it. The DON further stated all physician orders must be transcribed into the electronic medical record to ensure staff are aware of the prescribed treatment. The DON stated, the hospice nurse received the order and communicated it to the facility's licensed nurse. The DON stated, the facility licensed nurse forgot to transcribe the order into the electronic medical record.

Based on observation, interview, and document review, the facility failed to ensure expired medications were not available for use by residents. This failure had the potential for residents to received ineffective medication therapy. Findings: 1. During an inspection of the 8400 Floor Medication Cart located in Nursing Station 3 on February 3, 2025, at 12:10 p.m. with LVN 3, there was one discontinued bubble pack containing hydroxyzine (medication to treat itching) for Resident 3 in the cart along with active medications. In a concurrent interview, LVN 5 stated the medication was discontinued and was change from as needed to routine. LVN 5 stated the bubble pack should have been removed from the cart. In a concurrent interview, LVN 3 also stated the bubble pack should have been removed from the card and placed in the discontinued box in the medication room. 2. During an inspection of Medication Cart 3A located in Nursing Station 3 on February 3, 2025, at 3:20 p.m. with LVN 3, there was one used Humalog (fast-acting insulin to control blood sugar in diabetics) Qwikpen 100 units per milliliter with an open date of December 1, 2024, in the cart. In a concurrent interview, LVN 3 stated it had been more than 28 days based on the open date written on the pen. The facility's policy and procedure titled, Medication Labeling and Storage, revised, February 2023, was reviewed, and it indicated: .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on interview and record review, the facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care) at the same time the discharge notice was given to the resident, for one of three residents reviewed for closed records (Resident 88). This failure had the potential to delay advocacy and oversight of Resident 88's discharge plan, impacting continuity of care and resident rights. Findings: A review of Resident 88's Admission Record, indicated Resident 88 was admitted to the facility on [DATE], with a diagnoses which included fatty liver (a condition that can cause jaundice [yellowing of the skin and eyes]). A review of Resident 88's Minimum Data Set (an assessment tool), dated October 31, 2024, indicated, Resident 88 had Brief Interview of Mental Status (use to assess cognition), score of 15 (cognitively intact). A review of Resident 88's eINTERACT Change in Condition Evaluation, dated November 5, 2024, indicated, .Changes in skin color .Resident was assessed and noticed to be very jaundice .MD (medical doctor) made aware and said to send to ED (emergency department) for further evaluation . A review of Resident 88's Physician Discharge Summary Report, dated November 10, 2024, indicated, .discharged Date .November 5, 2024 .Disposition .Hospital (name of hospital) . A review of Resident 88's Notice of Transfer or Discharge, dated November 5, 2024, indicated a copy of the notice was hand delivered to Resident 88 upon discharge from the facility. A further review of Resident 88's medical records indicated there was no documented evidence the facility mailed or faxed the letter of transfer or discharge notice to the LTC Ombudsman at the same time Resident 88 received the notice upon discharge from the facility on November 5, 2024. On February 5, 2025 at 3:07 p.m., during a concurrent interview and review of Resident 88's notice of transfer or discharge record with the Social Service Director (SSD), she stated when residents are transferred or discharged from the facility, the LTC Ombudsman should be notified the same day or the next business day. The SSD stated Resident 88 was discharged on [DATE], and was provided the discharge notice upon leaving the facility. The SSD stated, the discharge notice was not sent to the LTC Ombudsman until December 2, 2024 (27 days later). The SSD further stated the Case Manager (CM) is responsible for sending the notice and did not do so. On February 5, 2025, at 3:29 p.m., during a concurrent interview and review of Resident 88's notice of transfer or discharge record with the CM, the CM stated, she did not send the notification letter regarding Resident 88's discharge to the LTC Ombudsman. The CM further stated, she should have sent the notice to ensure the LTC Ombudsman was made aware and able to advocate for Resident 88's care. A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated dated October 2022, indicated, .If discharge is initiated by the facility after .transfer to the hospital .The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman .Notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident .

Based on observation, interview, and record review, the facility failed to ensure for one of one resident reviewed (Resident 71), the resident's bathroom had a functioning paper towel dispenser. This failure had the potential to prevent Resident 71 from performing proper hand hygiene, increasing the risk of infection. Findings: On February 6, 2025, at 9:52 a.m., during a concurrent observation and interview inside Resident 71's bathroom with the Maintenance Supervisor (MS) and Resident 71, the MS stated the paper towel dispenser was not dispensing paper towels. Resident 71 stated she had reported the non-functioning towel dispenser to the Case Manager (CM) and the Infection Preventionist (IP) nurse. On February 6, 2025, at 10:01 a.m., during an interview with the IP nurse, the IP nurse stated Resident 71 had informed him on February 4, 2025, about the paper towel dispenser issue. The IP further stated he informed the MS but did not follow up to ensure the issue was resolved. On February 6, 2025, at 10:04 a.m., during an interview with the CM, she stated Resident 71 informed her last week and a while back that the paper towel dispenser in her bathroom was not functioning. The CM further stated she notified the front desk to inform Maintenance. On February 6, 2025, at 10:07 a.m., during an interview with the front desk staff (FDS), the FDS stated she did not inform the MS about the non-functioning paper towel dispenser. On February 6, 2025, at 10:11 a.m., during an interview with the MS, he stated the facility process requires staff to fill out a maintenance request form. The MS further stated he never received a maintenance request form regarding Resident 71's paper towel dispenser from anyone. On February 6, 2025, at 3:25 p.m., during an interview with the Director of Nursing (DON), the DON stated, the towel dispenser should be functioning so that Resident 71 could properly dry her hands after washing them. The DON stated, hand hygiene is essential in preventing the spread of infection. A review of facility's policy and procedure titled Homelike Environment, dated February 2021, indicated, .the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment .