Every finding on record at Riverwood Health Care

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for 2 of 3 sampled residents (Resident 1 and Resident 2) when:1. Resident 1's urinal (a portable plastic container that male residents use to urinate when they cannot get to the bathroom) was full of urine and was hanging on the edge of the bed without a lid cover; and,2. Resident 2's urinal was not labeled.These failures had the potential to spread infection and cause adverse health outcomes for Resident 1, Resident 2, and other residents residing in the facility.Findings:1. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses including necrotizing fasciitis (a rare, severe, and fast-spreading bacterial infection that destroys the tissue beneath the skin, commonly known as the flesh-eating disease), chronic viral hepatitis C (a long-term blood-borne infection caused by the hepatitis C virus [HCV] that lasts longer than six months), and lymphedema (a chronic condition causing swelling, tight skin, and a heavy feeling in the arms or legs due to blocked lymph fluid).During a concurrent observation and interview on 7/15/26, at 9:21 AM, with Licensed Nurse (LN) 1, Resident 1's urinal was observed. LN 1 confirmed that Resident 1's urinal was not labeled with identifying information and should have been labeled. LN 1 further confirmed that Resident 1's urinal did not have a covered lid on top and was full of urine while hanging off the end of the bed frame.2. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility with diagnoses including chronic respiratory failure (a long-term condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide), chronic congestive heart failure (a long-term condition where the heart cannot pump blood well, causing fluid to back up into the lungs and body tissues), and type 2 diabetes mellitus (a chronic condition where high blood sugar occurs because the body cannot use insulin properly or make enough of it).During a concurrent observation and interview on 7/15/26, at 9:20 AM, with LN 1, Resident 2's urinal was observed. LN 1 confirmed that Resident 2's urinal was not labeled with identifying information and should have been labeled.During an interview on 7/15/26, at 9:25 AM, with LN 1, LN 1 stated that it was her expectation for urinals to be labeled and have a covered lid on them. LN 1 further stated that urinals could get mixed up between residents if they were not labeled and that it was especially important to do so when there were more multiple residents using them in the same room. LN 1 further stated that having urinals labeled would allow the residents to not be confused as to which urinals belonged to them. LN 1 stated that a covered lid on the urinals would prevent them from spilling.During an interview on 7/15/26, at 10:29 AM, with the Infection Preventionist (IP), the IP stated that it was his expectation for urinals to be labeled and have a covered lid on them. The IP further stated that urinals that have urine in them without a lid could fall over and cause a dignity issue for the residents. The IP stated that staff should be emptying out the urinals as soon as they can. The IP further that he would not want to be in a situation where his urinal was full of urine without being emptied or covered.During an interview on 7/15/26, at 10:55 AM, with the Director of Nursing (DON), the DON stated that it was his expectation for urinals to be labeled and have a covered lid on them. The DON further stated that urinals could get mixed up if they were not properly labeled. The DON stated that urinals could tip over and spill which could cause an infection control issue. The DON further stated that his expectations were not met by having urinals not being labeled and without covers.During a review of the facility's policy and procedure (P&P) titled, Biohazard Labeling, revised 7/16, the P&P indicated, .Materials contaminated with blood or body fluids shall be labeled and discarded appropriately.During a review of the facility's P&P titled, Bedpan/Urinal, Offering/Removing, revised 2/18, the P&P indicated, .Remove the urinal from the bedside stand. Be sure that it is clean and dry.

Based on interview, and record review, the facility failed to notify the Responsible Party (RP) of a significant change in condition and the physician's intervention for one of three sampled residents (Resident 1), when Resident 1 was prescribed an antibiotic for a urinary tract infection (UTI - a urine infection) and Resident 1's RP was not notified.This deficient practice had the potential to deprive Resident 1's RP of the opportunity to participate in Resident 1's care, be informed of Resident 1's change in condition and treatment plan, ask questions, and make informed decisions regarding Resident 1's care and services.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses of, but not limited to, multidrug-resistant organisms (MDRO-germs that many antibiotics cannot kill), vascular dementia (memory loss and problems with thinking caused by reduced blood flow to the brain), and history of falling. The admission RECORD also indicated, .Responsible Party .Daughter .Review of Resident 1's [Name of Facility] Physician Progress Notes, dated 5/28/26, indicated, .Patient was seen and examined.stated she has dysuria [painful urination].Plan.UA [Urinalysis-testing the urine] with C&S [Culture and Sensitivity - a laboratory test to find the germ and the right antibiotic].Review of Resident 1's Order Details, dated 6/1/26, indicated, .Ciprofloxacin (antibiotic medication) tablet.for UTI for 5 days.Review of Resident 1's laboratory results, received date 6/1/26, indicated, .Culture, Urine.Enterobacter (a type of germ that can cause infections).During a concurrent interview and record review on 7/10/26, at 2:08 PM, with the Interim Director of Nursing (DON), Resident 1's electronic medical record (EMR) was reviewed. The DON stated that it was his expectation that follow-up documentation in the form of nursing progress notes, should have been completed for Resident 1's urinary change in condition. The DON confirmed that the Nurse Practitioner (NP) reviewed the C&S results and, on 6/1/26, ordered an antibiotic for treatment of a UTI. The DON further confirmed that the NP's progress note documented that Resident 1 had positive findings consistent with a UTI. The DON stated that it was his expectation that the nurse who received and implemented the antibiotic order would notify Resident 1's RP of the new treatment. Further review of Resident 1's EMR, the DON confirmed there was no documentation that the RP had been notified of Resident 1's UTI diagnosis or the initiation of antibiotic treatment. The DON stated that notification of the RP was important so they would be informed of Resident 1's condition and plan of care. The DON further stated that if the initial nurse did not provide the notification, subsequent shifts should have ensured the RP was updated.Review of facility policy and procedure titled, Acute Condition Changes - Clinical Protocol, revised 3/18, indicated, Assessment and Recognition: The physician will help identify individual with a significant risk for having acute changes of condition during their stay.In addition, the nurse shall assess and document/report the following . recent labs.All current diagnoses.All current medications.The physician and nursing staff will review the details of any recent hospitalization.the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation.this discussion should consider the patient's overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker).

Based on interview, and record review, the facility failed to ensure proper post-fall assessment or interventions were implemented for 1 of 4 sampled residents (Resident 1) when:1) The facility did not hold a post fall Interdisciplinary Team (IDT) meeting for Resident 1's fall on 6/17/26. 2) Resident 1's fall care plan was not updated with new specific interventions after Resident 1's fall on 6/17/26; and,3) Resident 1's neurological checks (focused assessment to monitor a resident's neurological (brain, spinal cord, and nerves) function) was not completed at the designated intervals after Resident 1's unwitnessed fall on 6/17/26.This failure could have delayed the identification of any changes in Resident 1's condition after her unwitnessed fall on 6/17/26, hindered the timely introduction of personalized fall prevention strategies, increased the risk of recurrent falls and further injury, and had the potential to negatively impact the health, safety, and overall well-being of Resident 1.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses of, but not limited to anxiety disorder (a condition of constant worry or fear), vascular dementia (memory problem caused by poor blood flow to the brain), and history of falling.Review of Resident 1's clinical record titled, Change In Condition Evaluation, dated 6/17/26, indicated, .patient found lying on the floor on her back with knees bent and crossed with pillow behind her head.patient stated I fell I fell but was unable to provide context as to why she fell.Recommendation of Primary Clinician(s).neuro checks and monitoring.Review of Resident 1's clinical record titled, Neurological Assessment (Head Injury/Unknown Fall), dated 6/17, indicated a facility neurological monitoring flow sheet used to document post-fall neurological assessments. The form included designated intervals for assessments every 15 minutes, 30 minutes, and 1 hour, with sections to document: Vital signs, including blood pressure, temperature, pulse, and respirations; Respiratory pattern; Right and left pupil (the dark opening in the center of the eye) size and reaction; Upper and lower extremity strength; Level of consciousness (oriented, disoriented, restless, drowsiness); Speech (clear or garbled); Response to name and pain; Presence or absence of environmental awareness, seizure activity (sudden abnormal electrical activity in the brain), headache, and vomiting; and Nursing signature. The document contained completed neurological assessments at 2:10 p.m., 2:25 p.m., 2:40 p.m., and 2:55 p.m. (15-minute intervals). The remaining sections designated for subsequent 30-minute and 1-hour neurological assessments were blank.During a review of Resident 1's clinical record titled, Care Plan Report, in the section titled, Interventions/Tasks, indicated, .fall mat [cushion placed on the floor to reduce injury if a person falls] as ordered Date initiated 5/26/26.Bilateral floor mat as ordered Date initiated 6/10/26.During a review of Resident 1's clinical record titled, Care Plan Report, in the section titled, Focus, Date Initiated 6/15/26, Date Revised 6/16/26, indicated, .High Risk for falls and injury related to .Poor judgement, poor safety awareness, limitation of mobility, Recent fall in the last 30 days, Functional range of motion limitation . Further review of the document under the section titled, Interventions/Tasks, Date Initiated 6/15/26, indicated, .Orient resident to person, place, time, routine and event.Provide assistance needed with ADL care.Keep bed in low position.Keep room and common areas free from clutter.Review of Resident 1's clinical record titled, Post Fall Evaluation, dated 6/17/26, indicated, .Fall Details.Activity at the time of fall.3. Other.Other activity.unable to determine.Contributing Factors.5. Floor mat on floor.a. Yes.6. Poor lighting.a. Yes.During a concurrent interview and record review on 7/9/26, at 9:20 AM, with the Social Services Director (SSD), Resident 1's medical record was reviewed. The SSD stated that IDT care conferences were conducted for new admissions, quarterly and annual reviews, and whenever a resident experiences a significant change in condition. The SSD explained that the purpose of the IDT care conference was to discuss significant changes or concerns with the resident and/or the responsible party (RP), collaborate with the physician (MD) and other IDT members, and update the resident's care plan as needed to reflect individualized interventions. The SSD confirmed that Resident 1's last documented care conference occurred on 5/20/26. The SSD further acknowledged that fall incidents should have prompted an IDT care conference to identify the root cause of the fall, evaluate whether appropriate fall prevention interventions were in place, develop additional recommendations as needed, communicate those recommendations to the MD and the RP, and revise Resident 1's care plan accordingly to promote Resident 1's safety and well-being.During a concurrent interview and record review on 7/10/26, at 12:51 PM, with Licensed Nurse (LN) 1, Resident 1's EMR was reviewed. LN 1 confirmed that Resident 1 sustained an unwitnessed fall on 6/17/26. LN 1 stated that the fall represented a change in condition (CIC - a change in the person's health) requiring a comprehensive post-fall evaluation and assessment. LN 1 stated because the fall was unwitnessed that neurological (neuro) checks should have been completed to monitor for potential neurological changes or injury. LN 1 explained that the neuro check documentation was maintained on a paper form and, upon review, confirmed that the neuro checks were incomplete for Resident 1's fall on 6/17/26. LN 1 further reviewed the post-fall evaluation and confirmed the nurse who filled out the form documented that they were unable to determine what Resident 1 was doing at the time of the fall, indicating that additional follow-up through an IDT review was needed to identify the root cause of the fall and determine whether revisions to Resident 1's fall care plan were warranted. LN 1 stated that completing the post-fall process, including the IDT review, updating the care plan, and performing neuro checks, was important to help prevent future falls, promote resident safety, and reduce the risk of injury. LN 1 stated that the licensed nurse could initiate updates to the care plan based on the initial post-fall assessment, with additional revisions made after the IDT developed further recommendations. LN 1 further stated that completing neuro checks was essential because they help identify any neurological decline or other changes in Resident 1's condition that require ongoing monitoring and timely intervention.During a concurrent interview and record review on 7/10/26, at 2:08 PM, with the Interim Director of Nursing (DON), Resident 1's EMR was reviewed. The DON confirmed that after Resident 1's 6/17/26 fall, no IDT meeting had been conducted, the fall care plan had not been updated, and the neurological (neuro) checks were not completed consistently. The DON stated that all of these actions were expected components of the facility's post-fall process but acknowledged that they did not occur for Resident 1. The DON further stated that failure to complete these interventions placed Resident 1 at risk for delayed identification of neurological changes or decline, worsening of the resident's condition, delayed implementation of appropriate interventions, and potential rehospitalization.Review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised date 12/16, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan.The care planning process will. facilitate resident and/or representative involvement . describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes. interventions address the underlying source(s) of the problem area(s).The Interdisciplinary Team must review and update the care plan.Review of facility P&P titled, Falls - Clinical Protocol, revised date 3/18, indicated, Assessment and Recognition.the nurse shall assess and document/report.Vital signs.Change in cognition or level of consciousness; Neurological status.Monitoring and Follow-Up: . The staff, with physician's guidance, will follow up on any fall . Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas (a blood clot inside the head after a head injury) or other intracranial bleeding (bleeding inside the skull or around the brain) could occur up to several weeks after a fall.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.Review of the facility P&P titled, Neurological Assessment, revised date 10/10, indicated, .Purpose: The purpose of this procedure is to provide guidelines for neurological assessment.upon physician order, when following an unwitnessed fall.when indicated by resident condition.When assessing neurological status, always include frequent vital signs.Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures).This may be indicative of increasing intracranial pressure (ICP - the pressure inside the brain). Documentation.information should be recorded in the resident's medical record.

Based on interview, and record review, the facility failed to provide written notification to the State Agency (SA) at the time of the position change of the facility's Director of Nursing (DON) for a census of 87 residents, when the Assistant Director of Nursing (ADON) assumed the role of the Interim Director of Nursing (DON) on 6/29/26, and the facility did not report the change of the DON position as of 7/10/26.This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 87 residents.Findings:During an interview on 7/9/26, at 3:48 PM, with the Interim Director of Nursing (DON), the DON stated that he assumed the role of Interim Director of Nursing effective 6/29/26 and had been performing all responsibilities of the Director of Nursing since that date. The DON further stated that based on his understanding from the previous Director of Nursing, a change in the facility's nursing leadership, including the Director of Nursing position, should be reported to the appropriate State Agency. The DON stated that he had not completed, signed, or submitted any forms or documentation related to the required reporting of his appointment. The DON further stated that notifying the State Agency of a change in the Director of Nursing position was important to ensure the facility identified the individual serving as the primary clinical nursing leader and point of contact for the nursing department. The Interim DON explained that such notification established the appropriate chain of command, promoted accountability for nursing services, and allowed the State Agency to verify that the individual serving in the Director of Nursing role possessed the qualifications necessary to oversee the facility's clinical operations.During an interview on 7/9/26, at 12:36 PM, with the Operations Manager (OM), the OM stated that the Assistant Director of Nursing (ADON) assumed the role of Interim Director of Nursing (DON) effective 6/29/26. The OM further stated that the facility had not submitted any notification or application to the SA because the facility believed submission was not required until a permanent DON was hired. The OM stated that the facility was waiting to hire a permanent DON before submitting the required documentation and acknowledged uncertainty regarding the regulatory process for reporting an Interim DON. The OM further stated that it would be important for the SA to know that a qualified Registered Nurse (RN) was serving in the role of the DON because that individual would oversee the facility's nursing services. The OM confirmed that despite the change in nursing leadership effective 6/29/26, the facility had not submitted written notification or any documentation to the and was waiting until a permanent DON was hired before making any notification.A review of the SA database did not indicate the DON application was received from the facility.Review of an undated facility provided job description titled, Director of Nursing, indicated, .Position Summary: Plan, organize, develop and direct the overall operation of the Clinical/Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations.to ensure that the highest degree of quality care is maintained at all times. Qualifications: Valid state RN License, in good standing.

Based on observation, interview, and record review, the facility failed to exercise reasonable care to protect the personal property of one of three sampled residents (Resident 1) from potential loss when Resident 1's Inventory of Personal Effects (a list of a resident's personal belongings) had not been updated since 10/28/20, continued to list hearing aids that were no longer available for Resident 1's use, and did not accurately reflect Resident 1's current clothing. This failure had the potential for Resident 1's personal property to not be adequately safeguarded and accounted for, placing Resident 1's personal belongings at risk for loss or misplacement.Findings: Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility in 2020 with diagnoses including mood disorder (a mental health condition that affects a person's emotions and behavior), psychosis (a mental health condition that can cause difficulty recognizing what is real), and bilateral hearing loss (reduced hearing in both ears).Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to evaluate a resident's thinking and memory) dated 6/11/26 indicated Resident 1 had a BIMS score of 3, which reflected severe cognitive impairment (13-15 = intact, 8-12 = moderate impairment, 0-7 = severe impairment).Review of Resident 1's Care Plan, in the section titled Focus, initiated on 11/5/20, indicated, .[Resident 1] Communication Deficit R/T [related to] uses hearing aid, with periods of confusion and forgetfulness. In the section titled Interventions, indicated .Assist with hearing aid placement and maintenance.Review of Resident 1's INVENTORY OF PERSONAL EFFECTS dated 10/28/20 indicated Resident 1 had two hearing aids, one dress, one sweater, and one pair of underwear.During a concurrent observation and interview on 7/1/26 at 1:40 PM with Resident 1 in Resident 1's room, Resident 1 was not wearing hearing aids in either ear and demonstrated difficulty hearing by not responding to questions, repeating similar sounding words, stated she did not understand, and requested to be left alone.During an interview on 7/1/26 at 2:10 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had hearing problems. CNA 1 further stated she was unaware Resident 1 had hearing aids.During a concurrent interview and record review on 7/1/26 at 4:12 PM with Minimum Data Set Coordinators (MDSC - nurses responsible for completing federally required assessments) 1 and MDSC 2, Resident 1's MDS Assessment (Minimum Data Set - an assessment used to evaluate a resident's care needs) dated 6/11/26 was reviewed. In the section titled Section B - Hearing, Speech, and Vision, indicated Resident 1's hearing was adequate and that Resident 1 used hearing aids. MDSC 1 stated Resident 1's hearing was not adequate and acknowledged Resident 1 did not have hearing aids available, contrary to the MDS assessment on 6/11/26. During an interview on 7/1/26 at 4:52 PM with Resident 1's family (RF), the RF stated Resident 1 had hearing aids upon admission to the facility and that the hearing aids were lost while at the facility and replaced by the facility. The RF stated Resident 1 did not like the fit of the replacement hearing aids, so the family took them home years ago.During a concurrent observation and interview on 7/1/26 at 5:02 PM with the Assistant Director of Nursing (ADON) in Resident 1's room, Resident 1's closet contained multiple clothing items, including a black jacket that was not listed on Resident 1's Inventory of Personal Effects. The ADON also confirmed Resident 1 did not have hearing aids available although hearing aids were listed on Resident 1's Inventory of Personal Effects. The ADON stated Resident 1's Inventory of Personal Effects, dated 10/28/20, had not been updated when changes occurred to Resident 1's personal belongings, including the addition of the black jacket and the removal of the hearing aids. The ADON stated staff were expected to update the inventory whenever family members brought or removed personal belongings. The ADON stated the inaccurate Inventory of Personal Effects prevented the facility from accurately accounting for Resident 1's personal belongings, increasing the risk that the resident's personal property could be lost or misplaced and preventing the facility from ensuring the resident's belongings were properly safeguarded.Review of the facility's policy and procedure (P&P) titled Safeguarding Personal Property/Theft-and-Loss Policy, revised in 10/2025, indicated, .Facility will exercise reasonable care to protect and promote the safety and security of personal belongings. A property inventory shall be completed to identify personal property brought into the facility upon admission. Subsequent updates shall be made following the addition or removal of personal property from the facility. Facility staff shall update inventory records promptly upon request.

Based on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for one of three sampled residents (Resident 1) when:1. Resident 1's skin conditions during the nurse's required weekly long-term care evaluations (Weekly Summary - a weekly nursing assessment used to evaluate and document changes in a resident's condition based on a comprehensive assessment of the resident), completed on 2/13/26 and 2/20/26, were not identified and documented. Additionally, the facility failed to ensure Resident 1's weekly long-term care evaluation, due on 5/1/26, was completed; and,2. The facility staff failed to implement the communication care plan intervention to assist with hearing aid placement and maintenance for Resident 1.These failures resulted in inaccurate assessments being added to Resident 1's health care record, and had the potential to delay treatment, and implementation of resident-specific interventions, increasing the risk for skin breakdown, infection, and further skin deterioration, and had the potential for Resident 1 not to reach her highest practicable physical, mental, and psychosocial well-being due to hearing loss.Findings:1. Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including type 2 diabetes mellitus (high blood sugar), osteoarthritis (joint pain and stiffness), mood disorder (a mental health condition that affects a person's emotions and behavior), psychosis (a mental health condition that can cause difficulty recognizing what is real), and unspecified bilateral hearing loss (reduced hearing in both ears).Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to evaluate a resident's thinking and memory) dated 6/11/26 indicated Resident 1 had a BIMS score of 3, which reflected severe cognitive impairment (13-15 = intact, 8-12 = moderate impairment, 0-7 = severe impairment).During an interview with Resident 1's family (RF) on 7/1/26 at 9:46 AM, the RF stated Resident 1 had multiple skin issues that were not identified by facility staff, including a sore on the left heel and rashes under Resident 1's breasts, which the RF discovered and reported to nursing staff. The RF further stated that skin issues would not have been identified or treated without the RF bringing them to the facility's attention.During a concurrent interview and record review on 7/1/26 at 3:27 PM with the Nurse Supervisor (NS), Resident 1's assessments were reviewed. Resident 1's eINTERACT Change in Condition Evaluation .[a nursing assessment completed when a resident has a change of condition to evaluate the resident and notify the provider] dated 2/18/26 at 9:40 PM indicated the RF reported Resident 1's left heel skin felt hard. Nursing staff assessed the area as a callous and obtained treatment orders from the provider. Resident 1's Weekly Summary dated 2/13/26 indicated Resident 1 did not have skin issues. The Weekly Summary dated 2/20/26 documented no skin issues or skin changes since the previous evaluation. The NS acknowledged the Weekly Summary dated 2/20/26 was inaccurate because Resident 1 experienced a skin change between 2/13/26 and 2/20/26, as evidenced by the callous assessed on 2/18/26. Resident 1's Weekly Summaries were further reviewed with the NS and indicated the required Weekly Summary due on 5/1/26 was not completed. Resident 1's eINTERACT Change in Condition Evaluation . dated 5/4/26 at 1:23 PM documented redness under Resident 1's right breast, and treatment orders were obtained from the provider. The NS acknowledged the missed Weekly Summary due on 5/1/26 could have identified the skin change earlier.During an interview on 7/1/26 at 5:05 PM with the Assistant Director of Nursing (ADON), the ADON stated nursing staff were expected to complete Weekly Summaries by the required due date and accurately evaluate residents to identify changes in condition, including skin issues. The ADON further stated that missed or inaccurate Weekly Summaries could delay the identification and treatment of skin conditions and could lead to further skin deterioration.Review of the facility's policy and procedure titled Weekly Summary, revised 1/2029, indicated, .It is the policy of this facility for licensed nurses to complete progress notes on a weekly basis. It is the responsibility of the licensed charge nurse to evaluate a resident's status and condition, including progress thereof, with any treatment programs, on a weekly basis. When evaluating the resident and completing the weekly licensed progress notes, the licensed charge nurse should document the resident's skin condition and complete a body assessment. It is important that the licensed nurse accurately report the resident's status and condition. 2. Review of Resident 1's Care Plan, in the section titled Focus, initiated on 11/5/20, indicated, .[Resident 1] Communication Deficit R/T [related to] uses hearing aid, with periods of confusion and forgetfulness. The Goal included, Resident will communicate needs without frustration. Resident's ability to interact with others will be enhanced with interventions through next review date. The section titled Interventions, indicated . Observe and report to MD [Physician] with decrease hearing function .Assist with hearing aid placement and maintenance.Coordinate with responsible party/surrogate decision maker regarding hearing aid battery replacement.Review of Resident 1's INVENTORY OF PERSONAL EFFECTS dated 10/28/20 indicated Resident 1 had two hearing aids, one dress, one sweater, and one pair of underwear.During a concurrent observation and interview on 7/1/26 at 1:40 PM with Resident 1 in Resident 1's room, Resident 1 was not wearing hearing aids in either ear and demonstrated difficulty hearing by not responding to questions, repeating similar sounding words, stated she did not understand, and requested to be left alone. No other types of communication devices were observed with Resident 1.During an interview on 7/1/26 at 2:10 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had hearing problems. CNA 1 further stated she was unaware Resident 1 had hearing aids.During a concurrent interview and record review on 7/1/26 at 4:12 PM with Minimum Data Set Coordinators (MDSC - nurses responsible for completing federally required assessments) 1 and MDSC 2, Resident 1's MDS Assessment (Minimum Data Set - an assessment used to evaluate a resident's care needs) dated 6/11/26 was reviewed. In the section titled Section B - Hearing, Speech, and Vision, indicated Resident 1's hearing was adequate and that Resident 1 used hearing aids. MDSC 1 stated Resident 1's hearing was not adequate and acknowledged Resident 1 did not have hearing aids available, contrary to the MDS assessment on 6/11/26. The MDSC 2 stated no other hearing assistive device was used during the interview of Resident 1 to complete Section B - Hearing, Speech, and Vision. When MDSC 2 was asked whether Resident 1's hearing impairment could have affected the interview, the MDSC 2 acknowledged it could have.During an interview on 7/1/26 at 4:52 PM with Resident 1's family (RF), the RF stated Resident 1 had hearing aids upon admission to the facility and that the hearing aids were lost while at the facility and replaced by the facility. The RF stated Resident 1 did not like the fit of the replacement hearing aids, so the family took them home years ago.During a concurrent observation and interview on 7/1/26 at 5:02 PM with the Assistant Director of Nursing (ADON) in Resident 1's room, Resident 1's closet contained multiple clothing items, including a black jacket that was not listed on Resident 1's Inventory of Personal Effects. The ADON also confirmed Resident 1 did not have hearing aids available although hearing aids were listed on Resident 1's Inventory of Personal Effects. The ADON stated Resident 1's Inventory of Personal Effects, dated 10/28/20, had not been updated when changes occurred to Resident 1's personal belongings, including the addition of the black jacket and the removal of the hearing aids. The ADON stated staff were expected to update the inventory whenever family members brought or removed personal belongings. The ADON stated the inaccurate Inventory of Personal Effects prevented the facility from accurately accounting for Resident 1's personal belongings, increasing the risk that the resident's personal property could be lost or misplaced and preventing the facility from ensuring the resident's belongings were properly safeguarded.During an interview on 7/1/26 at 5:05 PM with the ADON, the ADON stated the facility had hearing amplifiers and communication boards available and stated they should have been offered to Resident 1 to assist with communication. ADON acknowledged Resident 1's refusal of care could partially be related to difficulty understanding staff because of Resident 1's hearing impairment. The ADON stated Resident 1 already had confusion and that not being able to hear or understand staff could increase confusion, frustration, anxiety, resistance to care, miscommunication, and trigger adverse behaviors. ADON agreed the communication assessment (MDS) was not accurate because it did not reflect Resident 1's current hearing impairment or communication needs.Review of the facility's policy and procedure (P&P) titled Safeguarding Personal Property/Theft-and-Loss Policy, revised in 10/2025, indicated, .Facility will exercise reasonable care to protect and promote the safety and security of personal belongings. A property inventory shall be completed to identify personal property brought into the facility upon admission. Subsequent updates shall be made following the addition or removal of personal property from the facility. Facility staff shall update inventory records promptly upon request.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (intentional act of causing injury or trauma to another person through bodily contact) for one of three sampled residents (Resident 2) when on 3/3/26 Resident 1 became upset, started yelling at Resident 2 and hit Resident 2 on the back of the head with a fist. This failure had the potential to cause physical injury and psychosocial distress (anxiety, depression, fear, social withdrawal, or behavioral changes) to Resident 2.Findings:A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included but not limited to epilepsy (chronic brain disorder characterized by a tendency to have recurring, unprovoked seizures), depression (long lasting mood disorder that goes beyond feeling sad), muscle weakness, unsteadiness on feet, and traumatic brain injury (a brain injury caused by a sudden external physical force like being hit in the head).A review of Resident 2's minimum data set (MDS -a resident assessment and screening tool which identifies care needs), dated 2/24/26, under the section titled, .Section C: Cognitive Patterns, - (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) indicated, Resident 2's Brief Interview for Mental Status (BIMS - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment]) was 7 out of 15 which indicated Resident 2 had severe cognitive impairment (a significant decline in mental abilities including memory).During an interview on 3/17/26 at 11:48 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 3/3/26, while she was getting Resident 2 ready to go the shower room, she heard Resident 1 yelling at Resident 2. CNA 1 stated Resident 1 was upset, so she moved Resident 2 into the hallway while she gathered shower supplies to prevent the incident from escalating. CNA 1 explained, once she moved Resident 2 into the hallway, she went and notified Resident 1's Licensed Nurse (LN) that Resident 1 was upset and was yelling at Resident 2. CNA 1 further stated she told the LN that the residents should be separated. CNA 1 stated she returned to Resident 2 and escorted him to the shower room. CNA 1 explained, when she returned to the room with Resident 2 after his shower about 15 minutes later, she moved Resident 2 into the room toward the back of the room in front of Resident 2's bed. CNA 1 stated that as she was along the back wall getting Resident 2's toothbrush from his nightstand, she observed Resident 1 get up from his bed, approach Resident 2, and hit Resident 2 in the back of the head with a fist. CNA 1 explained that she called for help and staff came to the room and separated the residents.During a follow-up observation and interview on 3/18/26 at 8:34 AM, the room shared between Resident 1 and Resident 2 was observed with CNA 1. CNA 1 demonstrated where Resident 1's bed was closest to the entrance of the room, and where Resident 2 sat in the wheelchair in front of his bed toward the back of the room. CNA 1 explained that Resident 2 had his back to the door and Resident 1's bed and could not see Resident 1 approach him. CNA 1 demonstrated how she was standing along the back wall at Resident 2's nightstand when she observed Resident 1 get up and hit Resident 2.During an interview on 3/17/26 at 1:37 PM. with LN 1, LN 1 stated she responded to the call for help from CNA 1 on 3/3/26 and observed Resident 1 standing in the middle of the room between the two beds. LN 1 further stated that she and CNA 1 tried to calm Resident 1 down, and they had to separate Resident 1 and Resident 2 because they were yelling at each other. LN 1 stated Resident 2 told her he was sucker punched in the back of the head. LN 1 further stated Resident 2 was upset.During an interview on 3/18/26 at 8:57 AM, with LN 2, LN 2 confirmed he was the nurse assigned to Resident 1 and Resident 2 on 3/3/26 and responded to their room after a CNA told him about the residents fighting. LN 2 explained by the time he got to the room Resident 1 and Resident 2 were already separated. LN 2 stated Resident 2 was checked for injuries. LN 2 stated Resident 2 told him that Resident 1 came over and hit him in the back of the head. LN 2 further stated he thought Resident 2 was surprised, scared, and startled that Resident 1 hit him.During an interview on 3/18/26 at 9:32 AM, with CNA 2, CNA 2 stated that she was assigned to Resident 1 on 3/3/26. CNA 2 stated that she was told in morning report (standard communication between healthcare workers where outgoing staff exchange information with oncoming staff about resident's care, behaviors, and plans) on 3/3/26 a few hours before Resident 1 hit Resident 2 that Resident 1 could get agitated or upset easily and was rude.During an interview on 3/18/26 at 9:57 AM, with LN 3, LN 3 stated Resident 1 and Resident 2 had been known to have disagreements and argued about the lights being on in the room and the television being too loud during the night. LN 3 stated it happened a few different times about two weeks after they were roomed together. LN 3 further stated Resident 1 was known to yell out for staff to come to his room, and he was not patient with them. LN 3 stated she did not document or report to anyone the previous arguments between Resident 1 and Resident 2 because she felt she resolved them.During a concurrent interview and record review on 3/17/26 at 3:33 PM, with the Social Services Director (SSD), the SSD reviewed the medical record of Resident 1. The SSD verified there was no record of previous behaviors or incidents documented in Resident 1's medical record. The SSD stated she was surprised when she learned Resident 1 hit Resident 2 on 3/3/26. The SSD further stated when she checked on Resident 2, he told her he was shocked by it because the hit came from behind and he had not expected it.During a concurrent interview and record review on 3/18/26 at 11:43 AM, Resident 1's and Resident 2's medical record was reviewed with the Director of Nursing (DON). The DON stated when an LN was notified that residents argued, she expected the LN to address it immediately to prevent it from escalating. The DON reviewed both Resident 1 and Resident 2's medical record. The DON confirmed she could not find any documentation of previous disagreements between Resident 1 and Resident 2, and she could not find any documented concerns with Resident 1's behaviors. The DON stated it was her expectation that staff document and share all incidents between residents that could lead to abuse. The DON further confirmed she had no knowledge of any previous incidents between Resident 1 and Resident 2. The DON explained that had she or her team been aware of the previous incidents between Resident 1 and Resident 2 they would have initiated a room change for resident safety.A review of Resident 1's care plan titled, History of substance use disorder.Use of/addiction to illegal drugs., dated 2/12/26, indicated, .Interventions.Report any changes in mood status.A review of Resident 2's care plan titled, Impaired mood secondary to depressive symptoms.Feeling down, depressed, or hopeless., dated 2/21/26, indicated, .Interventions.Explore the resident's reason/s for social withdrawal and other episodes of depressive symptoms .Identify any triggers.A review of the facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, revised 10/25, the P&P indicated, .Each resident has the right to be free from abuse.Physical abuse includes.hitting, slapping, pinching.4. Prevention.Facility will implement policies and procedures to prevent and prohibit abuse.Identifying and remediating situations in which abuse.is more likely to occur.Assessment and care planning appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse for two of two sampled residents when:1. The facility did not complete a thorough interview of a Certified Nursing Assistant (CNA) witness who had reported an argument between Resident 1 and Resident 2 to the Licensed Nurse (LN) on 3/3/26, prior to Resident 1 hitting Resident 2;2. The facility's investigation did not reveal information regarding Resident 1's behavior, and incidents that showed arguments between Resident 1 and Resident 2 or interviews from staff with knowledge of them; and,3. The Director of Nursing (DON) was tasked with the responsibility of completing the investigation by the previous Administrator, even though the DON had never completed an investigation before.These failures prevented the implementation of interventions (specific, purposeful actions performed by healthcare professionals to address a resident's needs, prevent complications, and achieve established, measurable goals) to protect Resident 1 from being hit by Resident 2. The failure to thoroughly investigate and interview additional staff also resulted in the facility not being aware of several past incidents, by not getting a full picture of the events that led to the abuse.Findings:A review of Resident 1's care plan titled, History of substance use disorder.Use of/addiction to illegal drugs. dated 2/12/26, indicated, .Interventions.Report any changes in mood status.During an interview on 3/17/26 at 11:48 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 3/3/26 while she was getting Resident 2 ready to go the shower room, she heard Resident 1 yelling at Resident 2. CNA 1 stated Resident 1 was upset, so she moved Resident 2 into the hallway while she gathered shower supplies to prevent the incident from escalating. CNA 1 explained once she moved Resident 2 into the hallway, she went and notified Resident 1's Licensed Nurse (LN) that Resident 1 was upset and was yelling at Resident 2. CNA 1 further stated she told the LN that the residents should be separated. CNA 1 stated she returned to Resident 2 and escorted him to the shower room. CNA 1 explained when she returned to the room with Resident 2 after his shower about 15 minutes later, she moved Resident 2 into the room toward the back of the room in front of Resident 2's bed. CNA 1 added that as she was along the back wall getting Resident 2's toothbrush from his nightstand, she observed Resident 1 get up from his bed, approached Resident 2, and hit Resident 2 in the back of the head with a fist. CNA 1 explained that she called for help and staff came to the room and separated the residents.During an interview on 3/18/26 at 8:57 AM, with LN 2, LN 2 confirmed he was the nurse assigned to Resident 1 and Resident 2 on 3/3/26 and responded to their room after a CNA told him about the residents fighting. LN 2 explained by the time he got to the room Resident 1 and Resident 2 were already separated. LN 2 stated Resident 2 told him that Resident 1 came over and hit him in the back of the head. LN 2 stated that he did not document the incident between the residents in their medical record since the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were already in the room taking statements from the residents and witnesses. During an interview on 3/18/26 at 9:32 AM, with CNA 2, CNA 2 stated that she was assigned to Resident 1 on 3/3/26. CNA 2 stated that she was told in morning report (standard communication between healthcare workers where outgoing staff exchange information with oncoming staff about resident's care, behaviors, and plans) on 3/3/26 a few hours before Resident 1 hit Resident 2 that Resident 1 could get agitated or upset easily and was rude.During an interview on 3/18/26 at 9:57 AM, with LN 3, LN 3 stated Resident 1 and Resident 2 had been known to have disagreements and argued about the lights being on in the room and the television being too loud during the night. LN 3 stated it happened a few different times about two weeks after they were roomed together. LN 3 further stated Resident 1 was known to yell out for staff to come to his room, and he was not patient with them. LN 3 stated she did not document or report to anyone the previous arguments between Resident 1 and Resident 2 because she felt she resolved them. During a concurrent interview and record review on 3/18/26 at 12:55 PM with the ADON, the facility document titled, Verification of Incident Investigation/Administrative Summary, dated 3/7/26, was reviewed. The ADON confirmed he took the statement on the document that indicated, .CNA witness reported [Resident 1] approached [Resident 2] and struck once on the back of the head with a closed fist while [Resident 2] was seated. The ADON confirmed that only two staff were interviewed for the incident. The ADON stated he and the DON split the statements and he took a statement from CNA 1 and the DON took the statement from LN 1. The ADON stated he asked CNA 1, What happened and What did she witness? The ADON further stated he did not ask any follow up questions or ask clarifying questions. The ADON could not recall whether he received any formal training on taking statements from staff or residents and investigating abuse.During a concurrent interview and record review on 3/18/26 at 11:43 AM, with the Director of Nursing (DON), Resident 1's and Resident 2's medical record was reviewed. The DON stated when a LN was notified that residents argued, she expected the LN to address it immediately to prevent it from escalating. The DON reviewed both Resident 1 and Resident 2's medical record. The DON confirmed she could not find any documentation of previous disagreements between Resident 1 and Resident 2, and she could not find any documented concerns with Resident 1's behaviors. The DON stated it was her expectation that staff documented and shared all incidents between residents that could lead to abuse. The DON further confirmed she had no knowledge of any previous incidents between Resident 1 and Resident 2. The DON explained that had she or her team been aware of the previous incidents between Resident 1 and Resident 2 they would have initiated a room change for resident safety. The DON stated she was assigned to complete the abuse investigation and five-day follow-up investigation report (a requirement for long-term care facilities to submit a detailed report to the State Agency [SA] within five working days of an alleged incident of abuse, neglect, or mistreatment)) that was submitted to the State Agency (SA) by the previous Administrator and confirmed it was her first time fully completing an investigation. The DON confirmed she shared the duties of the investigation with the ADON. The DON further confirmed she did not have any additional documentation to provide for the investigation and was not trained in how to complete an abuse investigation.During an interview on 3/18/26 at 1:38 PM, with the Acting Administrator (ADM), the ADM confirmed it was not a normal facility process for the DON to complete the five-day follow-up investigation and added that the DON stepped up to help out. The ADM explained it was important for the DON and the ADON to have been trained in the investigative process to better understand and grasp interviewing and compliance. The ADM further stated he had expected the DON and ADON to check in with each other to find out what happened and added, there needed to be some communication. The ADM explained risk of not completing a thorough investigation was that missed key parts of the investigation could put the residents at risk when the facility should have already intervened. A review of the facility policy titled, Alleged or Suspected Abuse and Crime Reporting, revised 10/25, indicated, .Each resident has the right to be free from abuse.Employees are responsible for immediately reporting to the facility administrator.any incidents of suspected or alleged abuse.Reports shall be thoroughly investigated.Investigation will focus on determining whether abuse.has occurred, identifying the extent and cause, and providing complete and through [sic] documentation of events. Within 5 working days of the incident, facility will complete a verification of incident investigation report.to the state agency.

Based on interview and record review, the facility failed to provide written notice at the time of the position change of the Director of Nursing (DON) to the State Agency (SA) for a census of 85 residents, when the current DON started the DON position on 12/10/25, and the facility did not report the change of the DON position to the SA until 1/7/26.This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 85 residents.Findings:During an interview on 3/18/26 at 11:43 AM with the DON, the DON confirmed she started her position as the DON with the facility on 12/10/25. The DON stated she was asked by the corporate (typically oversee billing, payroll, human resources, clinical compliance, and strategic management to ensure facilities meet state and federal standards) for all her licensing information but did not know when the change of leadership notification was sent to the SA.During a concurrent interview and record review on 3/18/26 at 1:38 PM, with the acting Administrator (ADM), the ADM reviewed the change of DON documents dated 1/7/26. The ADM confirmed the DON's documents were mailed to the SA on 1/7/26 and not at the time the change occurred. The ADM stated he was not aware of the time requirement.A review of the facility provided letter address to the SA, dated 1/7/2026, indicated, .CHANGE OF DIRECTOR OF NURSING Application. Further review revealed the letter was signed and dated by the DON on 1/7/26A review of the SA database revealed a received receipt of the DON application from the facility on 1/13/2026.

Based on interviews, and record reviews, the facility failed to provide adequate respiratory care services, immediate ongoing clinical assessment, treatment, and identified changes in condition as per professional standards of practice for one out of two sampled residents (Resident 1) when,1. LVN (Licensed Vocational Nurse) 1 did not notify the Physician of Resident 1's change in condition when he had shortness of breath and low oxygen saturation level on [DATE],2. LVN 1 increased Resident 1's oxygen therapy from 2 liters to 4 liters without a Physician's order, 3. LVN 1 adjusted Resident 1's oxygen liter flow and did not escalate Resident 1's care to a qualified healthcare professional, not following their scope of practice, and,4. Hospital discharge orders for Resident 1's weekly CBC were not transcribed over and were not followed.These failures resulted in physician not being aware of Resident 1's change in condition, delay in adequate assessment with potential of need for higher level of care not being identified, delay in adequate care and treatment and Resident 1 died within 2 hours of change in condition on [DATE].Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2026 with diagnoses including acute osteomyelitis (a serious bone infection usually caused by bacteria that spread through the bloodstream, nearby tissues, or open injuries), sepsis (a life threatening body's extreme response to an infection causing tissue damage), cellulitis and abscess of mouth (a common, potentially serious bacteria skin infection and underlying tissues, often causing rapid-spreading redness, warmth, swelling, and pain), diabetes type 2 (a chronic condition where the body resist insulin or fails to produce enough causing high blood sugar), essential hypertension (is a type of high blood pressure that has no clearly identifiable cause), blindness of both eyes, depression (a mood disorder causing persistent sadness, a loss of interest in activities, and an inability to function in daily life), sleep apnea (a common serious disorder where treating repeatedly stops and starts during sleep often causing loud snoring, choking and severe daytime tiredness), morbid obesity (a chronic malfunctional disease characterized by excessive fat storage), and anxiety.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool use to guide care) dated [DATE], indicated Resident 1 had a score of 12 on the Brief Interview for Mental Status exam (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information, a BIM score of 13-15 indicates intact cognition). Resident 1's BIMS score of 12 indicated moderate cognitive impairment (thinking and memory problems are noticeable and affect daily function).A review of Resident 1's Hospital Inpatient Discharge Instructions, indicated, . visit date [DATE].Your diagnosis Facial cellulitis Sepsis without acute organ dysfunction DM type 2 .Hypertension.SKILLED NURSING FACILITY[SNF] admission ORDERS.Oxygen Orders: Start oxygen at 2 L/min [liters per minute] for shortness of breath, chest pain, oxygen saturation less than 90% and notify physician immediately.CBC [Complete Blood Count: a blood test that measures the number, size, and characteristics of blood cells and platelets to assess overall health and detect medical conditions] and Chem 7 [a blood panel test that measures seven key chemical components to evaluate kidney function, electrolyte balance, and overall metabolic health] to be drawn weekly after SNF admission.Notify physician for Change in Condition: If patient has one or more of the following conditions, conduct full assessment and notify Physician .Abnormal lung sounds with new or increased O2[Oxygen] requirement to maintain O2 sat> [greater than] 88% .Shortness of breath while sitting still .Any abnormal labs . Facility staff had Resident 1's Hospital Inpatient Discharge Instructions signed that Resident 1's hospital discharge orders were noted and carried out on [DATE].A review of Resident 1's Physician's Orders dated [DATE], indicated, . Oxygen @ [at] 2 L/min via nasal canula [a thin flexible tube with two prongs inserted into the nostril allowing oxygen to flow directly into the nose] continuously every shift. A review of Resident 1's Physician's Orders dated [DATE], indicated, .CPAP [machine that delivers continuous air through the nose or mouth to keep the airways open while a person sleeps] ON at 9pm and OFF at 7 am. Review of Resident 1's care plan initiated on [DATE], indicated, .Focus .Requires IV therapy [a medical process that administers fluids, medications and nutrients directly into a person's vein] R/T [related to]: (Facial Cellulitis) .Interventions . Observe for signs and symptoms of embolism: shortness of breath; chest pain; cough; wheezing; skin that's cool, clammy, or bluish; rapid or irregular heartbeat; weak pulse .if air embolism is suspected .notify MD and call emergency personnel (911) .Review of Resident 1's care plan initiated on [DATE], indicated, .Focus .At risk for Cardiac Distress [a condition in which the heart suddenly and unexpectedly stops beating] R/T: Hyperlipidemia [high cholesterol level], HTN [Hypertension: high blood pressure] .Goal .Resident will be free signs and symptoms of cardiac distress .Observe and notify MD when resident is experiencing change in level of consciousness, shortness of breath, chest pain .Follow up labs .Review of Resident 1's care plan initiated on [DATE], indicated, .Focus .Elevated Cholesterol/Lipid Level [a blood test that is used to monitor and screen a person's risk of heart disease] .Goal .Resident will not develop complications of hypercholesterolemia/hyperlipidemia [high cholesterol levels] such as shortness of breath .Interventions .Observe for signs and symptoms of shortness of breath, chest pain secondary to heart disease .Follow up labs as ordered and report to MD .A review of Resident 1's nurse progress note, dated [DATE], indicated, . LATE ENTRY. Received resident in bed, Lying in bed comfortably, alert, and oriented x [times] 3, CPAP machine in place, oxygen in place at 2 LPM [liter per minute] via nasal canula around 07:50 AM. At same time Resident c/o [complained of] SOB [shortness of breath], checked O2 sat [oxygen saturation] 88 %. Increased Oxygen to 4 LPM via nasal canula and administered Albuterol [a medicine that relaxes airway muscles and help with breathing] 2 puffs as ordered. re check resident O2 sat at 08:15 a.m., O2 sat reading was 94 % to 95% .At 10:10 AM NP [Nurse Practitioner] make[sic] rounds and noted resident non-responsive, call the attention of writer, Code Blue [an emergency code signally a life-threatening medical situation] announce[sic] rightaway [sic] initiated CPR [Cardiopulmonary resuscitation: a critical, life-saving emergency procedure performed on people whose breathing or heart has stopped] called 911 at 10:13.10:26 AM Paramedics(911) pronounced death. Further review of Resident 1's progress notes failed to show that physician was notified of Resident 1's change in condition sooner than 10:10am, when NP found him unresponsive.A review of Resident 1's Situation Background Assessment Recommendation (SBAR; a communication framework used in healthcare to ensure accurate, concise and timely transfer of information, especially during critical situations or patients handover) Form and Progress Notes, dated [DATE], at timestamped 11:00 a.m., indicated, . Appearance, summarize your observation and evaluation, Resident c/o sob, checked O2 sat 88 %, increased oxygen at 4 LPM and administered albuterol 2 puffs, all am medication administered as ordered, tolerating well. Recheck O2 saturation reading was 94 to 95% . Further review of Resident 1's SBAR indicated physician was not notified of Resident 1's change in condition until 10:10 a.m. on [DATE].During an interview on [DATE], at 3:00 p.m., with LVN1, LVN1 confirmed during change of shift, on [DATE] at around 7:40 a.m., the Certified Nursing Assistant (CNA) on morning shift informed LVN 1 that Resident 1 was complaining of shortness of breath and had a low saturation of 88%. LVN 1 further stated she gave Resident 1 his Albuterol 2 puffs as per orders. LVN 1 added she increased his oxygen therapy from 2 LPM to 3 LPM, gradually to 4 LPM via nasal cannula, and kept it at 4 LPM. LVN 1 further stated she stayed in Resident 1's room till 8:15 a.m. to monitor Resident 1's condition. LVN 1 stated she did not get any orders from the Physician to increase Resident 1's oxygen from 2 LPM to 4 LPM, and she used her nursing judgement to titrate the oxygen. LVN 1 confirmed it was a change in Resident 1's condition when he had shortness of breath and low oxygen saturation at 88%. LVN 1 verified she did not call or notify the Physician of Resident 1's change in condition. LVN 1 stated she was passing medications and did not get the chance to do so. LVN 1 added the NP was doing rounds when she found Resident 1 unresponsive and not breathing around 10:10 a.m. LVN 1 stated the facility's policy was to notify the Physician of a change in resident's condition right away.During a concurrent interview and a record review on [DATE], at 2:40 p.m., with the Director of Nursing (DON), the DON stated it was not in LVNs' scope of practice to assess a resident who had a change of condition. The DON further stated an LVN was expected to notify a Registered Nurse to perform a full clinical nursing assessment when a resident had a change in condition. The DON confirmed LVN 1 did not escalate Resident 1's care to a qualified nurse who could have performed clinical assessment under their scope of practice for Resident 1, when Resident 1 had a change of condition on [DATE]. The DON stated LVN 1 should have immediately notified the Physician about Resident 1's change in condition on [DATE]. The DON further stated that LVN 1 should not have titrated Resident 1's oxygen without a physician's order, to make sure there was no underlining cause to Resident 1's shortness of breath, to prevent LVN 1 from practicing beyond their scope, and for Resident 1's wellbeing and safety. During an interview on [DATE], at 12:11 p.m., the DON stated LVN 1 adjusted Resident 1's oxygen flow rate using her nursing judgement to stabilize Resident 1 when he had shortness of breath. The DON stated it was not within LVN's scope of practice to adjust resident's oxygen flow rate since recent change in rules and regulations as of last year. During an interview on [DATE], at 4:20 p.m., with the DON, the DON stated when LVN 1 increased Resident 1's oxygen from 2 LPM to 4 LPM without getting a Registered Nurse (RN) or notifying the physician had a potential risk for delay of treatment and risk for harm or death.During an interview on [DATE], at 1:46 p.m., the DON confirmed an oxygen therapy care plan was not developed for Resident 1. The DON stated Resident 1 was on oxygen therapy and not having a care plan could result in lack of coordinated care and poor, inconsistent care.During a concurrent interview and a record review on [DATE], at 3:35 p.m., with the DON, of Resident 1's Order Review History Report dated [DATE] - [DATE], the DON confirmed there were no orders for weekly CBC to be drawn. The DON confirmed Resident 1's hospital discharge order to do CBC weekly was not transcribed over to facility orders and was not completed. The DON had no response whether the CBC was drawn for Resident 1. The DON could not provide evidence that Resident 1's CBC labs were drawn and were not able to find any CBC results for Resident 1.During an interview on [DATE], at 12:11 p.m., the DON verified Resident 1 was admitted to the facility with orders of IV antibiotics for infection and to complete CBC weekly upon admission to the facility and CBC weekly order was not transcribed and completed. The DON stated the importance of doing CBC as ordered was to see Resident 1's baseline for the facility, to make sure the IV antibiotics he was on for infection were compatible, to check his liver and kidney function. The DON stated his vital signs did not show signs of worsening infection pertaining to his cellulitis. The DON stated if they would have seen signs of infection, then they would have escalated him to the higher level of care. During an interview on [DATE], at 3:49 p.m., with the NP, the NP stated on Wednesday, [DATE], at 10:10 a.m., she was doing her usuals rounds and found Resident 1 in bed unresponsive, no pulse, and no respiration. The NP stated Resident 1 still had his CPAP on when she found him. The NP further stated she immediately called code blue and started CPR. The NP stated the CPAP should have been taken off at 7 a.m. as ordered. The NP added CPAP would have been beneficial to Resident 1 when he was sleeping. The NP stated staff should not have titrated Resident 1's oxygen from 2 LPM to 4 LPM without an order. The NP further stated if a residents' condition had changed, it was the facility's responsibility to immediately notify the Physician. The NP stated no one from the facility notified her or the Physician about Resident 1's change of condition on [DATE] until she herself found Resident 1 unresponsive at 10:10 a.m., during her rounding. The NP stated whatever orders were on Resident 1's hospital discharge form were valid orders and facility staff should have transcribed them into facility admission orders, especially for any lab orders such as CBC pertaining to Resident's 1 antibiotic therapy.During an interview on [DATE], at 2:16 p.m., with the Facility's Medical Director (MD), the MD stated he did not recall he received any telephone call or notification from the facility about Resident 1's change of condition the morning prior to finding him unresponsive, no pulse, and no respiration. The MD further stated it was the NP who called him to notify him that Resident 1 was found unresponsive, no respiration, and no pulse. The MD stated he expected facility staff to notify him or his NP immediately of a resident's change in condition such as chest pain, shortness of breath, low oxygen saturation, or change in mental status. The MD stated staff should not be titrating oxygen orders, that if he ordered to give oxygen at 2 LPM, it needed to have been carried out as such. The MD added that when staff increased Resident 1's oxygen from 2 LPM to 4 LPM due to shortness of breath and low oxygen saturation, this was a change in condition and should have been reported to him immediately. The MD stated the reason staff should have notified him of Resident's 1's change in condition was so he could do further work up, look for the causes to prevent any adverse events, for patient safety, and comfort. The MD stated if facility could have notified him of Resident 1's change in condition immediately he might have given the orders to send him to the emergency for further evaluation and high-level care. A review of facility's policy and procedure titled, Change in a Resident Condition or Status, dated 2017, indicated, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): . c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status. d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument [a mandatory, standardized system used in nursing homes to assess resident's clinical/functional status, develop individualized care plans, and monitor health changes] .A review of facility's in-service record on topic Respiratory Guidance LVN/RN Scope of Practice dated [DATE], indicated, .The Respiratory Care Board (RCB) has established a new regulation at California Code ofRegulations section 1399.365 that specifies the basic respiratory tasks and services LVNs may perform without conducting respiratory assessments that went into effect [DATE]. The regulation aims to enhance patient safety .some of the FAQ [Frequently Asked Questions] .Can LVNs initiate or adjust oxygen therapy? No. Initial setup or adjustment of oxygen liter flow or concentration is specifically excluded under 16 CCR section 1399.365(c)(6). Initiation of oxygen therapy requires a respiratory assessment and clinical judgment, which must be performed by a licensed RCP [Respiratory Care Practitioner] or, in certain settings, a RN under their own overlapping scope of practice. LVNs and other non-RCP personnel may assist by physically applying oxygen delivery devices (e.g., nasal cannula, face mask) only after an RCP or RN has made the clinical decision to initiate therapy. They may not independently decide to start or adjust oxygen, even under a standing PRN order, since determining when oxygen is needed requires a respiratory assessment. *Review residents on oxygen therapy. Have specific oxygen orders and discuss with the physician if titration orders are needed. The RN and/or Respiratory Therapist will initiate or titrate/adjust oxygen as ordered .LVNs mustcontinue to work under the supervision of a licensed respiratory care practitioner, registered nurse, or physician.According to Board of Vocational Nursing and Psychiatric Technicians, Changes to Respiratory Care Scope of Practice Go Into Effective [DATE] The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) would like to inform licensees, employers and educators of regulations adopted by the Respiratory Care Board (RCB) impacting the scope of practice licensed vocational nurses (LVNs) going into effect on [DATE]. These regulations impact the LVN scope of practice with various changes, as described below. BVNPT licensees, employers and educators are expected to comply with the regulations. LVNs CANNOT perform the following: Manipulation of an invasive or non-invasive ventilator.Assessment or evaluation of observed and gathered data from chest auscultation, palpation, and percussion.Pre-treatment or post-treatment assessment.Preoxygenation or endotracheal or nasal suctioning.Initial setup, change out, or replacement of a breathing circuit or adjustment of oxygen liter flow or oxygen concentration.https://www.bvnpt.ca.gov

Based on interview and record review, the facility failed to ensure a baseline care plan including the interventions and instructions needed to provide effective and person-centered care as per professional standards of quality care was developed for one of three sampled residents (Resident 1), when Resident 1 was admitted to the facility with oxygen therapy and an oxygen care plan was not developed for Resident 1. This failure had the potential to receive inadequate respiratory care for Resident 1.Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including acute osteomyelitis (a serious bone infection usually caused by bacteria that spread through the bloodstream, nearby tissues, or open injuries), sepsis (a life threatening body's extreme response to an infection causing tissue damage), cellulitis and abscess of mouth (a common, potentially serious bacteria skin infection and underlying tissues, often causing rapid-spreading redness, warmth, swelling, and pain), diabetes type 2 (a chronic condition where the body resist insulin or fails to produce enough causing high blood sugar), essential hypertension (is a type of high blood pressure that has no clearly identifiable cause), blindness of both eyes, depression (a mood disorder causing persistent sadness, a loss of interest in activities, and an inability to function in daily life), sleep apnea (a common serious disorder where treating repeatedly stops and starts during sleep often causing loud snoring, choking and severe daytime tiredness), morbid obesity (a chronic malfunctional disease characterized by excessive fat storage), and anxiety.Review of Resident 1's Hospital Inpatient Discharge Instructions, indicated, . visit date 1/20/26.SKILLED NURSING FACILITY[SNF] admission ORDERS.Oxygen Orders: Start oxygen at 2 L/min [liters per minute] for shortness of breath, chest pain, oxygen saturation less than 90% and notify physician immediately.Notify physician for Change in Condition: If patient has one or more of the following conditions, conduct full assessment and notify Physician .Abnormal lung sounds with new or increased O2 [oxygen] requirement to maintain O2 sat> [greater than] 88% .Shortness of breath while sitting still .Any abnormal labs . Facility staff had Resident 1's Hospital Inpatient Discharge Instructions signed that Resident 1's hospital discharge orders were noted and carried out on 1/23/26.Review of Resident 1's Physician's Orders dated 1/23/26, indicated, . Oxygen @ [at] 2 L/min via nasal canula [a thin flexible tube with two prongs inserted into the nostril allowing oxygen to flow directly into the nose] continuously every shift. Review of Resident 1's care plans failed to show that an oxygen care plan was developed.During a concurrent interview and record review on 3/10/26, at 12:11 p.m., the DON verified Resident 1 was admitted to the facility with oxygen therapy. The DON stated baseline care plan summary served as residents' baseline care plan. The DON confirmed Resident 1's baseline care plan summary dated 1/25/26, did not include specific interventions and instructions to provide effective and person-centered care plan for oxygen therapy. The DON stated a specific oxygen care plan was not developed for Resident 1.During an interview on 3/10/26, at 12:11 p.m., the DON stated the importance of developing an oxygen care plan for a resident who would be admitted with oxygen therapy was to help improve continuation of care.Review of facility policy titled, Baseline Care Plan Summary revised October 2025, indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan shall: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident .

Based on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 87 residents who ate facility prepared meals when:1. Over ripe and spoiled produce was available for use in the walk-in refrigerator; 2. Black small bugs were found crawling on the onions and flying within the container that encompassed the onions; 3. Cutting boards and tray line pans were found with food particles, black, and brown colored substances on them; and,4. Several pots, pans, bowls, and trays were found stacked wet (in ready-to-use areas).These failures had the potential to put residents who ate the facility prepared meals at risk for foodborne illnesses.Findings:1. During a concurrent observation and interview on 9/9/25, at 8:18 AM in the walk-in refrigerator with the Dietary Service Supervisor (DSS), the following items were observed available for use and the following findings were confirmed with the DSS: a. Approximately 7 of 25 tomatoes were mushy to touch, had broken skin, and had a fuzzy black and green substance on them. b. Approximately 8 of 12 lettuce heads were discolored, noted to be brown and soft in texture with a brown moisture at the base of them. c. Approximately 3 of 6 stalks of celery were found to have various shades of brown with some brown leaves fallen off and stem soft in texture and wilted. d. Approximately 20 of 20 zucchini had a black and white fuzzy spotted substance scattered around them. e. Approximately 1 of 7 containers of strawberries had a white fuzzy substance scattered around them. f. Approximately 13 of 13 potatoes were found sprouted and with circular dark brown spots and have a soft texture. During an interview on 9/9/25 at 8:18 AM, the DSS acknowledged the condition of the product and stated that they were not in a condition to be served. The DSS removed the damaged produce and had it discarded. The DSS stated the staff would discard the produce prior to serving if found in that condition. During an interview on 9/12/25 at 10:49 AM, the Registered Dietician (RD) stated the expectation was for produce to be free of mold, discoloration, and any signs of breakdown. The RD stated the risk to the residents when the produce is compromised, germs could be present. The RD stated these germs could make the residents sick with foodborne illnesses (getting sick after eating or drinking something contaminated with nasty germs). The RD stated the quality of the food is negatively affected as well. The RD stated her expectations were that produce that was found should be discarded. Review of facility policy STORING PRODUCE, dated 2023, indicated, .1. Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple, or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items. 7. Keeping fresh vegetables tightly wrapped with as little air in the bag/container as possible will keep them fresh longer. 8. When storing vegetables that should remain crisp, such as lettuce and other leafy greens, fresh herbs, celery. stay fresh longer if you place them in a sealed bag.9. Remove the wilted or spoiled portions of lettuce, celery, and other vegetables in the refrigerator often so they don't cause the rest of the vegetables to spoil.2. During the initial kitchen tour with the Dietary Service Supervisor (DSS), on 9/9/25 at 8:48 AM, the DSS confirmed the onions had black spots and circular discoloration on them with a soft texture. The DSS also confirmed the presence of small black bugs crawling on the onions and flying withing the white container they were stored in. During a follow up observation of the kitchen with the DSS on 9/10/25 at 2:19 PM, the DSS confirmed more onions were added to the container. The DSS stated that the facility just received their food delivery. During an observation of the container, the container was noted to have black small bugs crawling on the onions and flying within the container. The DSS confirmed the presence of the bugs and attempted to swat them with her hand. The DSS stated when this occurs the facility would contact a company that would provide a spray to kill the bugs. During an interview with the Registered Dietician (RD), on 9/12/25 at 11:35 AM, The RD stated the quality of the onions did not meet her expectations. The RD stated, the expectations were for the onions to be discarded and not for any chemicals or repellents to be sprayed on them. The RD stated, the onions found that were soft in texture, with black spots, and discoloration pose a risk for food borne illness for the residents. The RD stated, the presence of the bugs on the onions indicated that the food was old and needed to be discarded. A record review of a facility provided document titled, MISCELLANEOUS AREAS, dated 2023, indicated, .FLY AND VERMIN CONTROL Flies are carriers of disease and are a constant enemy of high standards of sanitation in Food & Nutrition Services Department . A record review of a facility provided document titled, STORING PRODUCE, dated 2023, indicated, .Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple, or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items . 3. During a concurrent observation and interview on 9/9/25, at 8:25 AM in the cook's preparation area, with the DSS the following items were observed to be available for use and were confirmed with the DSS and sent to be rewashed after: a. Two midsize metal tray line pans were sitting on the counter with clear liquid scattered around it and food particles. b. One green cutting board was found with multiple layers of an orange brownish dried substance with dried fruits seeds on it. c. One white cutting board was found with a dried brown substance on it. During a concurrent interview and record review with the RD on 9/12/25 at 10:49 AM, the RD stated the food particles remaining on the kitchenware is unacceptable and could present as a health risk of food borne illness to the residents. The RD stated these conditions were unsanitary and could attract rodents. The RD stated her expectations were for the kitchenware to be cleaned, sanitized, air dried, and put away without food particles. A record review of an undated facility provided document titled Policies and Procedures Care and Cleaning of Commercial Cutting Boards; durable plastic composition, the policy indicated, .In order to maintain an prevent any bacteria harboring in cutting boards used in our facility, cutting boards must be properly used, cleaned and maintained.Do not let liquids sit on board for any extended time.Wash cutting boards with hot soapy water and sanitize them thoroughly after use; follow manufactures recommendations for washing them in the commercial dishwasher. A record review of a facility provided document titled POT AND PAN WASHING, dated 2023, the policy indicated, .Pots and pans will be properly sanitized. The preferred method is to run all pots and pans through the dish machine. Review of the FDA 2022 Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(A) Equipment Food-Contact surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris 4. During a concurrent observation and interview on 9/9/25 at 8:48 AM, under the kitchen preparation table and under the tray line table there were 11 out of 30 wet tray line pans identified. The DSS acknowledged the condition of these tray line pans and stated that she was not sure how they got wet and mentioned the possibility of water leaking from the tray line table on the tray line pans. After confirmation the DSS removed the wet pans and had them washed. During an interview on 9/12/25 at 11:10 AM, the RD stated all dishes and cookware should be washed, sanitized, and air dried. The RD stated water attacks bacteria which could enter the food and make it unsafe by causing a food borne illness. The RD stated the condition the wet tray line pans were found in did not meet her expectations and will be addressed. A record review of a facility provided document titled DISHWASHING, dated 2023, the policy indicated . Dishes are to be air dried in racks before stacking and storing. A record review of a facility provided document, 3-COMPARTMENT PROCEDURE FOR MANUAL DISHWASHING dated 2023, the document indicated, .All items are air-dried, which means no water droplets present.

Based on observation, interview, and record review, the facility failed to ensure safe handling of Hazardous drugs (or HD, drugs that have the potential to cause harm to healthcare workers or patients when not handled properly), safe use of resident care devices (small devices that measure blood pressure (or BP, the force exerted by the blood on the walls of the arteries as it flows through the body) or heart beat), and timely measurement of blood sugar levels, based on standards of practice with a resident census of 87, when:Hazardous medications were not consistently labeled as hazardous to alert nursing staff on safe handling as observed during Resident 56's medication administration, and during a medication cart inspection for Resident 42, Resident 16, and Resident 76.Staff's personal blood pressure devices were used when the facility's blood pressure device malfunctioned during a medication administration observation for Resident 92.Resident 5's blood sugar was measured after Resident 5 consumed most of her meal tray but the doctor's order indicated the sugar level to be measured prior to the meal for insulin (drug to treat blood sugar disease) administration.These failed practices could contribute to unsafe resident care, undesirable resident outcomes, and the safety of both staff and residents could be compromised.Findings:1. During a medication administration observation, accompanied by Licensed Nurse 3 (LN 3), in the facility's Hall number 4, on 9/9/25, at 9:27 AM, LN 3 administered 12 medications to Resident 56. LN 3 without gloved hands administered a hazardous medication called Divalproex Sprinkle capsule (Same as valproic acid, drug used to treat mood disorder or used to prevent brain seizure) in a pill cup to Resident 56.The label on the Divalproex Sprinkle bubble pack did not have an alert for hazardous drug handling. The label, at the bottom, with a very small font wording, indicated If you become pregnant, do not take this drug.In an interview with LN 3, at the main nursing station, on 9/12/25, at 10:13 AM, LN 3 stated she was not aware that valproic acid was hazardous and required handling with use of gloves. LN 3 stated pharmacy labeling and Medication Administration Record (or MAR, a document that listed drug orders and instructions on when or how to administer) instructions would have helped with knowing to use gloves during drug administration.During an observation and inspection of the facility's medication cart for Hall number 2, accompanied by LN 4, on 9/9/25, at 10:20 AM, the cart stored two medications in pill form as follows:Valproic Acid for Resident 16 and Oxcarbazepine (medication for treatment of seizure) for Resident 76 that did not have a label for safe handling as a hazardous drug.During an observation and inspection of the facility's treatment cart (a mobile cart that stores skin medications and supplies), in Hallway number 2, accompanied by LN 7, on 9/10/25, at 11:07 AM, the treatment cart stored a tube of a topical skin product called Tacrolimus ointment (used to treat the symptoms of eczema (severely dry and itchy patches of skin) by suppressing the body's immune system) for Resident 42. The Tacrolimus ointment label was not marked for being hazardous to touch and it was co-mingled with other topical products in the top drawer without being stored in a Ziplock bag.In a concurrent interview with LN 7, at the main nursing station, and review of Resident 42's MAR, on 9/12/25, at 9:02 AM, LN 7 stated the MAR did not have a comment on safe handling of the ointment. LN 7 stated she used one pair of gloves when administering any topical products.During an interview with the Director of Nursing (DON), on 9/12/25 at 10:55 AM, the DON stated that her expectation was for nurses to use gloves when handling hazardous medications. The DON stated pharmacy should have labeled hazardous drugs and the MAR should have had directions on handling hazardous drugs to help with compliance and safety. During a concurrent interview and review of the facility's policy, titled Care of Patients On Chemotherapy (drugs used to treat cancer), dated 12/2019, the policy did not address handling of non-chemotherapy drugs listed as hazardous. The DON stated currently the facility had a policy regarding hazardous chemotherapy drugs, but she needed to coordinate with pharmacy to help with a policy on other hazardous drug use and handling.During a phone interview with the Consultant Pharmacist (CP) on 9/12/25 at 1:07 PM, the CP stated he will inform the pharmacy regarding the inconsistency with labeling hazardous medications and would recommend to the facility through his review to add HD handling instructions on the MAR.Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 12/2024, last accessed on 9/15/25 via https://www.cdc.gov/niosh/docs/2023-130/default.html and https://www.cdc.gov/niosh/docs/2025-103/default.html , the documents indicated Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. The document under Managing Hazardous Drug Exposures: Information for Healthcare Settings indicated, .In areas where hazardous drugs are present, the surfaces and external parts . that are handled may be contaminated with these drugs. thus, gloves should be used to prevent dermal exposure . Implement labeling of containers of hazardous drugs . Double-bag or place in a sealed container. NIOSH suggests careful precautions and safeguards to protect workers, fetuses, and breastfed infants. Further review of the document indicated to use single gloves for handling intact tablet form and double gloves for handling oral liquid or topical forms of the hazardous medications as directed. The NIOSH list included oxcarbazepine, tacrolimus and divalproex as HD to be handled with gloves during medication administration.2. During a medication pass observation, with LN 4, in facility's Hall number 2, on 9/9/25, at 10:07 AM, LN 4 used the facility's blood pressure device and went into Resident 92's room. LN 4 stated the blood pressure device was not working and it may have had a dead battery. LN 4 then reached into the bottom of the cart drawer and pulled another BP device from a bag to take inside the room to measure the BP. LN 4 stated the beige-colored BP device was hers.During a concurrent interview with LN 6, in Hall number 3, and medication cart inspection, on 9/10/25, at 10:24 AM, the cart stored two different BP devices in the bottom drawer of the cart. LN 6 stated the black colored BP device on top of the cart was her own and she would use it if needed.In an interview with the Director of Nursing (DON), in her office, on 9/12/25, at 10:56 AM, the DON stated the facility did not allow the use of wrist type BP devices or use of staffs own BP devices. The DON stated that the accuracy of measurements could not be guaranteed if nursing staff use their own BP devices on residents.A review of the facility's policy titled, Assistive Devices and Equipment revised in July 2017, indicated, Our facility provides, maintain, trains and supervises the use of . equipment for residents. The policy under Device Condition indicated devices and equipment will be maintained on schedule and according to manufacturer's instructions.A review of American Medical Association (AMA, organization representing doctors) publication, dated 3/7/25, titled 4 big ways BP measurement goes wrong, and how to tackle them, the publication indicated, .Adding to inaccuracy are automated devices that have not been tested for accuracy, which can account for errors in systolic BP.https://www.ama-assn.org/public-health/prevention-wellness/4-big-ways-bp-measurement-goes-wrong-and-how-tackle-them3.During a concurrent interview and medication pass observation, with LN 5, in Hall 2, on 9/9/25, at 5:22 PM, LN 5 entered Resident 5's room and measured the blood sugar when the food tray was in front of the resident and almost finished. LN 5 after measuring the blood sugar, administered insulin per doctor's order. LN 5 once out of the room stated she was running behind and was late in measuring the blood sugar prior to dinner. LN 5 states the resident had 80 percent of her dinner consumed when the blood sugar was measured. LN 5 stated measuring the blood sugar after a resident was eating a main meal, could have made the blood sugar go higher.Review of Resident 5's MAR, dated 9/2025, the MAR indicated FSBS (Finger Stick Blood Sugar-when finger poked to get blood for testing sugar) before meals- Start Date- 3/16/25.During an interview with the Director of Nursing (DON) on 9/12/25 at 10:55 AM, the DON stated that nursing staff are expected to check residents' blood glucose levels before meals as ordered. The DON stated that the nurse should inform the residents and coordinate with dietary staff regarding timing of blood glucose monitoring and insulin administration.A review of American diabetes Association (ADA, a national organization dedicated to care of diabetes) position statement, dated 1/1/19, titled STANDARDS OF MEDICAL CARE IN DIABETES - 2019 indicated, .BEDSIDE BLOOD GLUCOSE MONITORING.In the patient who is eating meals, glucose monitoring should be performed before meals . The position statement under Noncritical Care Setting indicated If the patient is eating, insulin injections should align with meals. In such instances, . glucose (sugar) testing should be performed immediately before meals.https://diabetesjournals.org/care/article/42/Supplement_1/S173/31340/15-Diabetes-Care-in-the-Hospital-Standards-of

Based on observation, interview, and record review the facility failed to ensure safe pharmaceutical services with a resident census of 87 when:Emergency medication Kits (Ekit, a supply of prescription medication reserved for emergency use when needed) use, opening, and its contents were not accounted for in the IV medication Ekit (Intravenous, into the vein) and refrigerator medication Ekit in the main medication room.Facility staff's personal purse was stored in the medication room counter-top where prescription and controlled drugs (drugs that required doctor's prescription and subject to abuse) were stored.Pharmaceutical delivery records for prescription and controlled drugs were not signed and reviewed by licensed staff upon delivery. These failed practices could contribute to lack of accountability and risk of drug diversion (diversion is unauthorized use of drugs).Findings:During a concurrent interview and inspection of facility's main medication room, accompanied by the Assistant Director of Nursing (ADON) and Licensed Nurse 2 (LN 2), on 9/9/25 at 10:39 AM, two opened Ekits, including an IV Ekit and Refrigerator Ekit, were reviewed for accuracy of content and its use. The opened Ekits had a yellow color seal tag indicating it was opened after delivery by the provider pharmacy as confirmed by ADON. The refrigerator Ekit review did not show any items removed. The IV Ekit contents did not show any medication was removed. The IV Ekit content included an antibiotic (medication used to kill bacteria) called clindamycin in IV form that was not listed on the Ekit's content list. The IV Ekit content additionally included two zip-lock bags with two opened syringe boxes of Dextrose 50% (percent) carpujet (prefilled syringe of IV form of sugar used during an emergency for blood sugar disease; 50% is percent, a fraction of 100). ADON acknowledged the findings and stated he needed to contact the provider pharmacy for clarification.During a concurrent interview and review of Ekit binder (a binder with sheets that recorded Ekit use by nursing staff), with the ADON, in the main medication room, on 9/9/25 at 11:28 AM, the binder marked as Emergency Kit Pharmacy Log, did not have any paper documentation of use by nursing staff since 2/2025. The binder did not show records of opening the refrigerator EKit or IV Ekit after pharmacy delivery of a new red-sealed (pharmacy sealed kits were marked by a red color seal) Ekits. ADON stated that when a kit was opened, the documentation should have been recorded in the Ekit form followed by a call to pharmacy for delivery of a new kit.Review of undated Ekit paper form titled, Emergency Kit Pharmacy Log, the log sheet indicated, Call order . into pharmacy; Fill out appropriate areas in log; When completed, place copy on pharmacy log clipboard; Return yellow copy to pharmacy in emergency kit. The form further indicated the white copy was for the facility.During an interview with the Director of Nursing (DON) on 9/10/2025 at 3: 50 p.m., the DON confirmed that a yellow EKit seal indicated the Ekit has been opened, while a red seal means the Ekit was intact and had not yet been opened by facility staff. The DON further stated that the facility's process for accessing the Ekit required a physician order first. The DON stated that when staff removed a medication from the Ekit, the removal should have been documented on the Ekit sheet provided by the pharmacy and the yellow copy should have gone back to the pharmacy while the white copy was retained by the facility. The DON stated the staff were expected to call the pharmacy to request a replacement medication. The DON stated she would consult with the pharmacist about the clindamycin IV found inside the Ekit that was not included on the medication list. The DON stated the opened box of D50% IV were not acceptable as she would not feel comfortable administering an opened, unsealed medication container to a resident. During a phone interview with the facility's Consultant Pharmacist (CP) on 9/12/2025 at 1:07 PM, the CP confirmed that a yellow tag indicated the Ekit had been opened, and all Ekit access should have been documented. The CP stated the facility should have informed the pharmacy when the Refrigerator Ekit seal was broken. The CP stated he was unsure if the clindamycin IV bag inside the IV Ekit without being listed was due to a shortage or the list not updated. Regarding the open D50% carpujet box, the CP stated the box should have been sealed, and he acknowledged the potential risk of contamination.Review of the facility's policy titled, Emergency Medications, revised on April 2007 indicated, .The contents of each emergency medication kit will be clearly listed.The consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit.Records of monthly inspection are maintained for at least one (1) year or as required by applicable laws and regulations. 2. During a concurrent interview and inspection of facility's main medication room, accompanied by ADON, on 9/9/25 at 11:30 AM, a dark color personal purse was located on the main countertop just below the discontinued drugs cabinet. ADON stated the staff could have their purses stored in the medication room temporarily. During an interview with the DON on 9/10/2025 at 3:50 PM, The DON stated that personal purses should not be placed inside the medication room due to potential risk of safety/medication diversion.During a phone interview with the facility's Consultant Pharmacist (CP) on 9/12/2025 at 1:07 PM, the CP stated that personal items, backpack or purses should not be stored in the medication room due to risk of medication diversion.A review of the facility's policy, titled Storage of Medication, revised in April 2007 indicated, . Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.A review of the facility's policy titled, pharmacy Services Overview, revised in April 2007 indicated, .Help the facility develop procedures.related to.storage system within the facility; to minimize loss of, or tampering with the medication supplies. 3. During a concurrent interview and record review of medication delivery documents, in the medical record office, accompanied by Med Record Director (MRD), on 9/10/25 at 2:30 PM, the MRD stated the records were bundled up together and saved in a box. The review of current and last two months of the medication delivery documents indicated the medication delivery sheets included the names of prescription medication, quantity of medications, and a resident's name. The record had a spot for nursing staff to sign and date. The prescription delivery records including controlled drugs did not have a signature confirming the acceptance of the medications.In an interview with unit Clerk (UC) on 9/10/25 at 2:15 PM, the UC stated when the medication delivery driver arrived at the facility, she directed the driver to licensed staff to accept and sign the acceptance of medication form.In an interview with a Licensed Nurse 6 (LN 6), on 9/10/25 at 2:28 PM, LN 6 stated pharmacy delivery forms are signed upon receipt. LN 6 stated the driver's electronic document should have been signed in addition to the checking in the items delivered and then the signed paper sheet should have gone into a binder in the cabinet.During an interview with the DON on 9/10/2025 at 4:36 PM, The DON stated that she expected her staff to sign the delivery form and check each item for all medications delivered.During a phone interview with the facility's Consultant Pharmacist (CP) on 9/12/2025 at 1:07 PM, CP stated the medicaion delivery form should have been signed because a wet signature (hand-written signature on paper) was good for accountability of handling and delivery of medications.During a concurrent interview with DON on 9/12/25 at 11 AM, and record review of the facility's medication delivery sheet, titled, Consolidated Delivery Sheets, with date range of 8/9/25 to 9/9/25, the record included both controlled and non-controlled medications without any markings or signature at the bottom of the sheet marked as Checked by . Print name . Date . Time. and Received by . Print name . Date . Time. The record included drug names such as methadone (an Opioid [classified by the government as having a potential for abuse and addiction] drug), Hydrocodone/APAP (or Norco, an opioid drug), and zolpidem (a controlled medication for insomnia) in addition to multiple non-controlled medication delivery sheets. The DON stated the delivery document should have been checked and signed upon receipt of drugs.Review of an email communication from facility's Administrator, dated 9/16/25, the email included two delivery documents from the provider pharmacy for non-controlled medication delivered on 9/10/25 and 9/11/25. The documents did not address the responsibility for the facility's record of delivery documentation including the controlled drug accountability.A review of the facility's policy titled, Pharmacy Services Overview, revised in April 2007, indicated, .Help the facility develop procedures.related to delivery.to minimize loss of, or tampering with medication supplies.Review of the facility's policy, titled Controlled Substances, dated 12/2012, the policy indicated, . The facility shall comply with all laws, regulation and the other requirements related to handling, storage, disposal and documentation of . controlled substances. The policy further indicated, .Controlled substances must be counted upon delivery. The nurse receiving the medication along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated control Substance record .

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 5 out of 41 facility rooms when window blinds were broken in Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]).These failures removed residents' rights to a dignified homelike environment, with the potential to result in psychosocial harm.Findings:During an observation on 9/09/25, at 10:58 AM, in room [ROOM NUMBER], the window blinds were observed to be broken.During a concurrent observation and interview on 9/09/25, at 12:59 PM, in room [ROOM NUMBER], Licensed Nurse (LN) 3 confirmed the window blinds were broken. LN 3 stated broken blinds were a dignity issue for the residents. LN 3 confirmed window blinds had spaces when they were closed and anyone could have looked inside room [ROOM NUMBER] from outside the window. LN 3 further stated there was a lack of privacy when window blinds were missing.During a concurrent observation and interview on 9/10/25, at 10:07 AM, in room [ROOM NUMBER], Certified Nursing Assistant (CNA) 1 confirmed the window blinds were broken. CNA 1 stated the window blinds had been broken since the morning of 9/10/25, and she had not notified the Director of Maintenance Services (DES).During a concurrent observation and interview between 9/10/25, at 8:36 AM, and 9/11/25, at 3:46 PM, the DES confirmed the window blinds in room [ROOM NUMBER] had three broken blind slats, room [ROOM NUMBER]'s blinds were twisted and shorter than the window frame, room [ROOM NUMBER] had dented blinds, room [ROOM NUMBER] had two blind slats broken, and in room [ROOM NUMBER] a blind slat was broken and missing. The DES stated staff did not notify him the blinds needed to be fixed. The DES stated the risk was that anyone could have peeped inside the resident's rooms through the broken and missing blinds.During an interview on 9/10/25, at 2:25 PM, the Administrator (Admin) stated facility staff members had verbalized to the DES that morning that blinds were missing/broken. The Admin stated the expectation was to have staff log in the maintenance logbook that there were missing/broken blinds. The Admin stated Residents may not have full privacy when window blinds were missing/broken.During a concurrent observation and interview on 9/12/25, at 11:18 AM, in room [ROOM NUMBER] Responsible Party (RP) 1 stated the window blinds had been broken for two weeks. RP 1 stated anyone could see inside room [ROOM NUMBER] and the blinds should have been fixed.A review of a facility document titled, Safe and Homelike Environment, dated 2022, indicated, .In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.A review of a facility document titled, Work Orders, Maintenance, dated 2010, indicated, .In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director.It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director.

Based on observations, interviews, and record review, the facility failed to ensure proper infection prevention practices were implemented and followed to provide a safe and sanitary environment and help prevent the spread of infection with a resident census of 87 when: 1. The facility stored a resident's kidney basin with clean dishes in the kitchen, creating a risk of cross-contamination; 2. Dietary staff failed to follow infection control practices of hand hygiene during tray line service; 3. Shared glucometer devices (a device used to measure blood sugar) were not cleaned and disinfected in-between resident care per manufacturer's specification for Resident 5 and Resident 105; and,4. A pill cutter was not cleaned before and after each use for Resident 108. These failed practices had the potential to place the residents at risk for developing an infection and the potential to result in the spread of the infection within the facility. These lapses in infection prevention and control practices placed the residents at risk for avoidable harm.1. Findings: 1. During a concurrent observation and interview with the Dietary Service Supervisor (DSS) during the initial kitchen tour on 9/9/25 at 8:18 AM, a kidney basin was observed stocked and stored with the clean dishes. During a concurrent interview and record review with the Registered Dietician (RD), on 9/12/25 at 11:20 AM, the RD confirmed the presence of a used kidney basin stored with clean dishes. The RD stated that kidney basins did not belong in the kitchen and was a resident's personal item. The RD stated once the basin was identified in the kitchen it should have been thrown away immediately. The RD stated the kidney basin presented an infection control risk of cross contamination and this type of practice did not meet her expectations. During an interview with the DSS on 9/12/25 at 2:30 PM, the DSS stated if she was aware of the kidney basin being stocked and stored in the kitchen she would have thrown it away. The DSS stated the kidney basin should not have been in the kitchen and placed with the dishes. 2. During an observation of lunch tray line service on 9/11/25 at 12:15 PM, the [NAME] (CK 1) was observed grabbing her phone with gloved hands and continued to serve the lunch tray line. Multiple times during the tray line the cook was observed placing a full gloved hand on her clothing and continued to serve the residents without initiating hand hygiene. During an interview on 9/12/25 at 1 PM, CK 1 acknowledged touching her phone and stated her alarm was going off which is why she touched her phone and stated that phones carry a lot of germs. CK 1 acknowledged touching her clothing excessively with her gloved hands and stated that she knew that she was not supposed to be doing that but got distracted. CK 1 stated that she was aware of the proper protocol and acknowledges that she should have removed her gloves and washed her hands after touching her phone and personal items. CK 1 stated not washing her hand placed the residents at risk for becoming sick because the phone had a lot of germs. During an interview with the Registered Dietician (RD) on 9/12/25 at 11:34 AM, the RD stated the expectation of staff during tray line if they were to touch their clothing or any personal items while serving or preparing food was to remove their gloves, perform hand hygiene, and put a new set of gloves on. The RD stated the risk of not following the infection control practices for hand hygiene is food borne illness and cross contamination. A record review of a facility provided document titled, GLOVE USE POLICY, dated 2023, the policy indicated, .POLICY: The appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled.WHEN GLOVES NEED TO BE CHANGED.5. As soon they become soiled as when.using the phone. Review of the FDA 2022 Food Code, Section 2-301.14, titled, When to Wash, dated 1/18/23, the document indicated, .(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms.(D) Except as specified in 2-401.11(B).(I) After engaging in other activities that contaminate the hands. (https://www.fda.gov/food/fda-food-code/food-code-2022) 3. During concurrent medication administration observation and interview with Licensed Nurse (LN) 5, on 9/9/25 at 4:50 PM, LN 5 was observed taking a glucometer device along with supplies into the Resident 105's room. LN 5, with gloved hands, poked the left middle finger with a sharp lancet device (a disposable device used to poke finger to get blood for testing) to get blood from the finger. LN 5, then soaked the test strip attached to glucometer with Resident 105's blood to get the blood sugar number. The glucometer dropped on the bed sheet when LN 5 tried to wipe the finger with an alcohol pad. LN 5 exited the room and changed her gloves and used one Clorox healthcare bleach germicidal wipe (brand name of wipe used to clean and kill germs on the surfaces) to wipe the outer surface of the glucometer for less than 5 seconds. LN 5 then placed the glucometer with the same wipe on the top of the cart. LN 5 stated that she needed to administer insulin (drug to treat blood sugar disease) to Resident 105 as ordered by the doctor. During concurrent medication administration observation and interview with Licensed Nurse (LN) 5, on 9/9/25 at 5:22 PM, LN 5 was observed taking the same glucometer device along with supplies into Resident 5's room while she was eating her dinner. LN 5 with gloved hands poked Resident 5's left middle finger with a sharp lancet device to get blood from the finger. LN 5, then soaked the test strip attached to glucometer with Resident 5's blood to get the blood sugar number. LN 5 exited the room and changed her gloves and used one Clorox bleach wipe to clean the outer surface of the glucometer for less than 5 seconds. LN 5 then placed the glucometer with the same wipe on the top of the cart. LN 5 proceeded to administer insulin to Resident 5 as ordered by the doctor. LN 5 stated she was trained to use one wipe to clean the glucometer, then wrap it with the same wipe and let it dry. LN 5 acknowledged that there was a risk of spreading infection if a device was not cleaned and sanitized properly. During an interview with the Director of Nursing (DON), on 9/12/25 at 10:55 AM, the DON stated that the facility's policy was to follow the manufacturer's instructions. The DON further stated that a two-step process using two different disinfectant wipes was important to clean and disinfect equipment to prevent the spread and risk of infection. During a concurrent interview with the Infection Prevention Nurse (IP), on 9/12/25 at 9:25 AM, and review of facility's policy on use of shared glucometer in between resident care, the IP stated that the cleaning process was to use a disinfectant wipe to clean the glucometer, after which nurses may either wrap the device with the same wipe or let it air dry for two minutes. The IP stated that if a bleach-based disinfectant (same as Clorox Healthcare Bleach Germicidal Wipes) was used, the device must air dry for three minutes. After reviewing the manufacturer's instructions for both the Sani-Cloth Germicidal Disposable Wipes (brand name wipe used to kill germs) and Clorox Healthcare Bleach Germicidal Wipes, the IP confirmed that the instructions required a two-step cleaning and disinfecting process to ensure safe use of a glucometer in-between resident care. The IP stated that failure to follow the manufacturer's instructions when wiping equipment could result in contamination. The IP further stated that the facility's written equipment cleaning policy was outdated and deferred to the DON for an updated version. During a concurrent review of the facility's policy, titled Cleaning and Disinfecting of Glucometer, dated 1/19, and interview with the DON on 9/12/25, at 10:56 AM, the policy indicated, The following policy provides guidance for cleaning and disinfection of glucometer in between resident use . Clean glucometer surface after EACH use . Disinfect (after each use) after cleaning the exterior surfaces following manufacturers' direction . The DON confirmed the two-step process of cleaning and sanitization based on policy and stated the policy needed to be updated. A review of the facility's policy, titled Administering Medications, dated 12/12, indicated, .Staff shall follow established facility infection control procedures.for the administration of medications. A review of the manufacturer's instruction of Sani-Cloth Germicidal Disposable Wipe box indicated, .CLEANING PROCEDURE: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove heavy soil.CONTACT TIME: Use second germicidal wipe to thoroughly wet surface. Allow to remain wet tow (2) minutes, let air dry.Do not reuse towelette. A review of the Clorox Healthcare Bleach Germicidal Wipes labeling information titled Technical Information Clorox Healthcare Bleach Germicidal Wipes, dated June 2017, indicated, To Clean and Disinfect and Deodorize Hard, Nonporous Surfaces: Wipe hard, nonporous surfaces to be disinfected. Use enough wipes for treated surface to remain visibly wet for the contact time listed on label. https://www.cloroxpro.ca/wp-content/uploads/2018/09/Clorox-HC-Bleach-Grm-Wipes-tech-info-NI-38488.pdf Review of the manufacturer of Assure Platinum glucometer, a brand name glucometer used by the facility, (by ARKRAY, the manufacturer of the glucometer), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, dated 9/24, last accessed on 9/18/25, via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions), indicated, .Can cleaning and disinfecting be accomplished with one wipe? No, Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. A review of the Center for Disease Control (CDC, a federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, last accessed on 9/18/25 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated, .Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated .Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared . 4. During a concurrent medication administration observation and interview of Licensed Nurse (LN) 4, on 9/9/25 at 9:58 AM, LN 4 was observed using a pill cutter that contained white powder residue inside to cut a acetaminophen (a medicine for fever and pain) tablet in half. LN 4 then administered the tablet to Resident 108. After administration, LN 4 returned the pill cutter to the medication cart (a mobile cabinet used to store medications). LN 4 stated that she should have cleaned the pill cutter before and after use to prevent risk of cross contamination of medications or allergic reactions. During an interview with the Director of Nursing (DON), on 9/10/25 at 3:50 PM, the DON stated that nurses are expected to clean and wash pill cutters before and after each use. A review of the facility's policy titled, Administering Medications, dated 12/12, the policy indicated, .Staff shall follow established facility infection control procedures.for the administration of medications. A review of the U.S. Centers for Disease Control and Prevention (CDC, a U.S government agency that works to protect people's health) publication titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24 indicated, .Clean.reusable medical equipment.prior to use on another patient or when soiled. (https://www.cdc.gov/infection-control/hcp/core-practices/index.html)

Based on observation, interview, and record review, the facility failed to ensure the safe storage and use of a resident's personal medication for 1 of 14 residents observed during a medication pass (Resident 102) when over the counter medications (OTC, a medication that can be obtained without prescription) and supplements (pills that provide nutrients like vitamins, minerals and herbs that may be missing from a person's daily food intake) were found at Resident 102's bedside without a physician's order.This failure had the potential to result in unsafe and/or unauthorized use of OTC medications and/or supplements that could have resulted in illness or injury to Resident 102 and/or other residents in the facility. Findings:During a concurrent observation and interview on 9/9/25, at 12:15 p.m., with Licensed Nurse (LN) 1, the following OTC medications and supplements were found at Resident 102's bedside:Two yellow capped bottles of a product labeled as Sualin, Natural cough and Cold Remedy, contained three different herbs on the bottle label.Two red capped bottles of a product labeled in a foreign language, contained 12 different ingredients listed on the bottle label.One purple colored bottle labeled as Hajmola, contained multiple herbal products and chemicals from [NAME]. One large bottle of a supplement called Nature Made Multi+ Omega-3 gummies (a supplement made in the United States, US)One large bottle of a supplement called Nature Made C 250 mg [milligrams - unit of measurement] Gummies, a vitamin product made in the US.LN 1 stated she was unaware of these medications and was surprised to see them at Resident 102's bedside.During a concurrent interview and record review on 9/9/25, at 12:30 p.m., with LN 1, Resident 102's electronic medical record (EMR) was reviewed. LN 1 confirmed Resident 102's EMR did not show any orders for Resident 102 to keep medications and/or supplements at the bedside, and the EMR did not show any orders to administer the medications and/or supplements found at the bedside. LN 1 stated she did not know the purpose of the foreign-labelled medications. LN 1 explained that the facility only administered medications prescribed by the attending physician. LN 1 identified the following risks of unauthorized medications and supplements at the bedside: Possible overdose Medication duplication Unauthorized access of medications by other residents Unknown side effects from the administration of non-prescribed medications During an interview on 9/10/25, at 3:50 p.m., with the Director of Nursing (DON), the DON stated Resident 102 had been at the facility for one week when the unauthorized medications were discovered. The DON further stated a care conference (a resident focused meeting with health care providers that focuses on the individual goals and needs of the resident) should have been held to address medication reconciliation (formal process of creating the most accurate and complete list of a resident's current medications and comparing that list against newly ordered medications) with the family. A review of the facility's policy titled, Administering Medications, revised 12/12, indicated, .Medications must be administered in accordance with the orders.A review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/14, indicated, .The interdisciplinary team [a group of diverse professionals with different areas of expertise who collaborate to address complex problems and achieve shared goals] reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis.A review of the facility's policy titled, Medication Brought to the Facility by the Resident/Family, revised in 4/07, indicated, .Residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility.

Based on observation, interview, and record review, the facility failed to ensure the protection of residents' personal information for a census of 81 when licensed nurse (LN) 8 left residents personal medical information unattended on the computer screen visible to anyone who walked by in the facility's dining room.This failure had the potential for misuse of residents personal information including identity theft. Findings:During a concurrent observation and interview in the facility's dining room on 9/9/25 at 12:15 PM, a computer was observed unattended with a residents medical information visible. Once LN 8 returned, they closed the computer and stated prior to stepping away from the computer the lock screen button should have been pressed to protect the residents privacy. LN 8 stated the purpose of locking the screen was to protect the resident's information from anyone accessing it who was not authorized. LN 8 stated that not protecting the residents health information places them at risk for identity theft.During an interview with the Director of Nursing (DON) on 9/12/25 at 12:42 PM, the DON stated after reviewing resident health information the expectation she had for her staff was to protect the residents information by locking the screen therefore an unauthorized person would not have access to it. The DON stated not doing so would place the residents' personal information at risk for theft.A record review of a facility provided document titled, Confidentiality of Information and Personal Privacy, dated October 2017, indicated, Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation 1. The facility will safeguard the personal privacy and confidentiality of all residents' personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications.4. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in two of four Medication carts (a mobile cart that holds patient medications and supplies), in one out one treatment carts (a mobile cart that holds medical and wound treatment supplies) and in one out of one medication rooms (a locked room used to store medications and supplies) with a resident census of 87 when:1.Medication cart in hallway #2 stored an undated Humalog insulin pen (drug used for blood sugar disease in a pen shape product) 2.Main medication room stored two opened vials of Aplisol (same as Tuberculin Purified Protein, use to test for TB, or tuberculosis, a serious lung infection) which was not dated when it was first opened. The medication room stored an opened and undated eye drop bottle called Timolol (or Timoptic, used to treat eye disease). 3.Treatment cart in hallway #2 stored opened sterile (free from germs) wound care supplies and/or products without any expiration date (the date that product was no longer should be used).These failures had the potential to result in unsafe medication storage, increase the risk of medication errors, and negatively affect the well-being of residents. Findings: 1. On 9/9/2025 at 10:19 a.m., during a concurrent interview and inspection of the Hall-2 medication cart, with licensed Nurse (LN) 4, an undated Humalog pen was stored inside the cart. LN 4 stated that the insulin pen was safe for use within 28 days after opening and should have been labeled when it was first used/opened. 2. On 9/9/2025 at 10:30 a.m., during a concurrent interview and inspection of the main medication room, with LN 2 and the Assistant Director of Nursing (ADON), the following were observed:a. Two opened Aplisol testing agent vials were stored in the refrigerator without open-date markings. The manufacturer label on the Aplisol box indicated .Once entered (opened), vial should be discarded after 30 days .b. A Timolol eye drop bottle was found in the medication room with a broken seal and no open date markings. The prescription label on the bottle indicated, .Discard unused portion after 28days . LN 2 acknowledged the findings.During an interview with the Director of Nursing (DON), in her office, on 9/10/25 at 3:50 p.m., the DON stated she expected the nursing staff to write the date on the product when they first opened a drug with limited beyond use date. 3. On 9/10/2025 at 10:55 a.m., during a concurrent interview and inspection of the treatment cart with LN 7, the following were observed:a. A sterile ComfortFoam (wound dressing used for weeping wounds) packet was found open and stored in the treatment cart together with other closed/sealed products. The label on the packet indicated Do Not Use if Damaged, Do Not Reuse and Sterilized product. LN 7 stated the sterile ComfortFoam should have been discarded and not returned to the treatment cart.b. A large number of DermaSeptin Ointment (single use packets of an ointment used to protect the skin) packets were found stored in a bin without expiration dates.LN 7 was unable to locate the expiration dates on the DermaSeptin Ointment packets and explained that she routinely stacks new ointment in the bin each morning due to high daily usage. LN 7 stated she could not find the expiration date on the ointment packet, and it may have been on the original container from the manufacturer.A review of the facility's policy titled, Administering Medications, revised in December 2012 indicated, .The expiration/beyond date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.A review of the facility's policy titled, Adverse Consequence and Medication Errors, revised in April 2014, indicated, .Examples of medication errors include.Failure to follow manufacturer instruction and/or accepted professional standards.

Based on observation, and interview, and record review, the facility failed to ensure that staff treated residents with dignity and respect for 1 of 24 sampled residents (Resident 40) when staff referred to Resident 40 as a feeder during care, rather than addressing the resident by name or in a manner that upheld his dignity. This failure had the potential to demean Resident 40, negatively impact his self-esteem, and compromise Resident 40's right to be treated with dignity and respect. Findings:During a review of Resident 40's admission RECORD, indicated Resident 40 was admitted to the facility with multiple diagnoses including dysphagia (difficulty swallowing) and anxiety disorder (a condition in which a person has excessive worry, feelings of fear, dread, and uneasiness).During an observation on 9/9/25, at 11:59 a.m., in Resident 40's room, Certified Nursing Assistant (CNA) 3 was observed helping CNA 2 to provide care to Resident 40. CNA 3 stated to CNA 2, He [Resident 40] is a feeder now? During an interview on 9/9/25, at 12 p.m. with CNA 3, CNA 3 stated that staff should not have labeled Resident 40 as a feeder because it could have affected the resident's self-esteem. During an interview on 9/12/25, at 10:03 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that all staff were expected to treat residents with dignity and respect at all times. The ADON further stated that staff should have been mindful of their words and actions because demeaning language toward Resident 40 could have caused mistrust and low self-esteem.During an interview on 9/12/25, at 10:49 a.m., with the Director of Nursing (DON), the DON stated that her expectation was for staff to treat all residents with dignity and respect. The DON further stated that using terms such as feeder in front of residents could have negatively impacted Resident 40's psychosocial well-being. A review of the facility policy titled, Dignity, revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes.feelings of self-worth and self-esteem.8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling.

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) who were at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), had implemented elopement prevention measures in place when: 1. Resident 1 had exit seeking behaviors on [DATE] but orders for a wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) and monitoring for wandering behavior were not initiated according to Resident 1's care plan , and an elopement risk assessment was not completed; and, 2. Resident 1 ' s wander guard was not working when the elopement happened on [DATE]; and, 3. Resident 1 ' s charting for monitoring wander guard placement (where the device is on the body) was not consistently documented for the months of [DATE] and [DATE]; and, 4. Resident 3 ' s wander guard was found to be expired while being worn. These failures led to Resident 1 ' s elopement which resulted in a head injury, a hospital visit, and stitches, and the potential for Resident 3 to leave the facility unsupervised which could result in physical harm. Findings: 1. A review of Resident 1 ' s ADMISSION RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included dementia (a progressive state of decline in mental abilities), generalized muscle weakness, and history of falling. During a concurrent interview and record review with Licensed Nurse (LN) 2 on [DATE], at 9:50 a.m., Resident 1's exit seeking care plan was reviewed. LN 2 confirmed that Resident 1 had a care plan for exit seeking behavior due to wandering aimlessly that was initiated on [DATE]. LN 2 stated that if a resident had wandering behavior the resident ' s doctor should be notified and an order for wander guard would be obtained. LN 2 stated when an order was in place for wander guard it would pop up (in the resident ' s medical record) for each nurse to check if the wander guard was in place on the resident and was active. LN 2 confirmed that Resident 1 did not have an order for wander guard placement when the wandering behavior started on [DATE]. During a concurrent interview and record review with LN 3, on [DATE], at 10:28 a.m., Resident 1's exit seeking care plan and the facility's high risk for elopement binder kept at the receptionist's desk were reviewed. LN 3 stated Resident 1 was sitting on her wheelchair telling staff that she wanted to go home and was trying to look for exits on [DATE]. LN 3 confirmed that the care plan initiated on [DATE] for the exit seeking behavior included frequent monitoring and placement of a wander guard device under the interventions. LN 3 confirmed that there should have been an order obtained for the wander guard when the change in behavior happened on [DATE]. LN 3 stated it would have been important to have an order for the wander guard and monitoring in place when the behavior started on [DATE]. LN 3 stated that if a resident had an order in place for wander guard the nurse would check for placement of the device on the resident and the expiration date every shift. LN 3 stated that Resident 1 was especially at risk of elopement due to her dementia. LN 3 stated at the time of Resident 1's elopement there was not a receptionist sitting at the front desk like there usually was. The facility's high risk for elopement binder kept at the receptionist's desk was reviewed with LN 3. The binder revealed a facesheet (personal information about the resident) and photo for Resident 1. LN 3 stated the binder was to notify reception staff about residents who were at risk of eloping. A review of Resident 1 ' s exit seeking care plan, initiated on [DATE], indicated .Focus .[Resident 1] exit seeking behavior r/t [related to] [Resident 1] wanders aimlessly .Goal .[Resident 1] will not leave facility unattended through the review date .Interventions .Monitor location every .1 hr [hour] Document wandering behavior and attempted diversional interventions in behavior log .WANDER ALERT [wander guard] . A review of Resident 1 ' s medical record indicated an elopement risk assessment was completed on [DATE]. There was no elopement risk assessment completed on [DATE] when Resident 1 ' s exit seeking behavior started. During a concurrent interview and record review with the Director of Nursing (DON), on [DATE], at 3:32 p.m., Resident 1's medical record was reviewed. The DON stated it was her expectation that if a resident was determined to have wandering behavior, then an elopement risk assessment should have been initiated and orders should have been obtained for wander guard placement and behavior monitoring (for exit seeking). The DON confirmed that there was no elopement risk assessment, and no orders for both the wander guard placement and behavior monitoring when Resident 1 ' s wandering behavior started on [DATE]. During an interview with Resident 1 ' s doctor (MD), on [DATE], at 3:44 p.m., the MD stated that he recalls the change of condition initiated in [DATE] due to Resident 1 verbalizing wanting to go home but did not clearly remember if the facility ' s staff requested an order for the wander guard at the time. The MD stated that it was his expectation for the facility to initiate interventions including obtaining the order for the wander guard and elopement behavior monitoring if exit seeking behaviors were present. 2. During a concurrent observation and interview with Resident 1, on [DATE], at 9:13 a.m., Resident 1 stated that she was heading out to the parking lot in her wheelchair (on [DATE]) and the wheel hit the curb, and she fell out of the wheelchair and hit her forehead. Resident 1 motioned to the right side of her forehead. Resident 1 stated she was feeling alright now but was still a little sore. Resident 1 was observed with a healed scar on the right side of the forehead. A review of Resident 1 ' s physician order, dated [DATE], indicated, .Wander guard placement secondary to: (Elopement/exit seeking behavior). Monitor for placement every shift . During an interview with CNA 2, on [DATE], at 9:15 a.m., CNA 2 stated that the current wander guard was placed on Resident 1 on [DATE], but previously Resident 1 had a wander guard that was not working. CNA 2 stated that he worked on the day of the elopement ([DATE]) and everyone was busy that morning. CNA 2 stated that Resident 1 fell in the parking lot and was sent out to the hospital on the same day. CNA 2 stated that the nurses were the ones who document in the resident ' s chart for the presence of the wander guard and the CNA also checks if the wander guard was on. CNA 2 stated that it was important to ensure that the wander guard was functional because of the risk of elopement that can cause accidents or harm to residents. During an interview with LN 4 on [DATE], at 2:27 p.m., LN 4 stated that she was the nurse assigned to Resident 1 when the elopement happened on [DATE]. LN 4 stated that Resident 1 verbalized a lot about needing to leave the facility and would like to sit by the nurse ' s station. LN 4 stated that Resident 1 had a wander guard on before the elopement incident. LN 4 stated that she was passing medications at the end of the hallway when the elopement happened at about 9:20 AM, when the housekeeping staff came running to LN 4 yelling and stating that Resident 1 was bleeding. LN 4 stated that Resident 1 was seen by housekeeping staff who was driving through the facility ' s parking lot when Resident 1 fell off the wheelchair. LN 4 stated that Resident 1 was already sitting on her bottom when she arrived and saw that Resident 1 had a deep gash to her right forehead with lots of bleeding. LN 4 stated that she cut off Resident 1 ' s wander guard before the paramedics came and transported Resident 1 to the hospital. LN 4 stated that Resident 1 received stitches at the hospital and came back the same day around 5 p.m. LN 4 stated that she immediately called the DON and had read the expiration date on the wander guard, which was expired, dated [DATE]. LN 4 stated that she tested the wander guard by the door and the alarm did not go off. LN 4 stated that Resident 1 did not have an order in place for the wander guard before the elopement but Resident 1 had the wander guard in place. LN 4 stated that the wander guard was for resident ' s safety. LN 4 stated it was important for the wander guard to be in place, functioning, and not expired to avoid any accidents. LN 4 stated Resident 1 had been seen by staff ,d+[DATE] minutes prior to the incident and if there was an order in place for wander guard and an order for monitoring, then staff would have been checking the wander guard's functionality and the incident may have been prevented. A review of Resident 1 ' s discharge document titled Discharge Instructions Document, dated [DATE], indicated .You were seen today for a fall and a laceration of the forehead .I put 8 stitches in your forehead for the cut . During an interview with the DON, on [DATE], at 3:32 p.m., the DON stated that Resident 1 had a wander guard on at the time of the elopement and that the nurse told her that the wander guard did not go off. The DON stated that the Maintenance person mainly checked the wander guard devices, but the nurses also checked for the functionality as well. The DON confirmed that Resident 1 had a care plan in place that was started on [DATE] that included the wander guard as an intervention. The DON stated that the risk of the wander guard not working was resident elopement. The DON stated that the resident's safety was important and that the staff are expected to follow interventions to prevent elopement. The DON confirmed that the LN should have obtained orders for wander guard, behavior monitoring, and completed an elopement screening when Resident 1's behavior of wanting to the leave the facility was determined on [DATE]. The DON stated that this incident could have been prevented if orders were in place to ensure staff were monitoring Resident 1's wander guard placement and exit seeking behaviors. During an interview on [DATE], at 1:21 p.m., the Administrator (ADM) stated that he could not determine where the November and [DATE] logs were which showed the wander guard devices functionality were being checked by the maintenance department. During an interview with Resident 1 ' s doctor (MD) on [DATE], at 3:44 p.m., the MD stated that he was notified of the elopement but was not aware that the wander guard was not working on [DATE]. The MD stated that if the wander guard was checked and if it was working, an alarm would go off and the facility staff would have acted on it promptly. The MD stated that the facility should have monitored Resident 1 due to the wandering behavior and made sure that the wander guard was in place and functional. The MD further stated that the facility should look after resident ' s safety and should be proactive to prevent accidents. 3. During an interview with LN 1, on [DATE], at 9:23 a.m., LN 1 stated that the nurse was responsible for checking the wander guard placement and expiration date of the device every shift. During a concurrent interview and record review with LN 2 on [DATE], at 9:50 a.m., LN 2 stated that the nurses were charting for wander guard placement in the electronic medical record under a section for devices. LN 2 stated that if there was an order in place, it would pop up for each nurse to check if the wander guard was in place and active. A review of Resident 1 ' s monthly report to monitor for wander guard placement every shift with a start date of [DATE], indicated the following dates without any documentation: [DATE] evening and night shift, [DATE] day shift, [DATE], [DATE] and [DATE] day and evening shifts, [DATE], [DATE] day shift, and [DATE] day and night shifts, [DATE] and [DATE] day and evening shifts, [DATE] day, evening and night shifts, and [DATE] day shift. The monthly report for the month of [DATE], indicated the following dates without any documentation: [DATE] and [DATE] day and evening shift, [DATE] day shift, [DATE] day and night shift, [DATE] and [DATE] day shift, [DATE] day and evening shift, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] day shifts. During a concurrent interview and record review with the DON, on [DATE], at 3:32 p.m., Resident 1 ' s monthly report to monitor for wander guard placement for [DATE] and [DATE] was reviewed. The DON confirmed that there were several days on both months that did not have documentation. The DON stated that her expectation was for staff to have monitored and charted according to the order to make sure that all orders were being followed and completely documented. 4. A review of the facility ' s list provided for residents with a wander guard titled .Order Listing Report . indicated Resident 3 ' s order, .Wander guard placement secondary to: risk for elopement every shift . During a concurrent observation and interview with the Maintenance Assistant (MA) and LN 4, on [DATE], at 2:17 p.m., Resident 3 was observed with a wander guard device on the right ankle. The MA and LN 4 confirmed the expiration date on Resident 3 ' s wander guard was [DATE] and that the date indicated that it was expired. LN 4 stated that when a wander guard was determined expired the process was to notify the Maintenance person and the DON. During an interview with LN 4 on [DATE], at 2:27 p.m., LN 4 stated that when she reported Resident 3 ' s expired wander guard to the DON, she was told that the wander guard was still good 1.5 years after the expiration date. During an interview with the DON, on [DATE], at 3:32 p.m., the DON stated that the risk of the wander guard not working was resident elopement. A review of the facility document titled Wander Management Transmitters User Guide, dated ,d+[DATE], indicated .Each transmitter is stamped with a warranty expiration date. This date indicates the date that RF Technologies ' warranty on that transmitter expires. If the warranty period has expired, discard the transmitter immediately .WARNING: Using a transmitter beyond the printed expiration date can result in system failure and/or elopement .Visual Inspection .1. Verify that the warranty expiration date that is stamped on the transmitter is not expired .Weekly Testing .