Every finding on record at Roseville Care Center

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for three of three sampled residents, Resident 3, Resident 133 and Resident 13 when:1. Licensed Nurse 6 (LN 6) administered the medication Isosorbide Mononitrate 30 mg tablet (a prescription medication used to prevent chronic chest pain caused by coronary artery disease [heart condition where the major blood vessels supplying your heart become narrowed or blocked]) to Resident 3 without checking his blood pressure as prescribed by the physician;2. LN 6 did not administer the correct route and dosage of the medication Miacalcin Solution 200 UNIT/ACT nasal spray (It is primarily used to treat postmenopausal ostreoporosis [weak bones]) to Resident 133 as prescribed by the physician; and3. LN 6 administered the medication Metoprolol Succinate 25 mg (treats high blood pressure, chest pain, and heart failure. It slows heart rate, reducing the strain on heart, which helps lower the risk of heart attacks and strokes) to Resident 13 without checking his blood pressure as prescribed by the physician.These failures resulted in three medication errors identified out of 30 opportunities during the observation of medication administration; the facility medication error rate was 10%.Findings:1. During an observation of medication administration on 7/8/26 at 8:28 a.m., with LN 6, LN 6 did not check Resident 3's blood pressure and was observed to prepare and administer Resident 3's morning medications which included Isosorbide Mononitrate 30 mg tablet.Reconciliation of the observed medication administration for Resident 3's current Order Summary Report, (OSR) dated 7/4/26, indicated, .Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension DO NOT CRUSH OR CHEW, HOLD IF SBP LESS THAN 110 OR HR LESS THAN 60.During a review of Resident 3's Medication Administration Record (MAR), dated, 7/5/26, the MAR indicated, .Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension DO NOT CRUSH OR CHEW, HOLD IF SBP LESS THAN 110 OR HR LESS THAN 60.During an interview on 7/8/26 at 10:37 a.m., with LN 6, LN 6 acknowledged, Resident 3's blood pressure should have been checked before administering Resident 3's medication Isosorbide tablet as prescribed by the physician. LN 6 agreed it is important to follow the parameter (parameters ensure the medication was properly given) to keep the residents free from harm thus promoting safety measures.During an interview on 7/9/26 at 8:41 a.m., with the Director of Nursing (DON), the DON acknowledged the nursing staff must follow the physician's order such as checking the resident's blood pressure before giving the blood pressure medication.During a phone interview on 7/9/26 at 12:11 p.m., with the facility's Pharmacy Consultant (PC), the PC stated the nursing staff should follow the physician's order including the parameters. The PC further stated parameters ensured drugs are given safely and effectively for the residents well-being. 2. During an observation of medication administration on 7/8/26 at 8:37 a.m., with LN 6, inside the room of Resident 133, LN 6 sprayed the medication Miacalcin Solution nasal spray to Resident 133's right nostril.Reconciliation of the observed medication administration for Resident 133's current OSR dated 6/18/26, indicated, .Miacalcin Solution 200 UNIT/ACT (Calcitonin (Salmon)) 1 spray Alternating nostrils one time a day for osteoporosis Rotate between right/left nostril with each new dose.During a review of Resident 133's MAR, dated, 6/19/26, the MAR indicated, .Miacalcin Solution 200 UNIT/ACT (Calcitonin (Salmon) 1 spray Alternating nostrils one time a day for osteoporosis Rotate between right/left nostril with each new dose.During a review of Resident 133's Administration Details Record (ADR), dated 7/8/26, the ADR indicated the nursing staff did not administer the correct route and dosage of the medication Miacalcin Solution nasal spray as ordered by the physician on the following dates:1 spray Nare-both on 6/24/26 at 9:12 a.m.1 spray Nare-both on 6/25/26 at 8:08 a.m.1 spray Nare-both on 6/26/26 at 7:33 a.m.1 spray Nare-both on 6/27/26 at 7:41 a.m.1 spray Nare-both on 6/28/26 at 8:36 a.m.1 spray Nare-both on 6/29/26 at 8:42 a.m.1 spray Nare-both on 6/30/26 at 7:27 a.m.1 spray Nare-both on 7/1/26 at 7:25 a.m.1 spray Nare-both on 7/2/26 at 8:25 a.m.1 spray Nare-both on 7/3/26 at 7:26 a.m.1 spray Nare-both on 7/4/26 at 7:11 a.m.1 spray Nare-left on 7/5/26 at 9:23 a.m.1 spray Nare-both on 7/6/26 at 8:58 a.m.1 spray Nare-both on 7/7/26 at 7:49 a.m.1 spray Nare-left on 7/8/26 at 8:51 a.m.During an interview on 7/8/26 at 2:23 p.m., with LN 6, LN 6 confirmed she sprayed the Miacalcin nasal spray to Resident 133's right nostril although she documented that she sprayed Resident 133's left nostril on 7/8/26 at 8:51 a.m.During an interview on 7/9/26 at 8:41 a.m., with the DON, the DON stated, the nasal spray Miacalcin was ordered by the physician on 6/18/26, and it was written ambiguously, the nurses should have clarified the order from the prescribing physician. The DON further stated her expectation from the nurses is to follow the physician's order. The DON confirmed the nursing staff documented under Resident 133's ADR that they administered the Miacalcin nasal spray to both nares daily, indicating that the medication was given by the wrong route and dosage. The DON continued, the facility's goal is to keep the residents safe and free from harm.During a phone interview on 7/9/26 at 12:11 p.m., with the facility's Pharmacy Consultant (PC), the PC stated the nursing staff should follow the physician's order including the parameters. The PC further stated parameters ensured drugs are given safely and effectively for the residents well-being. The PC continued, the Miacalcin nasal spray was supposed to be given daily, with 1 spray alternatively to left and right nostrils, and if the medication was given differently from the physician's order, the prescribing physician should be notified. 3. During an observation of medication administration on 7/8/26 at 9:10 a.m., LN 6 did not check Resident 13's blood pressure and was observed to prepare and administer Resident 13's morning medications which included Metoprolol Succinate 25 mg tablet (treats high blood pressure, chest pain, and heart failure. It slows heart rate, reducing the strain on heart, which helps lower the risk of heart attacks and strokes).Reconciliation of the observed medication administration for Resident 13's current OSR dated 6/23/26, indicated, .Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for Atrial Fibrillation. Hold for SBP less than 110 or HR less than 60. Do not crush or chew tablet.During a review of Resident 13's MAR, dated, 6/24/26, the MAR indicated, .Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for Atrial Fibrillation. Hold for SBP less than 110 or HR less than 60. Do not crush or chew tablet.During an interview on 7/8/26 at 10:37 a.m., with LN 6, LN 6 acknowledged, Resident 13's blood pressure should have been checked before administering Resident 13's medication Metoprolol tablet as prescribed by the physician. LN 6 agreed it is important to follow the parameter to keep the residents free from harm thus promoting safety measures.During an interview on 7/9/26 at 8:41 a.m., with the DON, the DON acknowledged the nursing staff must follow the physician's order such as checking the resident's blood pressure before giving the blood pressure medication.During a phone interview on 7/9/26 at 12:11 p.m., with the facility's Pharmacy Consultant (PC), the PC stated the nursing staff should follow the physician's order including the parameters. The PC further stated parameters ensured drugs are given safely and effectively for the residents well-being.During a review of facility's policy and procedure titled, Physician Orders, reviewed October 2025, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order.

Based on observation, interview, and record review, the facility failed to ensure the unsupervised Medication Cart 4, (MC4) parked in a busy hallway of Station D where residents, visitors and staff were constantly passing by, remained locked for the census of 177.This failure had the potential to leave accessible medications susceptible to theft or medication diversion.Findings:During a concurrent observation and interview with the Quality Nurse, (QN) which started on 7/6/26 at 11:19 a.m., the MC4 was parked unlocked and unsupervised at Station D hallway as visitors, residents and staff were passing by. At 11:29 a.m., QN came by at Station D, and confirmed the MC4 was unlocked and unattended. QN also noted that there were residents and staff that are constantly passing by the MC4. The QN stated Licensed Nurse 5 (LN 5) was assigned to MC4 and she's on her lunch break. The QN further stated medication cart should always remained locked to prevent possible drug diversion or theft that may risk resident's safety.During an interview with LN 5, on 7/6/26 at 11:50 a.m., LN 5 stated that she did not lock her MC4 before she took her lunch break. LN 5 further stated, she should have locked her MC4 as leaving it unlock makes it accessible to visitors, staff and residents passing by and may result to injury or harm.During an interview with the Director of Nursing, (DON) on 7/9/26 at 8:41 a.m., the DON stated the medication cart should remained locked when not in use and unattended. The DON mentioned that there were multiple visitors, staff, and residents passing by in Station D hallway where the MC4 was parked and noted that they could easily access the medication. Furthermore, the DON stated, the patient's information on the medication bubble pack (method of organizing medications into individual doses) posed a privacy risk and constitutes a HIPAA violation (Health Insurance Portability and Accountability Act, federal law created to safeguard sensitive patient medical information from being disclosed without the patient's consent).During a review the facility's policy and procedure, titled Storage of Medications, (SOM) reviewed October 2025, the SOM indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.1. Drugs and biologicals used in the facility are stored in locked compartments.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 177 residents when:1. Staff did not wear required personal protective equipment (PPE) when providing high contact care to Resident 149 and to Resident 84 who were both on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. A shared glucometer [a machine use to measure blood sugar level] was not sanitized between residents' use; and,3. A shared blood pressure [BP] machine was sanitized inside the EBP room after use and gloves were not changed before sanitizing the said BP machine.These failures resulted in an increased risk for cross contamination, and potential exposure of residents to germs and infection. Findings: 1a. A review of Resident 149's clinical record indicated Resident 149 was admitted April of 2026 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting right dominant side, diabetes mellitus (a chronic condition causing too much sugar in the blood which inhibits the body's natural wound-healing capabilities), and non-pressure chronic ulcer (a long-lasting open sore on the skin caused by an underlying medical condition rather than pressure from immobility) of lower leg. A review of Resident 149's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/4/26, indicated Resident 149 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 149 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 149's care plan, dated 4/29/26, indicated, Enhanced Barrier Precautions: [Resident 149] requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Chronic wounds BLE [bilateral lower extremities- both lower legs] venous stasis ulcers [slow-healing, open sores typically found on the lower legs or ankles] .Enhanced barrier precautions will be followed during highcontact resident care activities .Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities ( .dressing .hygiene .brief changes, toileting assistance .). During an observation on 7/6/26 at 11:12 a.m. in Resident 149's room, a staff was observed providing ADL care, brief change, and incontinence care to Resident 149 while only wearing gloves and not wearing a gown. There was an EBP signage posted in front of Resident 5's room which indicated, The Six Moments of Enhanced Standard Precautions .For these six groups of care activities, use hand hygiene, gloves, and gowns .Morning & evening care .Toileting & changing incontinence briefs . During a subsequent interview on 7/6/26 at 11:34 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 confirmed that he was only wearing gloves when he provided ADL care, brief change, and incontinence care to Resident 149. CNA 1 stated that there was no need for him to wear gown when doing ADL care, brief change, and incontinence care to Resident 149. CNA 1 further stated he was aware about the signage that Resident 149 was on EBP to prevent Resident 149 from getting infection. A review of the list of residents on EBP, provided by the Infection Preventionist (IP), on 7/7/26 at 3:49 p.m. indicated Resident 149 was on EBP due to wound on BLE. 1b. A review of Resident 84's clinical record indicated Resident 84 was admitted June of 2026 and had diagnoses that included fracture (a break in the continuity of a bone) of right tibia (a bone in the lower leg), infection following a procedure, Methicillin Susceptible Staphylococcus Aureus infection (MSSA- a serious infection that has a high risk of complications and death), and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). A review of Resident 84's MDS Cognitive Patterns, dated 6/10/26, indicated Resident 84 had a BIMS score of 12 out of 15 which indicated Resident 84 had a moderately impaired cognition. A review of Resident 84's care plan, dated 6/5/26, indicated, Enhanced Barrier Precautions: [Resident 84] requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Indwelling device: Mid-line [midline IV- a short-term catheter inserted in the upper arm that stops before the central veins] to RUE [right upper extremity- right upper arm] and Hx [history of] MDRO .Enhanced barrier precautions will be followed during highcontact resident care activities .Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities ( .device care .). During an observation on 7/6/26 at 4:03 p.m. in Resident 84's room, Licensed Nurse (LN) 2 was observed accessing and administering Resident 84's medication through his midline IV on right upper arm while only wearing gloves and not wearing a gown. There was an EBP signage posted in front of Resident 84's room which indicated, The Six Moments of Enhanced Standard Precautions .For these six groups of care activities, use hand hygiene, gloves, and gowns .Caring for devices & giving medical treatments . During a subsequent interview on 7/6/26 at 4:09 p.m. with LN 2, LN 2 confirmed that she was only wearing gloves when she accessed the midline IV and administered medication to Resident 84. LN 2 stated, Not that I know of when asked if she was supposed to wear gown when accessing and administering IV medication through a midline. LN 2 also confirmed she was aware of the signage that Resident 84 was on EBP. LN 2 further stated she would always wear gloves but not gown when administering medication through a midline. A review of the list of residents on EBP, provided by the IP, on 7/7/26 at 3:49 p.m. indicated Resident 84 was on EBP due to In-Dwelling Mid-line. During an interview on 7/8/26 at 2:58 p.m. with the IP, the IP stated she would expect staff to wear gowns and gloves when performing high contact activities to residents on EBP to protect the residents from getting infection. During an interview on 7/9/26 at 10:19 a.m. with the Director of Nursing (DON), the DON stated staff are supposed to gown up and follow the process of EBP when changing briefs, doing incontinence care, and accessing and administering medication through a midline line to residents who are on EBP so that MDROs would not spread. A review of the facility's policy and procedure (P&P) titled, Multidrug-Resistant Organisms; Infection Precaution & Enhanced Standard Precautions, revised 10/2025, indicated, Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism .Enhanced Barrier Precaution will be integrated in the care of residents with chronic wounds or indwelling medical devices during high-contact residents care activities regardless of their multidrug-resistant organism status .EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP use in wounds generally include open & chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tear with an adhesive bandage .or similar dressing .EBP use in medical devices include central lines .For residents for whom EBP are indicated, EBP is employed when performing high-contact resident care activities . Findings: 2. During a review of Resident 180's admission Record, (AR) indicated, Resident 180 was admitted to the facility on [DATE] with diagnoses that included Diabetes, and Cellulitis of Right Lower Limb. (Cellulitis is a common bacterial infection of the deeper skin layers and underlying tissue. It occurs when bacteria enter the body through a cut, bite, or crack in the skin.) During a review of Resident 180's Order Summary Report, (OSR) dated 6/24/26, indicated, Finger stick blood glucose q AC and q HS (q-every, AC before a meal, HS hour of sleep) before meals and at bedtime, During a review of Resident 180's OSR, dated 7/7/26, the OSR indicated, .TX Nurse: right lower leg venous stasis ulcer: cleanse with vashe, [wound cleanser used to clean, irrigate, and debride acute and chronic skin wounds] pat dry, triad paste [wound dressing] to peri wound, [wound edge] santyl ointment to wound bed, [ointment to remove dead tissue] oil emulsion gauze,[wound dressing] abd pad, [multi-layered medical dressing used to manage heavily draining wound] gauze roll, secure with tape, apply tubi grip [compression, support bandage] size F or G (depending on patient tolerance) . During a concurrent observation and interview with LN 7, on 6/8/26 at 11:29 a.m., LN 7 took the blood sugar of a resident from Station D and did not sanitize the glucometer after using the meter. LN 7 then proceeded to Resident 180's room. Resident 180's room had an EBP signage (guidance on what and how to properly wear the PPE to promote standard infection control precautions) posted by the door. Inside the room of Resident 180, LN 7 brought in the plastic basket that contained the un sanitized glucometer and placed the basket on top of Resident 180's bedside table and took Resident 180's blood sugar. LN 7 confirmed he did not sanitize the glucometer before using it to Resident 180. LN 7 stated he should have practiced infection control to prevent cross contamination between residents. During an interview on 7/9/26 at 12:27 p.m., with the Infection Preventionist, (IP) the IP stated, the glucometer should be sanitize each use with wipes [name of the brand], such as to use 1 wipes to clean/scrub the glucometer, throw the wipes, get a fresh wipes and use it to wrap the glucometer, set it aside and let it sit for 4 minutes this is the proper way to sanitize the glucometer. The IP further stated that the nursing staff were trained to sanitize the glucometer and expected to do as they were trained. 3. During a review of Resident 171's admission Record, (AR) indicated, Resident 171 was admitted to the facility on [DATE] with diagnosis that included Diabetes, Pressure Ulcer of Sacral Region, Stage 2 (bottom of the spine, it presents as a shallow, open pink/red wound or an intact/ruptured blister.) During a review of Resident 171's Order Summary Report, (OSR) dated 6/29/26, indicated, Pressure injury ST.2 [also known as bedsore] to coccyx- [tail bone] clean with NS, pat dry, apply skin prep to periwound, apply triad paste [wound dressing] cover with foam dressing. every day shift. During a concurrent observation and interview with LN 9 on 7/9/26 at 8:20 a.m., Resident 171's room had an EBP signage posted by the door. LN 9 was wearing gown and gloves while inside the room of Resident 171. LN 9 took Resident 171's blood pressure (BP) using the facility's blood pressure machine (BPM) equipment. When done, while LN 9 was still inside the room of Resident 171 and wearing the same gown and gloves, LN 9 sanitized the BPM. LN 9 admitted that she was wearing the same gown and gloves she wore when she took the BP of Resident 171, and then sanitized the BPM while inside the room of Resident 171. LN 9 stated that she should have taken off her gown and gloves, stepped out of Resident 171's room, put on a new pair of gloves and sanitize the BPM. LN 9 further stated she should have practiced infection control to keep the residents safe. During an interview on 7/9/26 at 8:41 a.m., with the Director of Nursing (DON), the DON stated, the staff must observe and practice infection control as they were trained to follow the guidelines for promoting infection control. The DON further stated that if staff breach infection control, she will intervene to prevent possible cross-contamination as part of her role, adding, That's just me. During an interview on 7/9/26 at 12:27 p.m., with the Infection Preventionist (IP), The IP specified that the nursing staff should remove the used gown and gloves, put on a pair of clean gloves, and sanitize the BPM outside the resident's room. The IP's expectation was for the staff to practice infection control to prevent the spread of infection and protect the vulnerable residents from health risks. A review of the facility's policy and procedure, titled Multidrug-Resistant Organisms; Infection Precaution & enhanced Standard Precaution revised October 2025, indicated, .1. Follow Standard Precautions as a baseline practice 2. Consider the individual resident's clinical situation and facility resources in deciding whether to implement Enhanced Standard Precautions (for colonization) or Contact Precautions (for active infections).

Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for two of 37 sampled residents (Resident 2 and Resident 126).This failure had the potential to worsen Resident 2 and Resident 126's wounds and negatively affected their physical, mental, and psychosocial well-being. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted in March 2026 with diagnoses that included non-pressure chronic ulcer of left heel, diabetes (insufficient insulin production) and chronic kidney disease (impaired filtration of waste and fluids). During a concurrent record review of Resident 2's clinical record and interview with Director of Nursing (DON) on 7/8/26 at 9:32 a.m. The DON confirmed no documentation Resident 2's left heel wound was assessed on 4/27/26. The DON stated she would expect the nurse to have completed an assessment every week. During an interview on 7/8/26 at 9:49 a.m. with the Treatment Nurse (Tx Nurse) he confirmed there was no wound assessment documented for Resident 2's left heel during the week of 4/27/26. A review of the facility's policy and procedure titled, Wound Care, revised October 2025 indicated, The following information should be recorded in the resident's medical record:.6. Assessment data (i.e., wound bed color, size, drainage. etc.) obtained when inspecting the wound. A review of Resident 126's clinical record indicated Resident 126 was admitted in January 2026 with diagnoses that included muscle weakness and peripheral vascular disease (reduced circulation of blood to body parts). A review of Resident 126's Order Summary Report, with start date 5/20/26, indicated, TX NURSE: Right heel arterial wound [open sore caused by poor circulation]: Cleanse with NS [normal saline], pat dry, triad paste [paste to manage and heal wounds] to peri wound [around the wound], [brand name-wound gel] to wound bed, xeroform gauze [type of wound gauze], ABD pad [thick pad], gauze roll, Tubi grip [elastic bandage] size F. every day shift. During an interview on 7/8/26, at 9:49 a.m., with the Tx Nurse, the Tx Nurse stated all completed wound treatments are documents in the EMAR (electronic medical administration record) and any blank boxes meant the treatment was not done. The Tx Nurse further stated if treatments are not done as physician ordered, wounds could potentially get infected and/or larger in size. During a concurrent interview and record review on 7/8/26, at 11:35 a.m., with the Assistant Director of Nursing (ADON), Resident 126's EMAR for the month of June 2026 was reviewed. The ADON stated Resident 126 had daily wound treatment physician orders and any blank boxes in the EMAR meant the treatment was not done. The ADON confirmed the treatment orders were not done as ordered on 6/3/26, 6/7/26, 6/11/26, and 6/23/26. A review of the facility's policy and procedure titled, Physician Orders, reviewed October 2025 indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order.The licensed staff shall carry out physician/nurse practitioner's orders as prescribed.

Based on observation, interview, and record review, the facility failed to ensure one out of 37 sampled residents (Resident 168) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 168's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) bag was left out of the privacy bag and flat on top of the base of the bedside table.This failure had the potential for Resident 168 to develop possible urinary catheter complications such as infection.Findings:A review of Resident 168's clinical record indicated Resident 168 was admitted May of 2026 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), infection and inflammatory reaction due to cystostomy catheter (suprapubic catheter), neuromuscular dysfunction of bladder (the nerves and muscles in the urinary bladder don't work together properly), retention of urine (caused by a blockage or a failure of the bladder to squeeze hard enough to expel all of the urine), and muscle weakness.A review of Resident 168's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/28/26, indicated Resident 168 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 8 out of 15 which indicated Resident 168 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 168's Bladder and Bowel Status, dated 5/28/26, indicated Resident 168 uses indwelling urinary catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time).A review of Resident 168's physician order, dated 5/26/26, indicated, Supra pubic catheter is in privacy bag .at all times. every shift.A review of Resident 168's care plan, revised 6/4/26, indicated, Suprapubic Catheter .for NEUROMUSCULAR DYSFUNCTION OF BLADDER: At risk for complications with urinary system related to indwelling catheter .Indwelling Catheter: provide catheter care and empty catheter every shift and as needed .Privacy cover to catheter bag as indicated to promote dignity.A review of Resident 168's physician order, dated 6/30/26, indicated, Suprapubic Catheter .for NEUROMUSCULAR DYSFUNCTION OF BLADDER. Monitor Q [every] Shift For Placement/Functioning every shift.During an observation on 7/8/26 at 11:29 a.m. of Resident 168, in Resident 168's room, Resident 168 was observed lying on their bed and was connected to a urinary catheter tube attached to a urinary catheter bag which was left out of the privacy bag, not hanging, and was left flat on the base of the bedside table.During a concurrent observation and interview on 7/8/26 at 12:15 p.m. with Licensed Nurse (LN) 3, in Resident 168's room, Resident 160's urinary catheter bag was observed left out of the privacy bag, not hanging, and was left flat on the base of the bedside cart. LN 3 confirmed the observation. LN 3 stated the urinary catheter bag should not have been left like that and should have been placed inside a privacy bag and hung on the bedside. LN 3 further stated there could be issues with the resident's dignity if the urinary catheter bag was left out of the privacy bag and there would be a risk for urine backflow which could cause complications like infection if the bag is left flat on the base of the bedside table. During an interview on 7/8/26 at 2:34 p.m. with the Director of Staff Development (DSD), the DSD stated urinary catheter bags should be placed inside privacy bags and should be hung on the bedside. The DSD further stated that this practice could result in resident dignity issues and a potential for urinary catheter complications like infection, if the urinary catheter bag was left out of the privacy bag, not hung, and left flat on the base of the resident's bedside table. During an interview on 7/9/26 at 10:19 a.m. with the Director of Nursing (DON), the DON stated that urinary catheter bags should be placed inside privacy bags for the resident's dignity and should be hanging and not left flat to prevent urine backflow which could cause complications and possible infection.A review of the facility's P&P titled, Catheter Management, revised 10/2025, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Foley bag must be in a privacy bag .Be sure the catheter tubing and drainage bag are kept off the floor .A review of the facility's P&P titled, Catheter Care, Urinary, revised 10/2025, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections .Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to ensure delivery of Intravenous (IV) therapy (administration of fluids or medications into the vein) was consistent with standards of practice and the facility's policy and procedures (P&P) for one out of 37 sampled residents (Resident 200) when Resident 200's Peripherally Inserted Central Catheter (PICC line- a long, flexible tube inserted into a large vein, typically in the upper arm, and threaded to a central vein above the heart, and is used for long-term intravenous treatments such as antibiotics) transparent dressing was not changed at least every seven (7) days.This failure had the potential to result in PICC line complications, possible infection, and for Resident 200 to not achieve his highest practicable well-being.Findings:A review of Resident 200's clinical record indicated Resident 200 was previously admitted in June of 2026 and had diagnoses that included osteomyelitis (a serious infection of the bone), cellulitis (skin infection that causes redness, swelling, pain, and warmth in the affected area) of left lower limb, and Methicillin-resistant Staphylococcus Aureus infection (MRSA- an infection caused by a type of bacteria that is resistant to many common antibiotics and can lead to life-threatening bloodstream, lung, or joint infections).A review of Resident 200's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/2/26, indicated Resident 200 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 106 had an intact cognition (mental process of acquiring knowledge and understanding).A review of Resident 200's physician's order, dated 6/26/26, indicated, IV [intravenous- inside the vein]-Peripheral-transparent dressing change on admission and every 4 days thereafter or PRN [as needed].A review of Resident 200's care plan, initiated 6/29/26, indicated, Vascular Access: [Resident 200] is at risk for complications due [to] the presence of a PICC line for the treatment of osteomyelitis with IV antibiotic therapy .Change dressing as ordered .During a concurrent observation and interview on 7/6/26 at 10:59 a.m. with Resident 200, in Resident 200's room, Resident 200 was observed lying on bed, awake, and had a PICC line on right upper arm with a transparent dressing labelled, 6/24. Resident 200 stated the transparent dressing has never been changed since he was admitted in the facility.During a concurrent observation and interview on 7/6/26 at 11:14 p.m. with Treatment Nurse (TN) 1, of Resident 200, in Resident 200's room, Resident 200 had a PICC line on his left upper arm with a transparent dressing labelled, 6/24. TN 1 confirmed the observation. TN 1 stated PICC line dressings should be changed at least every seven (7) days or as ordered. TN 1 also stated he was not sure why Resident 200's PICC line dressing was not changed. TN 1 further stated there would be a risk of infection which could lead to complications if the PICC line dressing was not changed at least every 7 days.During an interview on 7/8/26 at 2:34 p.m. with the Director of Staff Development (DSD), the DSD stated that PICC line dressings are typically changed weekly unless otherwise stated in physician's order. The DSD further stated the resident would be at risk for infection if the PICC line dressing was not changed at least every 7 days. During an interview on 7/9/26 at 10:19 a.m. with the Director of Nursing (DON), the DON stated she would expect staff to follow orders on how often to change the PICC line dressing or the facility's policy, which is every 7 days. The DON further stated there would be a risk of infection of the resident or other complications if the PICC line dressing would not be changed as ordered or at least every 7 days.A review of the facility's P&P titled, Central Venous Catheter/ Peripherally Inserted Central Catheter Dressing Changes, reviewed 10/2025, indicated, The purpose of this procedure is to prevent catheter-related infections .Change dressings as needed .Change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (when wet, soiled, or not intact).

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 37 sampled resident, Resident 133, when Licensed Nurse 8, (LN 8) did not wear gloves when she administered Entecavir tablet) [antiviral medication used to treat chronic hepatitis B (HBV) [long term liver infection] by preventing the virus from multiplying.] to Resident 133.This failure decreased the facility's potential to safely implement the physician's order and risk resident's safety.Findings:During a review of Resident 133's admission Record (AR), indicated Resident 133 was admitted to the facility on [DATE] with diagnoses that included Anemia (blood disorder), and Pathological Fracture (broken bones in an area already weakened by another disease, not by an injury).During a review of Resident 133's Order Summary Report, (OSR) dated 5/15/25, the OSR indicated .Entecavir Oral Tablet 0.5 MG (Entecavir). Give 1 tablet by mouth one time a day for hepatitis Wear gloves when handling.During a review of Resident 133's Medication Administration Record, (MAR) dated 5/16/25, the MAR indicated Entecavir Oral Tablet 0.5 MG (Entecavir) Give 1 tablet by mouth one time a day for hepatitis Wear gloves when handling.During a concurrent observation and interview on 7/8/26 at 4:04 p.m., with LN 8, LN 8 was observed administering medication without wearing gloves. LN 8 took out Resident 133's Entecavir tablet medication from the Bubble Pack/Medication Blister Pack (BP/MBP, method of organizing medications into individual doses) and dispensed the tablet in a cup. LN 8 acknowledged that she did not wear gloves when she took out the Entecavir tablet from the BP/MBP. LN 8 stated she should always practice safety.During an interview with the Director of Nursing (DON) on 7/9/26 at 8:41 a.m., the DON stated that the licensed nurses must follow the physician's orders, and the parameters indicated in the physician's order must be followed for the resident's and staff safety. During an interview with the Physician Consultant, (PC) on 7/9/26 at 12:11 p.m., the PC stated, Entecavir Tablet is a hazardous medication, and the nursing staff must wear gloves when handling and administering the medication to Resident 133 as ordered by the physician. The PC further stated the parameters are part of the physician's order and must be followed by the nursing staff.A document review of, NIOSH [National Institute for Occupational Safety and Health] List of Hazardous Drugs in Healthcare Settings, 2024, dated December 2024, indicated, .The purpose of the Alert was to increase the awareness among workers in healthcare settings and their employers about the health risks posed by working with hazardous drugs, and to provide them with measures for protecting their health.probably carcinogenic to humans. (Some may also have adverse developmental and/or reproductive effects.) .Drug - entecavir.A review of the facility's policy and procedure titled, Physician Orders (PO), indicated, 6. The licensed staff shall carry out physician/nurse practitioner's orders as prescribed.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of four sampled residents (Resident 4) when facility staff witnessed Resident 1 hit Resident 4. This failure resulted in Resident 4 to verbalize sadness and not be free from abuse and potential harm.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted [DATE] with diagnosis that included dementia unspecified severity with agitation (a progressive state of decline in mental abilities), and anxiety (an intense, excessive, and persistent feeling of fear, dread, or uneasiness).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/28/25, Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 1 had moderately impaired cognition.During a review of Resident 4's clinical record, Resident 4 was admitted [DATE] with diagnosis that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety, major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy), and parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors).During a concurrent review of Resident 1 and Resident 4's progress notes, dated 2/22/26, the progress notes indicated Resident 1 and 4 had been involved in an altercation (an argument or disagreement). Facility staff witnessed Resident 1 hit Resident 4 in the face.During a review of Resident 4's progress note dated, 2/22/26, the progress note indicated Resident 4 verbalized sadness and angry for the situation, and appears tearful.During a review of Resident 1's care plan revised 6/21/25, the care plan indicated psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms (i.e., striking out, grabbing others, combative, verbally, or physically abusive to Staff and patients. The goal indicated, .demonstrate adequate control of emotions which will not result in injury toself or others.During an interview on 3/3/26 at 12:15 p.m. with the Director of Nursing (DON), the DON stated that the expectation is to keep residents safe. Abuse can perpetuate and a resident can be hurt more. The goal is to have no abuse in the facility.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights revised February 2021, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include. be free from abuse.

Based on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of abuse for one of four sampled residents (Resident 1) when Resident 1 reported to nursing staff that she was injured by facility staff during patient care. This failure had placed Resident 1 and other residents in the facility at risk for potential physical abuse and/or psychosocial harm.Resident 1 was admitted to the facility October 2025 with multiple diagnoses which included muscle weakness and abnormalities of gait (manner of walking and limb movement) and mobility. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/5/25, indicated Resident 1 had moderate memory impairment. During an interview on 2/5/26, at 1:28 p.m., with Licensed Nurse (LN) 1, LN 1 confirmed Resident 1 had informed him that Resident 1 had gotten injured while receiving care by facility staff and that Resident 1 had felt unsafe. LN 1 stated he had not reported the allegation to facility management. During an interview on 2/5/26, at 2:52 p.m., with the Director of Staff Development (DSD), the DSD stated that her expectation from staff is that if they see a new injury they need to report immediately to the nurse. The DSD further stated that if a resident reports they got injured during care with another staff member the CNA is to report as potential abuse. During an interview on 2/5/26, at 3:10 p.m., with the Director of Nursing (DON), the DON stated the expectations were for staff to report to management any injury of unknown source or allegation of abuse. DON further stated if injuries or allegations of abuse were not reported, residents could potentially experience further abuse and be injured. During a review of Resident 1's Progress Note (PN), dated 11/5/25, the PN indicated, .patient [Resident 1] reported recent trauma to bilateral [both sides] legs/feet from dangling off of bed. Noted with large area of bruising to left lower leg.with 0.2cm [centimeter, unit of measurement] linear [straight] break in skin to lateral [side] aspect of L [left] lower leg.Patients preferences (using multiple staff members, gently moving legs) . During a review of Resident 1's hospital record titled, Inpatient Wound Care CAPI, date of service 11/6/25, indicated, Pt [patient] reports she was rolled by a CNA [Certified Nursing Assistant] at SNF [skilled nursing facility] and nearly fell OOB [out of bed] sustaining injuries to her left leg and right foot.Plantar [sole of foot] surface of L foot with circular red/maroon discoloration of unknown etiology [cause] possibly related to trauma. During a review of Resident 1's care plan initiated on 11/6/25, indicated, Resident has impaired skin integrity as evidenced by skin tear.related to trauma and is at risk for infection. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/22, the P&P indicated, All reports of resident abuse (including injuries of unknown origin0 .are reported to local, state and federal agencies and thoroughly investigated by facility management.if resident abuse.injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.within two hours of an allegation involving abuse or result in serious bodily injury; or.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview, and record review the facility failed to provide supervision to protect two residents (Resident 1 and Resident 2) from abuse when Resident 1 and Resident 2 had a physical altercation. This failure had the potential to result in physical injury or emotional distress for both Resident 1 and Resident 2. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2024 with multiple diagnoses including dementia (a condition characterized by impairment of brain functions, including memory loss and judgment), diabetes (too much glucose in the blood), osteoarthritis (the flexible tissue at the end of the bones, cartilage, wears down causing pain and decreased mobility). A review of Resident 1's Minimum Data Set (MDS-federally mandated assessment tool), Cognitive Patterns, dated 4/29/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-tool to assess cognition) score of 3 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Functional Abilities, dated 4/29/25, indicated Resident 1 used a wheelchair for mobility and had no impairment to upper and lower extremities. A review of Resident 1's Order Summary Report, indicated .Resident does not have the capacity to make her decisions . A review of Resident 1's Progress Notes, dated 7/8/25 at 12:59 p.m., indicated .At approx. [approximately] 1250 [12:50 p.m.] resident was on her wc [wheelchair] at the hallway by A-1 nurses station. This nurse observed resident and another resident hitting each other . [Resident 1] bump into [Resident 2] wc. [Resident 1] hit [Resident 2] by R [right] forearm, [Resident 2] hit her back hitting her to her L [left] forearm. This writer removed immediately [Resident 1] from the situation d/t [due to] resident confusion and orientation only to herself, apparently doesn't comprehend what is going on .This writer asked some questions regarding incident, but resident is unable to recall incident . A review of Resident 1's Progress Notes, dated 7/8/25 at 1:54 p.m., indicated .On 07/08/2025 at around 12:30 [p.m.], SS [Social Services] was notified by the DON [Director of Nursing] and nurse in charge that [Resident 1] and [Resident 2] were fighting in the A-1 hallway, both patient's were in a w/c. [Resident 1] hit the R arm of the victim first, victim hit back, they were both hitting each other's arms .Nurse in charge separated them, making sure they are both away from each other, both patient's refuse room change . A review of Resident 1's Progress Notes, dated 7/8/25 at 9:57 p.m., indicated .Per CNA [Certified Nursing Assistant], the resident around 1900 [7:00 p.m.] tried to hit resident [resident in a different room] but couldn't reach him, CNA moved this resident immediately away . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in September 2012 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (condition that impacts the blood flow to the brain), depressive disorder (mental health disorder characterized by depressed mood or loss of interest in activities), and epilepsy (seizure disorder). A review of Resident 2's MDS, Cognitive Patterns, dated 6/4/25, indicated Resident 2 had a BIMS score of 12 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's MDS, Functional Abilities, dated 6/4/25, indicated Resident 2 used a wheelchair for mobility and had no impairment to upper and lower extremities. A review of Resident 2's Order Summary Report indicated .Resident has capacity to make his/her decisions . A review of Resident 2's Progress Notes, dated 7/8/25 at 1:23 p.m., indicated .At approx. 1250 [12:50 p.m.] resident was on his wc at the hallway by A-! nurses station. This nurse observed resident and another resident hitting each other . [Resident 1] bump into [Resident 2] wc. [Resident 1] hit [Resident 2] first hitting him to R forearm, [Resident 2] hit her back, hitting to her left forearm . This writer asked resident what happened, resident stated I wanted to go outside to smoke, and she was on the way, blocking the hallway, she hit me first . During a joint interview on 7/9/25 at 1:19 p.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON stated she was present during the incident between Resident 1 and Resident 2 on 7/8/25 in hallway A. The DON stated both residents were in their wheelchairs near the nursing station. The DON stated Resident 1 accidentally hit Resident 2's wheelchair when she was trying to pass by Resident 2. The DON stated Resident 1 hit Resident 2 on the arm and Resident 2 hit her back. The DON stated when she asked Resident 1 about the incident, Resident 1 stated she did not remember. The DON stated that Resident 2 stated, If someone is hitting me, will hit back. That's how it's done if you grew up on the streets. During an interview on 7/9/25 at 2:08 p.m. with the Social Services Director (SSD), the SSD stated Resident 1 and Resident 2 were side by side in the hallway when the incident occurred. The SSD stated Resident 2 does not like to be touched and wants his own space. The SSD stated Resident 1 hit Resident 2 on the arm and then both residents started throwing their arms at each other. During an interview on 7/9/25 at 2:45 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was sitting at the nurse's station on 7/8/25 when incident occurred between Resident 1 and Resident 2. LN 1 stated Resident 1 and Resident 2 were in their wheelchairs beside each other when Resident 2 tried to pass by Resident 1 and bumped into Resident 1's wheelchair. LN 1 stated Resident 1 hit Resident 2 on the forearm and Resident 2 hit Resident 1 back and each resident hit back two to three times. LN 1 moved Resident 1 back to her room and asked her what happened. LN 1 stated Resident 1 did not know what happened. LN 1 stated she asked Resident 2 what happened, and he replied, She hit me first. She did it first, so I have to do something. LN 1 stated Resident 1 can be aggressive and tried to hit someone else that same evening. LN 1 stated Resident 1 has been physically aggressive towards staff and has hit and kicked staff. LN 1 stated Resident 2 had her Ativan (medication to treat anxiety) dose increased yesterday after second incident of trying to hit someone because the prior dose was not working. During an interview on 7/9/25 at 2:54 p.m. with CNA 1, CNA 1 stated Resident 1 can be resistive to care and will strike out at staff. CNA 1 stated Resident 2 sometimes gets angry, but CNA 1 was not aware of any physical aggression. During an interview on 7/9/25 at 3:00 p.m. with Resident 1, Resident 1 stated she did not recall any incident with Resident 2 or any other resident. When asked if anyone had hit her, Resident 1 stated she did not remember. During an interview on 7/9/25 at 3:08 p.m. with Resident 2, Resident stated he recalled incident with Resident 2 on 7/8/25. Resident 2 stated he was in his wheelchair and was trying to squeeze by Resident 1 in the hallway and Resident 1 moved her wheelchair and banged into him. Resident stated he quietly asked Resident 1, Do you understand why you shouldn't sit at the intersection where there are too many people. Resident 2 stated Resident 1 yelled No and started hitting him with both her arms. When asked if he hit back, Resident 2 stated, [Expletive] right. World I grew up in, if someone hits you, you have the perfect right to hit him back. If she is a mental case this place should not have her here. [Expletive] right I hit her back. Had no choice, then I hit her twice back. Staff finally woke up and moved her away from me which is what I was trying to do anyway. Hit back a couple of times and was done with the crazy .Wanted to go on with the rest of my day. Resident 2 stated he has not had any incidents with any other residents, only her mental case, an active menace. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 12/16, indicated .Our residents have the right to be free from abuse .This incudes but is not limited to freedom from .physical abuse .As part of the resident abuse prevention, the administration will: .Protect our residents from abuse by anyone including .other residents .Identify and assess all possible incidents of abuse .Protect residents during abuse investigations . A review of the facility's P&P titled Resident-to-Resident Altercations, revised 10/17, indicated .All altercations, including those that may represent resident-to-resident abuse, shall be investigated .Facility staff will monitor residents for aggressive/ inappropriate behavior towards other residents .or to the staff .If two residents are involved in an altercation, staff will .Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation .Review the events with the Nursing Supervisor and Director of Nursing and possible measures to try and prevent additional incidents .

Based on observation, interview and record review, the facility failed to ensure the proper dishwashing process and sanitary conditions were maintained in the dietetic services when: 1. Two serving metal pans with debris particles stacked together were found stored in a clean and ready-to-use storage area. 2. Dietary Aide (DA) 1 was not able to verbalize and/or demonstrate: -The practice of measuring the water temperatures for the automated dishwashing and -The knowledge of the temperatures and sanitation concentrations for the manual dishwashing by 3-compartment sink procedure. 3. The wash and rinse temperatures log and instructions of the dishwashing machine did not match the manufacturer's guidance. These failures had the potential to result in food contamination which could cause illness in 172 out of 172 medically vulnerable residents who received and consumed food from the facility kitchen. Findings: 1. A kitchen initial tour observation and concurrent interview with Dietary Supervisor (DS) on 6/24/25 at 9:08 a.m. was conducted. There were two of the one-third (1/3) sheet metal pans (pans that hold the food for meal distribution) found with brown sticky substances. DS confirmed and stated the substances were food particles. She further stated the metal pans should be cleaned and checked before being stored away. During a follow up interview on 6/26/25 at 10:42 a.m. with Registered Dietitian (RD), RD stated the dishes should be clean and the staff should check them before storing away. A review of facility policy and procedure (P&P) titled, Sanitation, revised October 2024, indicated, .Utensils .shall be kept clean, maintained .Equipment .and utensils shall be washed to remove or loosen soil by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . A review of facility P&P titled, Dishwashing, dated 2023, indicated, .Gross food particles shall be removed by careful scraping and pre-rinsing in running water .Dishes are to be air dried in racks before stacking and storing . A review of facility document titled, Job Description: Dietary Supervisor (DS), dated 2/2024, showed, .Maintain Kitchen . in a safe, orderly, clean and sanitary manner. 2. A concurrent observation of dishwashing process by the dishwashing machine and interview with DA 1 and DS on 6/24/25 at 9:33 a.m. was conducted. DA 1 explained the process but she was not able to verbalize the water temperatures of the dishwasher for the final wash and final rinse cycles. A concurrent review of undated facility document titled, Low Temperature Dish Machine Log, June 2025, showed, the wash water temperature recorded 135 degrees Fahrenheit (F) and the rinse water temperature recorded 110 degrees F on 6/24/25. DA 1 stated the wash and rinse water temperatures recorded on the log were at the correct range. DS confirmed and stated both the wash and rinse temperatures should be at least 120 degrees F. During an interview with DA 1 on 6/24/25 at 10:39 a.m., DA 1 stated she would start to wash dishes manually with the 3-compartment sink if the dishwasher was not working. DA 1 explained the process and stated the first sink was for wash, second sink was for rinse, and there was a big bucket used as third compartment for sanitizer to sanitize. DA 1 was not able to answer the proper water temperatures for the steps of wash and rinse, and the immersion time for the dishes in the sanitizer for the sanitizing step. DA 1 was not able to answer the concentration of the sanitizer (quaternary ammonium (quat), a type of chemical agent for sanitizing). A concurrent interview with DS for immersion time of the sanitizer, she read the posted instruction Steps for 3-Compartment Wash at the station and stated 30 seconds, and the concentration would be 200 ppm (part per million, a unit of measurement). A concurrent review of the quat solution instructions on the bottle label with DS, it indicated the immersion time was 60 seconds and the final concentration should be in the range of 200-400 ppm. During a follow up interview on 6/26/25 at 10:42 a.m. with RD, RD stated the dietary staff, especially the dishwasher, should have a good knowledge of both the automated and manual procedures for dishwashing. A review of a facility document titled, Food and Nutritional Services In-Service, Topic: Cleaning and Sanitizing of Dishes, Utensils, Pots and Pans, completed on 3/29/25 by DS and Assistant Dietary Supervisor (ADS). DS confirmed DA 1 attended the in-service. A review of facility P&P titled, Dishwashing, dated 2023, indicated low temperature machine, .use the machine at a range of 120-140 degrees F . A review of undated facility document titled, Log Temperature Dish Machine Log, it indicated, .Directions .wash & rinse temperatures should be equal to or greater than 120 degrees F, or follow manufacturer's recommendations .if temperature or chlorine levels are incorrect, discontinue use and notify supervisor immediately . A review of facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, revised October 2024, it stated, .The first compartment is for washing .hot water (110-120 degrees F) .Second compartment is for rinsing . clear hot water (110-120 degrees F) .The third compartment is for sanitizing .Test the concentration with the appropriate test strip, which is dipped in the sanitizer solution 10 seconds before reading Must read 200-400 ppm. Immerse all washed items for 60 seconds . 3. During a record review and a concurrent interview on 6/24/25 at 9:33 a.m. with DS, the temperature log of the dishwasher with a recorded entry on 6/24/25 for A.M. (morning) shift, stated a final wash at 138 degrees F and a final rinse at 110 degrees F. DS confirmed and stated both final wash and rinse temperatures should be at least 120 degrees F. During an interview, and concurrent record review on 6/26/25 at 10:42 a.m. with RD, RD acknowledged dishwasher DA 1 recorded a few times the final rinse temperature of 110 degrees F in the Dishwashing Machine Log for June 2025. RD reviewed the log and stated both the final wash and rinse temperature should be at least 120 F. During a concurrent interview and record review on 6/26/25 at 3:20 p.m. with Maintenance Supervisor (MS), MS confirmed the recommended wash and rinse temperatures visualized and posted on the dishwashing machine. The posted manufacturer's guideline stated for the chemical sanitizing dishwashing procedure, the minimum of 140 degrees F for the wash tank temperature and the minimum of 120 degrees F for the final rinse temperatures. During a concurrent interview and record review on 6/26/25 at 3:40 p.m. with DS and RD, DS and RD agreed they were not aware of the manufacturer's guidelines with the minimum wash temperature of 140 degrees F and rinse temperature of 120 degrees F that was posted on the facility's dishwashing machine. A concurrent review of the dishwasher temperature log for May and June of 2025, DS and RD confirmed most of the wash temperature were below 140 degrees F and some rinse temperatures were below 120 degrees F. RD and DS agreed the documented entries were not at manufacture's recommendations. RD and DS confirmed the directions of the dishwasher temperature log regarding the wash and rinse temperatures should be at least 120 degrees F were not at manufacturer's recommendations. A review of facility document titled, Low Temperature Dish Machine Log dated May 2025, stated, .Directions .1. Record wash and rinse temperatures and chlorine test before starting dishes. 2. Wash and rinse temperatures should be equal to or greater than 120 degrees F or follow manufacture's recommendations . 4. If temperature or chlorine levels are incorrect discontinue use and notify supervisor immediately . A review of facility P&P titled, Dishwashing, dated 2023, indicated, .Low-Temperature machine: If you do not have the manufacturer's recommendations, use the machine at a range of 120 degrees F to 140 degrees F . A review of facility P&P titled, Sanitization, revised October 2024, stated, .8. Dishwashing machines are operated using Low-Temperature Dishwashers (Chemical Sanitization). Wash temperature (120 degrees F), final rinse with 100-200 ppm .liquid sanitizer . A review of facility document titled, Job Description: Dietary Supervisor (DS), dated 2/2024, showed, .Maintain Kitchen .in a safe, orderly, clean and sanitary manner. A review of facility document titled, Job Description: Registered Dietitian (RD), dated 2/2024, showed, .Monitor food service operations to ensure conformance to .safety, sanitation and quality standards .

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of 52 sampled residents (Resident 170 and Resident 15) when: 1. Resident 170's LAL (low air loss, designed to prevent and treat pressure ulcers by reducing and redistributing pressure on the body) mattress was not followed as ordered; and 2. Resident 15's blood pressure medication was not administered as ordered. These failures increased the potential for Resident 170 to develop new pressure ulcers and for Resident 15 to experience complications. Findings: 1. A review of the admission Record indicated Resident 170 was admitted early part of June 2025 with diagnoses including rhabdomyolysis (breakdown of muscle tissue) and unstageable pressure ulcer (or pressure injury [PI], base of wound covered by a layer of dead tissue that may be yellow, brown or black and stage is unclear) of other site. A review of Resident 170's physician order dated 6/4/25 indicated treatment orders for five (5) PIs and an order for LAL mattress. During an observation on 6/24/25 at 9:24 a.m., Resident 170 was in bed and had a regular mattress. A concurrent observation and interview was conducted on 6/25/25 at 11:54 a.m. with the Treatment Nurse 1 (TN 1). The TN 1 confirmed Resident 170 had no LAL mattress. The TN 1 further confirmed Resident 170 had an order for LAL mattress dated 6/4/25. A concurrent interview and record review was conducted on 6/26/25 at 9:43 a.m., with the Minimum Data Set Assistant Coordinator 2 (MDSA 2). The MDSA 2 confirmed Resident 170's Medication Administration Record (MAR) indicated the LAL mattress was signed as present on 6/24/25 and 6/25/25. In an interview on 6/27/25 at 11:58 a.m., the Director of Nursing (DON) stated Resident 170 was moved to another room on 6/23/25 and unfortunately the staff did not move the LAL mattress with the resident. The DON stated her expectation was for nurses to check the LAL mattress and document in the Medication Administration Record (MAR). The DON further stated if LAL mattress was not available the staff should notify the Housekeeping Manager. The DON added Resident 170 had wounds and the LAL mattress was for offloading. A review of the facility's policy and procedure (P & P) revised October 2024 and titled, Pressure Ulcers indicated, .The licensed nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers .The physician/NP [nurse practitioner] will order pertinent wound treatments, including pressure reduction surfaces . A review of the facility's P & P revised October 2024 and titled, Physician Orders indicated, .The licensed staff shall carry out physician/nurse practitioner's orders as prescribed. 2. During a review of Resident 15's admission records, the records indicated Resident 15 was admitted in May 2025 with diagnoses that included hypertension (high blood pressure) and atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow). During a review of Resident 15's physician order, dated 5/15/25, the order indicated, Metoprolol Tartrate [medication to treat hypertension] .1 tablet by mouth two times a day for HTN [hypertension] Hold for SBP [systolic blood pressure - the pressure in the arteries when the heart beats] <100 or HR [heart rate] <60. During a review of Resident 15's Medication Administration Record (MAR), the MAR indicated the following: - Vital signs (measurements that reflect essential body functions) were not taken before holding or administering Metoprolol on the following dates: 5/23/25, 6/7/25, 6/14/25, 6/15/25, 6/24/25, and 6/25/25; - Metoprolol was given for BP: 96/51 mmHg [millimeters of mercury, a unit of pressure measurement] on 6/22/25; and, - Metoprolol was not given on the following dates with BP within limits: 5/18/25 - 102/56 mmHg 5/27/25 - 104/62 mmHg 5/30/25 - 104/51 mmHg 5/31/25 - 105/57 mmHg 6/1/25 - 106/50 mmHg 6/4/25 - 106/72 mmHg 6/10/25 - 107/66 mmHg 6/17/25 - 103/56 mmHg 6/24/25 - 104/60 mmHg During a concurrent interview and record review on 6/26/25 at 10:44 a.m. with Licensed Nurse 11 (LN 11), LN 11 confirmed Resident 15 had an order of Metoprolol twice a day and to hold dose if systolic blood pressure was less than 100 mmHg and heart rate was less than 60 beats per minute (bpm). LN 11 stated Resident 15's blood pressure will drop if Metoprolol was given outside the hold parameters. The LN 11 stated, It's important to check vital signs first before giving for the same reason. The LN 11 confirmed doses were also held for vital signs that were within the hold parameters and stated, I don't know why they held it .I'm not sure why they documented that .Resident BP can go up if we don't give it. During a concurrent interview and record review on 6/27/25 at 8:56 a.m. with the DON, the DON confirmed Resident 15 had an order for Metoprolol with hold parameters. The DON confirmed there were no vitals signs taken before administering or holding Resident 15's Metoprolol on 5/23/25, 6/7/25, 6/14/25, 6/15/25, 6/24/25, and 6/25/25, and stated, All the vitals need to be there whether you hold it or not. The DON further confirmed Resident 15's Metoprolol was administered on 6/22/25 for BP of 96/51 mmHg and that there were nine scheduled dates where Resident 15's Metoprolol doses were held even though the vitals signs were within parameters, and stated, This is not following the doctor's hold parameters .they [staff] are holding it even when residents bp is not low, the HR might go faster . During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 10/2024, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed .2. Medications are administered in accordance with prescriber orders, including any required time frame .8. The following information is checked/verified for each resident prior to administering medications: .b. Vitals signs, if necessary .

Based on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures to meet the needs of each resident and ensure that these procedures were consistent with standards of practice, when: 1. A medication for Resident 76 was not administered as prescribed by physician; 2. A prescribed medication was not available at the time of administration for Resident 529; 3. Resident 731 did not receive prescribed ointment treatment for multiple days; 4. Resident 68 received medication beyond the expiration date; 5. A loose unidentified medication was stored in the drawer with controlled substances, and 6. A loose pink pill was observed on the floor in hallway. These failures had the potential for worsening of resident's condition from receiving the smaller dose that was ordered, not receiving important medication and treatment as prescribed, receive medication with unsafe or reduced potency from being used past their expiration date, and diversion or misuse of controlled drugs and substances. Findings: 1. During a medication pass observation on 6/26/25, at 7:24 a.m., with Licensed Nurse 6 (LN 6), LN 6 was observed preparing Resident 76's morning medications, which included Flomax (a medication used to relax bladder muscle), 0.4 milligram (mg, dose of measurements). LN 6 placed one capsule of medication into a small plastic cup containing other medications and administered to Resident 76. The bubble pack label (a sealed package that holds the individual medications securely) indicated, Administer 2 capsule and give 30 minutes after the same meal each day. A review of Resident 76's physician order, dated 6/4/25, indicated, Flomax 0.4 mg, Give 2 capsule by mouth one time a day for benign prostatic hyperplasia (enlargement of prostate gland) 30 minutes after the same meal each day. During a follow up interview on 6/26/25, at 9:40 a.m., LN 6 acknowledged that she administered one capsule to Resident 76, and validated it was a wrong dose. LN 6 stated the the physician instructions directed nursing to administer Flomax medication 30 minutes after the meal and Resident 76 received all of his medications before the breakfast was served. A review of the facility's 'Administering Medications' policy dated 10/24 indicated, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time .before giving the medication. 2. During a medication pass observation on 6/26/25, at 7:45 a.m., with LN 7, LN 7 prepared Resident 529's morning medications and informed that one of the resident's medication Valsartan (a medication to control high blood pressure) 320 mg was not available for administration. LN 7 explained that the nurses faxed the refill request for Valsartan, but apparently there was a delay with pharmacy delivering the medication. LN 7 stated she will follow up with pharmacy regarding missing medication. A review of Resident 529's physician orders, dated 6/12/25, indicated that Valsartan 320 mg tablet was to be administered orally one time a day for high blood pressure. A review of Resident 529's Medication Administration Record (MAR) on 6/26/25 at 2:30 p.m., indicated that morning dose of Valsartan 320 mg scheduled for 8 a.m., had not been administered. During an interview on 6/26/25, at 2:35 p.m., the blood pressure medication not available for administration for Resident 529 was discussed with the Director of Nursing (DON). The DON stated the pharmacy delivered medications three times a day and the expectation was that there should be no delays with administering resident's medications. The DON acknowledged that sometimes there were issues with pharmacy delivering medications. A review of the 'Administering Medications' policy dated 10/24 indicated, Medications are administered in a safe and timely manner .in accordance with prescriber orders, including any required time frame. A review of facility's policy titled Medication Re-Ordering, dated 10/24 indicated, Medication refills are ordered by peeling the reorder strip from the label and placing it in the appropriate area on the order form provided by pharmacy. The licensed nurse notifies the pharmacy and provider if a medication is not filled on time and a medication is unavailable. 3. A review of the admission Record indicated the facility admitted Resident 731 in June 2025 with multiple diagnoses which included aftercare following a joint replacement surgery. A review of Resident 731's Order Summary Report (OSR) contained an order for Terbinafine (a cream used to treat fungal infections) 1%, directing nurses to apply to groin and buttocks topically (directly to the surface of the skin) two times a day for fungal infection for 2 weeks. A review of Resident 731's MARs indicated the resident did not receive treatment for fungal infection on 6/21/25, 6/22/25, 6/23/25, 6/24/25, and 6/25/25 dosages scheduled for 8 p.m., and 6/23/25, 6/24/25, and 6/25/25 dosages scheduled for 8 a.m. A review of the nursing progress notes dated 6/21/25 at 9:04 p.m., indicated the Terbinafine was not administered. The nurse documented, awaiting pharmacy to deliver. A review of the nursing progress notes dated 6/22/25, at 7:30 p.m., indicated the Terbinafine was not administered. The nurse documented, Unable to locate OTC [over the counter], ordered from Central Supply. A review of the nursing progress notes dated 6/25/25, at 7:58 a.m., indicated the Terbinafine was not administered. The nurse documented, Waiting for supply. A review of the nursing progress notes dated 6/25/25, at 7:11 p.m., indicated the Terbinafine was not administered. The nurse documented, Awaiting for supply. During a concurrent interview and record review on 6/26/25, commencing at 10:50 a.m., the DON acknowledged that Resident 731 had not received treatment for fungal infection for multiple days. The DON stated the nursing staff waited for antifungal medication delivery from pharmacy and yesterday the pharmacy informed the facility that the medication should come from house supply. The DON stated the expectation was that the nurses called the pharmacy and followed up on delivery; asked why it was not delivered and requested to deliver as soon as possible. The DON added, If not administered, a physician should be notified and then we go by his recommendation .If the medication is not available, the physician can prescribe another medication. The DON was unable to locate any records indicating that the nurses notified the physician that the resident had not been receiving prescribed untifungal medication for multiple days. A review of 'Administering Medications' policy dated 10/24 indicated, Medications are administered in a safe and timely manner .Medications are administered in accordance with prescriber order .Medication administration times are determined by resident needs and benefit. 4. During an inspection of Med Cart #2 on Station B and interview with LN 8 on 6/26/25, at 10:57 a.m., an inhaler medication Advair Discus (used to treat asthma) 500 microgram (mcg, a unit of measurement)/50 mcg was observed inside of the drawer. The date on the inhaler indicated it was removed and opened from the package on 5/11. LN 8 stated that she administered Advair medication to Resident 68 earlier this morning around 8 a.m. LN 8 stated that per manufacturer instructions, Advair medication should be discarded 30 days after the package was opened. LN 8 stated the nurses were to check the medication expiration date every time they administered medication to the resident and the expired medications should not be kept in medication cart and available for use. During an interview with DON on 6/26/25, commencing at 10:50 a.m., the DON stated nursing staff were expected to check expiration dates of all medications during medication administration and should never administer expired medications. The DON stated the nursing staff should have reordered Advair from pharmacy ahead of time and discarded the expired medication as indicated by manufacturer's instruction. A review of 'Administering Medications' policy dated 10/24 indicated, Medications are administered in a safe .manner .The expiration/beyond use date on the medication label is checked prior to administering. 5. During an inspection of Med Cart #2 on Station A with LN 10 on 6/27/25, at 10:45 a.m., LN 10 opened the drawer containing narcotics medications (strong medications administered for pain with a high potential for abuse and diversion), grabbed a small plastic medication cup with one white long tablet, opened the bottle containing of drug buster (a special container containing liquid for destruction of wasted or refused medications), and attempted to drop the medication into the bottle. The writing on the cup with medication inside indicated 'waste,' however had no medication name on it and did not contain resident's name for whom it was prescribed. LN 10 explained that the medication was Norco (narcotic medication to control pain) and needed to be wasted. LN 10 stated he accidentally popped out a wrong medication for Resident 133 and was waiting for another nurse to witness the medication destruction. A review of Resident 133's 'Controlled Drug Record,' indicated that Norco 5-325 mg was removed 6/27/25 at 9:50 a.m., and the left side of the document next to the date and time indicated 'wasted' and on the right side there were two initials confirming the waste. LN 10 stated the narcotic medication destruction had to be witnessed by another nurse and was unable to explain why the medication was not placed into buster container at the time another nurse initialed the waste and why he attempted to empty the cup with medication earlier without another nurse present. During an interview with DON on 6/26/25, commencing at 10:50 a.m., the DON stated the nurse should have another nurse to witness the medication destruction while it was placed into drug buster container as soon as possible. Discussed with the DON that the unidentified medication sitting in medication cup and a nurse attempting to destroy Norco without other nurse present. The DON explained the process and stated that controlled substances could not be destroyed without another nurse present who needed to co-sign the medication destruction at the same time it was wasted. A review of facility's policy titled, Discarding and Destroying Medications, dated 9/24, indicated, Medications will be disposed of in accordance with federal, state, and local regulations governing management of .controlled substances. 6. During an observation on 6/27/25 at 10:44 a.m. in the facility back hallway, a pink unidentified loose pill was observed on floor in the hallway outside of room [ROOM NUMBER] while a resident was observed passing by in their wheelchair. During a concurrent observation and interview on 6/27/25 at 10:47 a.m. with Licensed Nurse (LN 1), LN 1 confirmed pink unidentified medication on floor in hallway. LN 1 stated that pill should not be on the floor, another resident could take it and it could be harmful to them leading to a drug reaction. During an interview on 6/27/25 at 12:51 p.m. with DON, the DON acknowledged the medication on the facility floor via photograph. The DON stated nursing staff are expected to wait for the resident to swallow the medication and then document it was given. The DON further stated if medication is found in hallway someone may pick it up and take it and this could be harmful to them if they were allergic.

Based on observation, interview, and record review, the facility failed to ensure the planned menu spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) and recipes (a set of instructions for preparing a particular dish, including a list of the ingredients required) were followed for the therapeutic diets during the lunch meal distribution on 6/25/25 when: 1.Resident 14 with low fat and low cholesterol diet (a diet designed to lower elevated levels of cholesterol and other fats in the blood to reduce the risk of heart disease) received tartar sauce (a cold sauce, typically eaten with fish, consisting of mayonnaise) instead of a lemon slice for the lunch. 2.Four residents (Resident 36, 110, 147 and 152) with a fortified diet (a diet designed for residents who cannot consume adequate amounts of calories or proteins to maintain their weight or nutritional status) did not receive fortified food with their meals. 3.Three residents (Resident 62, 85 and 89) with mechanical soft texture diet (a diet designed with modified texture for residents who experience chewing and/or swallowing limitations) received the fish in dysphagia (difficulty swallowing) mechanical soft texture (food textures that are moist and mechanically altered, such as blended, grinded, chopped or mashed, to limit chewing and easier to swallow). 4.Five residents (Resident 17, 70, 109, 134 and 149) with dysphagia mechanical soft diet received dysphagia mechanical soft texture fish which did not follow the recipe. These deficient practices had the potential to result in 13 out of 172 residents who received meals from the facility kitchen not having meals which would meet their nutritional needs and the food textures for the prescribed diets. Findings: During a concurrent observation of lunch meal distribution and spreadsheet review on 6/25/25 beginning at 11:58 a.m., it was noted as followed: 1.Resident 14 with a low fat and low cholesterol diet received tartar sauce for the fish in the entrée. A concurrent review of the facility spreadsheet titled, Summer Menus, Week 4 Wednesday, indicated low fat and low cholesterol diet should receive a lemon slice for the fish. During an interview with Registered Dietitian (RD) on 6/26/25 at 10:42 a.m., RD stated the staff missed it and confirmed low fat/low cholesterol diet should get a lemon slice instead of tartar sauce. 2.Four residents (Resident 36, 110, 147 and 152) with a fortified food with their diets did not receive an extra one ounce (oz., unit of measurement) of margarine on the vegetables as fortified food with their meals. During an interview with RD on 6/26/25 at 10:42 a.m., RD confirmed the staff need to pay more attention during the meal distribution. She further stated the fortified foods were given for different reasons and usually for the residents who needed extra calories and sometimes as the intervention for weight loss. 3.Three residents (Resident 62, 85 and 89) with mechanical soft texture diet were served the fish that was prepared for dysphagia mechanical soft texture diet. It was noted the fish was grinded with small pieces of tomatoes. A concurrent review of Summer Menus, Week 4 Wednesday, indicated mechanical soft diet should serve flaked/moist fish with soft tomatoes. During an interview with RD on 6/26/25 at 10:42 a.m., RD reviewed the spreadsheet and stated the whole fish fillet was soft enough for mechanical soft texture. She further stated that mechanical soft texture and dysphagia mechanical soft texture should be different. RD stated the staff should follow the menu or spreadsheet. A review of facility document titled, Recipe: Fish Italiano, indicated, Mechanical Soft: Flake each portion of fish prior to serving .Top with cream sauce or broth to be sure fish is moist. Tomatoes should be soft . 4.Five residents (Resident 17, 70, 109, 134 and 149) with dysphagia mechanical soft texture diet who received dysphagia mechanical soft fish, and observed the fish was grinded with small pieces of tomatoes. A concurrent review of the Summer Menus, Week 4 Wednesday, indicated the fish for dysphagia mechanical soft diet should be grinded and moist and added one tablespoon (tbsp) of pureed tomatoes. During a concurrent review of the recipe and interview with RD on 6/26/25 at 10:42 a.m., RD agreed and stated the [NAME] did not prepare the fish for dysphagia mechanical soft diet correctly according to the recipe. The tomato should be pureed but not in pieces. She further stated the [NAME] may be misunderstood the instruction of the recipe. A review of facility document titled, Recipe: Fish Italiano, indicated the fish for dysphagia mechanical soft diet should be grinded with onions and moistened with pureed tomatoes (like tomato sauce) and seasonings. A review of the facility policy and procedure (P&P) titled, Menus revised October 2024, policy statement Menus are developed and prepared to meet the resident .needs .while following the established national guidelines and for nutritional adequacy . A review of facility document titled, Job Description: Cook, dated 2/2024, showed, .Ability to follow prepared menus . and ability to prepare special diets accurately . A review of facility document titled, Job Description: Dietary Supervisor, dated 2/2024, showed, .Check trays for accuracy before they are delivered . A review of facility document titled, Job Description: Registered Dietitian, dated 2/2024, showed, .Monitor food services control systems such as . portion control, preparation methods . in order to ensure that food is prepared and presented in an acceptable manner .Inspect diet trays for conformance to physician's diet orders prior to delivery .

Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures to prevent the introduction and spread of infections to residents, when: 1. The nursing staff did not implement EBP (enhanced barrier precautions) for Resident 731; 2. The housekeeping staff did not wear appropriate PPE (personal protective equipment) while cleaning inside a room on EBP; 3. Resident 25's nebulizer mask (a face mask that fits over the nose and mouth to deliver medication into the lungs) was not stored properly; and 4. Treatment Nurse provided care to an open wound and did not wear adequate PPE per EBP standards. These failures had the potential to spread infections among residents, staff and visitors. Findings: During an observation and interview with Resident 731 on 6/24/25, at 12:48 p.m., the resident was sitting upright in his in bed dressed in hospital gown. The resident was awake, alert and oriented. An indwelling Foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urine drainage) in dark privacy bag was attached to the frame of the bed. Resident 731 stated he also had a drain placed after his surgery for left hip. There was no EBP precaution sign posted next to the entrance to resident's room and there was no PPE's available for use when caring for Resident 731's drain and Foley catheter. A review of Resident 731's 'Enhanced Barrier Precautions' [EBP] care plan initiated 6/22/25 indicated that the resident required enhanced barrier precautions during high-contact care activities due the presence of indwelling wound vacuum (a medical device that helps wound heal by applying suction and drawing out excess fluid). One of the interventions indicated, Utilize PPE [personal protective equipment] gown and gloves; face-shield as indicated) during high-contact resident activities, [including] dressing, bathing .hygiene .device care, wound care. During a follow up observation on 6/24/25, at 4:08 p.m., there was no EBP sign posted on the wall next to Resident 731's room entrance. Upon entering the resident's room, observed a partially closed curtain and the nurse working with drainage canister. The nurse had gloves on but did not utilize a protective gown and/or face protection. During a concurrent observation and interview with Treatment Nurse 2 (TN 2), on 6/24/25, at 4:10 p.m., TN 2 stated he finished providing care to Resident 731's wound vacuum and replaced the drain canister. TN 2 stated he did not utilize any other PPE, except gloves while providing wound vacuum care. TN 2 stated he was not sure if the resident was on EBP. TN 2 pointed to resident's name on the wall and explained, If resident on EBP, there will be a purple dot next to his name and we keep PPEs in a little caddy inside the door. TN 2 stated there was no EBP sign posted and no purple dot next to resident's name. During an interview with DON on 6/27/25, at 9:50 a.m., the DON explained, Indwelling catheter and wound drain are automatically qualify for EBP. Should have sign EBP by the door, guidance of PPE donning/doffing, and PPE caddy inside the room on the inner side of the door. The DON added, Expect staff wearing PPE every time directly dealing with wounds, Foley care and drain care. 2. During an observation on 6/26/25 at 9:46 a.m. in room [ROOM NUMBER], Housekeeping Staff 1 (HS 1) was observed cleaning and mopping the room. Rooms 325 had a signage posted by the indicating the room is on enhanced barrier precaution (EBP) and HS 1 was observed wearing a mask but no gown. During an interview on 6/26/25 at 9:48 a.m. with HS 1, HS 1 confirmed room [ROOM NUMBER] was on EBP and stated she forgot to wear the gown while cleaning the room. HS further stated wearing proper PPE (Personal Protective Equipment) was important to protect her and the residents. HS 1 stated she will wear the gown but there was no gown available in the room and had to get a pack of gown from the supply room. During an interview on 6/27/25 at 8:56 a.m. with the Director of Nursing (DON), the DON stated, Expectation is to follow the assigned guidance [on EBP] .They [staff] might spread infection if you don't follow the precaution .Everybody that enters the door, even housekeeping . During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control, revised 8/2024, the P&P indicated, .11. Prevention of Infection .a. Important facets of infection prevention include: .(3) educating staff and ensuring that they adhere to proper techniques and procedures; .(7) implementing appropriate isolation precautions when necessary .d. The facility provides personal protective equipment, checks for its proper use, and provides appropriate means of disposal. 3. Resident 25's nebulizer mask (a face mask that fits over the nose and mouth to deliver medication into the lungs) was not stored properly. During a review of Resident 25's admission Record (AR), the AR indicated, Resident 25 was admitted on [DATE] with diagnoses which included morbid obesity (severe form of having too much body fat) and obstructive sleep apnea (sleep disorder that occurs when the airway becomes blocked while sleeping). During a review of Resident 25's Order Summary Report (OSR), dated 7/1/25, the OSR indicated Resident 25 had Ipratropium-Albuterol Solution (medication used to treat air flow blockage) . inhale orally via nebulizer every 6 hours for increased cough for 1 Week. During a concurrent observation and interview on 6/24/25 at 10:28 a.m. with LN 8 in Resident 25's room, Resident 25's nebulizer mask was observed on the nightstand uncovered next to a blue mesh bag. LN 8 stated Should be in a bag, should have been put in bag after use. LN 8 further stated that it could be a source of infection. During an interview on 6/27/25 at 10:48 a.m. with ADON 2, ADON 2 stated that nebulizer mask, when not in use should be stored in a bag as it is part of their infection control practices to prevent spread of infection and bacteria. During a review of the facility's P&P titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised November 2024, the P&P indicated, Infection Control Considerations Related to Medication Nebulizers: store the circuit in plastic bag, marked with resident's name, between uses . 4. A review of Resident 41's admission record indicated she was admitted on [DATE] with diagnoses of a fracture of her right pubis (a break in the pelvic bone) and a pressure-induced deep tissue damage of sacral region (tailbone). A review of Resident 41's most recent Skin and Wound Evaluation, dated 6/24/25, indicated the pressure injury to sacral/coccyx region now measured, 2.2 cm in length, 1.6 cm in width, no depth is documented, and wound bed was now 30% granulated tissue (healthy beefy red tissue) and 70% slough ( dead tissue that is usually yellow, tan, grey, or green in color, usually moist and stringy texture, that may be found in wounds) . A review of Resident 41's EBP Care Plan, last updated on 6/25/25 indicated that she continued to be on EBP for a chronic wound. During a concurrent observation and interview on 6/25/25 at 1:20 p.m. with Treatment Nurse 1(TN 1), TN 1 was observed putting gloves and a mask on before entering Resident 41's room and providing wound care. Outside Resident 41's room was a sign that indicated Resident 41 was on EBP and what personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) staff should wear when providing direct care. After wound care was completed, TN 1 stated, Yes, she is on EBP, that is the sign to the left of the door. The expectation is that we put on gloves, a gown, and a mask if indicated. TN 1 stated, I did not wear a gown while providing wound care to Resident 41, and confirmed that she should have. During an interview on 6/26/25 with the Assistant Director of Nursing 2 (ADON 2) at 3:45p.m, the ADON 2 stated if a resident was on EBP and had an open wound she would expect the nurse to wear a gown, gloves and a mask. The ADON 2 also stated, If a treatment nurse did not wear a gown while completing wound care this would not meet my expectation. A review of the facility door sign titled, The Six Moments of Enhanced Standard Precautions, shows a picture of steps to follow for these precautions as follows: hand hygiene, gloves, and gowns for morning and evening care, toileting, caring for medical devices, wound care, mobility assistance and cleaning the environment. A review of the facility's policy titled, Multidrug-Resistant Organisms; Infection Precaution and Enhanced Standard Precautions, indicated that effective 4/1/24 in compliance with CMS, that EBP employs targeted gown and glove use during high contact resident care activities including wound care.

Based on observation, interview, and record review, the facility failed to ensure the laundry was maintained in a sanitary manner and in good repair when the contaminated linen area was found dirty, and a window screen was damaged. This failure had the potential to result in the facility not providing safe and sanitary handling of laundry items used by residents for a census of 175. Findings: During a concurrent observation and interview on 6/26/25 at 9 a.m. with the Housekeeping and Laundry Supervisor (HLS) in the contaminated linen area in the laundry room, dust particles were observed on laundry supplies and racks. The windows in the area were also observed with dust particles on the screens, and one of the window screens was damaged and had a hole in it. The HLS confirmed the observations and stated, .it [laundry room] should be clean all the time because of infection. During an observation and interview on 6/26/25 at 9:26 a.m. with the Maintenance Worker 1 (MW 1) in the contaminated linen area in the laundry room, the MW 1 confirmed the window screen had a hole, there was dust on the windows and the storage rack was dirty. During a follow-up interview on 6/26/25 at 9:31 a.m. with the HLS, the HLS stated the contaminated linen area is cleaned once a week and the clean linen area is cleaned every shift. The HLS was not able to provide cleaning logs for both areas of the laundry room. During an interview on 6/27/25 at 11:33 a.m. with the Assistant Director of Nursing 2 (ADON 2), the ADON 2 stated, Expectation is like what I want with my house, I want everything to be clean .Even the soiled linen area should be cleaned, no dust particles, and should be kept clean . When photos of the hole on the window screen were shown, the ADON 2 stated, .we don't want animals or rodents to come in, that's not good for anybody .It's a way to prevent infection. During an interview on 6/27/25 at 1:53 p.m. with the Administrator (ADM), the ADM stated, Expectation is to fix anything that we are aware of in a timely manner .We want the building and the residents to have things that they need and for the building to function the way it should. During a review of the facility's policy and procedure (P&P) titled Physical Environment and Accommodations Policy, undated, the P&P indicated, .(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors .(c) All window screens shall be clean and maintained in good repair .

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for one of 52 sampled residents (Resident 731), when the facility did not follow a physician order for straight catheterization (a thin, flexible tube is inserted into the urethra to drain urine and removed immediately) when the resident complained of inability to urinate and inserted a Foley catheter (a flexible plastic tube inserted into the bladder) to provide continuous urinary drainage. This failure had the potential to result in urinary tract infection. Findings: A review of the admission Record indicated Resident 731 was admitted to the facility in June 2025 with multiple diagnoses which included aftercare following joint replacement surgery and retention of urine (inability to urinate). A review of the physician order for Resident 731, dated 6/21/25, indicated,If patient is unable to urinate after 6 hours, bladder scan [a portable medical device to measure how much urine the bladder has]. If bladder scan and RV [residual volume] greater than 450 [milliliters, ml, a unit of measurement], straight cath [catheterize] as needed. During an observation and interview with Resident 731 on 6/24/25, at 12:48 p.m., the resident was sitting upright in his bed dressed in hospital gown. An indwelling catheter in dark privacy bag was attached to the frame of the bed. The resident was awake, alert and oriented. Resident 731 explained that he was admitted to facility without Foley catheter. Resident 731 stated he was not able to urinate for the entire night and added, My bladder was full .hurt like hell. A review of Resident 731's clinical records failed to reveal a physician order for Foley catheter and there was no order for catheter care. There was no documented date and time when the catheter was inserted. Resident 731's record had no care plan initiated to address Foley catheter. A review of nursing progress notes dated 6/24/25, at 3:28 p.m., indicated, .daughter came and complain [sic] about Foley catheter she stated she did not want Foley if my dad is retaining do straight cath [catheterization] this writer explain [sic] patient retained a lot last night and complain [sic] for pain and tenderness .this writer handed a communication note to PA [physician assistant] about family concern and waiting for orders. During a concurrent interview and record review with Licensed Nurse (LN 6) on 6/26/25, at 9:40 a.m., LN 6 acknowledged that there was no physician order for Foley catheter insertion. During an interview on 6/26/25, at 2:35 p.m., the Director of Nursing (DON) stated the nursing staff did not follow physician's order for straight catheterization and inserted Foley catheter instead. The DON confirmed that Resident 731 did not have a physician order for Foley catheter insertion. A review of facility's 'Physician Orders' policy dated 10/24, indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order .Phone or written orders must be recorded in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date, and the time of the order.

Based on observation, interview and record review, the facility failed to protect one of 52 sampled residents (Resident 160) from further injury when they did not implement specified interventions from the care plan to prevent skin tears. This failure resulted in Resident 160 sustaining additional skin tears to her left leg. Findings: A review of Resident 160's admission record indicated she was admitted on [DATE] after a syncopal episode with a ground level fall resulting in a left femur (thigh bone) and left humerus (upper arm bone) fractures. A review of Resident 160's change of condition (COC) note, dated 6/7/25, indicated Resident 160 had sustained a new skin tear to left lower leg during a wheelchair transfer with a Certified Nursing Assistant (CNA). A review of Resident 160's Potential for Skin Tears care plan, initiated on 6/7/25, indicated interventions to prevent skin tears were to keep her nails trimmed and short, pad the wheelchair arms and legs, wear protective sleeves, use a pressure relief mattress, bunny boots, and caution during transfers. A review of Resident 160's COC note, dated 6/22/25, indicated a new skin tear to left knee when transferring from bed to wheelchair. During an observation on 6/24/25 with Resident 160 at 4:15 p.m, a large skin tear was noted to her left knee and there was another healing skin tear to her left lower leg. During an observation on 6/26/25 with Resident 160 at 1:45pm, Resident 160 was seen lying in bed, with no sleeves on, nails were very long and unkept, and her wheelchair arms and legs were not padded. During a concurrent observation and interview on 6/26/25 at 3:35 p.m with Licensed Nurse 2 (LN2), LN 2 stated, No, I do not see any padding on the wheelchair, she does not have sleeves on, and her nails are very long and need attention. During an interview on 6/27/25 with the Assistant Director of Nursing 2 (ADON 2) at 1:24 p.m, the ADON 2 stated, If there are interventions on the care plan it is the responsibility of both the CNA's and the LN's to ensure they are being completed. If the resident had orders for short, trimmed nails, sleeves and padding to wheelchair arms and legs to prevent skin tears then it should have been implemented. A review of the facility's policy and procedure titled Care Plans, Comprehensive dated 10/2024 at number (5) section (a) indicated that, the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review the facility failed to ensure that two of 52 sampled residents (Resident 82 and Resident 9) were free from unnecessary drugs including chemical restraints when medications were administered without specific target behaviors and diagnoses to support indication for use of these drugs. This failure resulted in the administration of medications without adequate indication for use. Findings: 1a. During a review of Resident 82's clinical record, the record indicated Resident 82 was admitted in late 2022 with multiple diagnoses including bipolar disorder (a mental condition manifested by extreme mood swings) and anxiety disorder (a mental condition manifested by worry, fear, or nervousness that is excessive, persistent, and interferes with daily life). A review of Resident 82's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 3/21/25, indicated Resident 82 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 10 out of 15 that indicated Resident 82 had moderately impaired cognition. During a review of Resident 82's physician's order dated 2/19/25, the order indicated, . ARIPiprazole Oral Tablet 10 MG (mg- milligram, a unit of measurement) Give 1 tablet by mouth at bedtime for Bipolar disorder M/B [sic. Manifested by] impulsive behaviors . During a review of Resident 82's physician orders dated 2/19/25, the order indicated, . Olanzapine Oral Tablet 5 MG Give 1 tablet by mouth at bedtime for bipolar disorder M/B [sic. manifested by] manic phases . During a review of the facility's Medication Regimen Review (MRR) for Resident 82, the record indicated, .Please clarify the indication for aripiprazole & olanzapine .it was being used for bipolar disorder. Antipsychotics are not typically used for depression, especially when the manifestation is manic phases . During a concurrent interview and record review on 6/27/25 at 3:13 p.m. with Director of Nursing (DON) and Assistant Director of Nursing 1 (ADON 1) of Resident 82's clinical record, the DON and ADON 1 confirmed Resident 82's MRR was reviewed by the physician and facility. ADON 1 reviewed symptoms experienced by Resident 82. ADON 1 and DON further acknowledged the resident order needed specific behaviors to monitor the resident accurately. 1b. During a review of Resident 9's clinical record, the record indicated Resident 9 was admitted in late 2024 with multiple diagnoses including Dementia (a decline in mental ability severe enough to interfere with daily life with symptoms including difficulty thinking and memory loss). A review of Resident 9's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 5/31/25, indicated Resident 9 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12 out of 15 that indicated Resident 9 had moderately impaired cognition. During a review of Resident 9's physician orders, dated 12/12/2024 the order indicated, . Depakote Tablet Delayed Release 500 MG (milligram- a unit of measurement) . Give 1 tablet by mouth in the evening for behaviors m/b [sic. Manifested by] dementia . During a review of the facility Medication Regimen review (MRR) dated 6/1/25 through 6/9/25 indicated, . The resident has an order for Depakote for behaviors m/b dementia. This is not a sufficient indication of manifestation for use of Depakote . During a review of the facilities (MRR) dated 6/1/2025 and 6/9/2025, the MRR indicated that, .The resident has an order for Depakote for behaviors m/b dementia. This is not a sufficient indication or manifestation for the use of Depakote During a concurrent interview and record review on 6/27/25 at 3:13 p.m. with DON and ADON 1 of Resident 9's clinical record, ADON 1 confirmed the order and MRR was reviewed by the physician and facility clinical staff. ADON 1 further acknowledged the recommendation from the MRR for Resident 9's Depakote order manifested by Dementia and stated the order needed to have specific target behaviors. ADON 1 further stated the recommendation was missed due to Resident 9 being in the hospital. ADON 1 further stated when Resident 9 was out in the hospital, the orders were put on hold. ADON acknowledged that she missed this pharmacy recommendation to update the order with behaviors despite physician having reviewed it. During a review of facility policy and procedure (P&P) titled, Psychotropic Medication Use, dated October 2024, the P&P indicated, . The physician/Nurse Practitioner will identify, evaluate, and document, with input from other disciplines as needed, symptoms that may warrant the use of psychotropic medications .

Based on interview and record review, the facility failed to ensure accurate assessments were completed for two of 52 sampled residents (Resident 170 and Resident 176) when: 1. Resident 170's Minimum Data Set (MDS- a federally mandated resident assessment tool) did not indicate the correct number of pressure ulcer or pressure injury (PU or PI) present on admission; and, 2. Resident 176's MDS did not reflect the resident's status at the time of discharge from the facility. These failures increased the potential for Resident 170 not to receive consistent care and for Resident 176 not to receive referral for necessary services in the community. Findings: 1. A review of the admission Record indicated Resident 170 was admitted early part of June 2025 with diagnoses including rhabdomyolysis (breakdown of muscle tissue) and unstageable pressure ulcer (or pressure injury [PI], base of wound covered by a layer of dead tissue that may be yellow, brown or black and stage is unclear) of other site. A review of Resident 170's admission MDS dated [DATE] indicated Resident 170 had five (5) unstageable pressure ulcers and four (4) of these pressure ulcers were present on admission. In an interview on 6/25/25 at 11:54 a.m., the Treatment Nurse 1 (TN 1) stated Resident 170 was admitted with five (5) PI. The TN 1 further stated Resident 170 had no new PI since admission. In an interview on 6/26/25 at 9:16 a.m., the MDS Assistant Coordinator 1 (MDSA 1) stated when she did the admission Assessment for Resident 170, she did not verify the number of PI from the TN 1. A concurrent interview and record review was conducted on 6/26/25 at 9:23 a.m. with the MDS Coordinator (MDSC). The MDCS confirmed Resident 170's MDS assessment dated [DATE] did not indicate the correct number of PI present on admission. The MDSC stated all information in the MDS should be accurate for resident to receive consistent care. In an interview on 6/27/25 at 12:06 p.m., the Director of Nursing (DON) stated her expectation was for the licensed staff doing the assessments to be careful with entering information for the accuracy of MDS Assessments. A review of the facility's policy & procedure revised October 2024 and titled, Resident Assessments indicated, .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments . Assessments are completed by staff members who are knowledgeable about the resident's needs .Persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 2. A review of the admission Record indicated Resident 176 was admitted early May 2025 after hospitalization for hip surgery from a fall at home. Resident 176 was admitted for rehabilitation and physical therapy. The goal was to discharge home with Home Health Physical Therapy. Resident 176 was discharged home on 6/1/25. A review of Resident 176's closed record reflected, Nurse's Notes dated 6/1/25 that indicated, Discharge papers reviewed by nurse in charge and resident 176 nurse explained all medication and all discharge summary. Resident 176 agree and all discharge papers signed by resident. Left the facility with improved condition via wheelchair with Resident 176 family member .Discharge to home. Record review of resident 176's MDS section A dated 6/1/25 indicated, a discharge status of 04. Short Term General Hospital (acute hospital). In an interview and concurrent record review with MDSA 1 on 6/25/25 at 3:15 p.m., MDSA 1 reviewed Resident 176's records and confirmed the resident was discharged home on 6/1/25. MDSA 1 further reviewed Resident 176's MDS section 04 and confirmed it was an incorrect discharge status. MDSA 1 stated Resident 176 did not discharge to Acute Care facility. She also stated that inaccurate documentation can affect CMS (Centers for Medicare and Medicaid) documentation and data. A review of the facility's policy & procedure revised October 2024 and titled, Resident Assessments indicated, .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments . Assessments are completed by staff members who are knowledgeable about the resident's needs .Persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on interview, and record review, the facility failed to assess, monitor, intervene and report changes for 1 of 3 sampled residents' (Resident 1) for signs of impaired circulation. This failure to assess and monitor Resident 1 for signs of impaired circulation, led to a delay in the provision of physician services, a delay in treatment, and subsequent amputation of Resident 1's right lower leg. Findings: Resident 1 was a [AGE] year old male admitted to the facility in (MONTH) of (YEAR) with multiple medical problems including high blood pressure, diabetes (high sugar in the blood), and previous [MEDICAL CONDITION]. A review of the clinical record, Resident Progress Notes: (Resident 1), dated 10/5/16, indicated he was transferred to the hospital in (MONTH) of (YEAR), with what was described as ischemic (restriction of blood supply to tissues) appearing L (left) LOWER EXTREMITY. Resident 1 returned to the facility after 5 days, on 10/4/16, with .extensive [MEDICAL CONDITION] (blockage) . diagnosis. Further review of Resident 1's clinical record revealed a document titled Care Plan Snapshot dated 11/18/17. An entry dated 11/18/17 at 12:14 p.m. noted by licensed nurse (LN 2) indicated: Problem .Start date 11/18/17 .Ineffective tissue perfusion r/t (related to) possible interruption of venous flow AEB (as evidenced by) cold, painful, pale/blue, decreased pedal pulses, and cap refill (capillary blood flow) refill greater than 3 seconds to RLE (right lower extremity) .Interventions .Send to ER (emergency room ). There were no other care plans provided by the facility that addressed assessment and monitoring of Resident 1's history and risk of blood clots prior to 11/18/17 at 12:14 p.m During an interview with LN 1 on 1/19/18 at 6:40 a.m., she stated certified nurses (CNA) assist residents out of bed in the morning and help residents with transfers, hygiene and showers. She stated the CNA's let her know if they see anything different so I can go look at it. LN 1 stated she went into Resident 1's room [ROOM NUMBER] times on 11/18/17, 8:30 a.m., 10:00 a.m., and 12:00 p.m. She stated, Around 12:00 p.m. (I) went back into room because CNA 1 told me again it (Resident 1's lower extremity) looked different. He had a pulse, but it (the pulse) had faded. LN 1 stated she called the unit manager (LN 2) and LN 2 looked at it. At that point, the son was on the phone. No, we did not call him. During a phone interview with the son of Resident 1 on 1/19/18 at 3:56 p.m., he stated, I came in to visit, nobody called me, got there around 10:30-10:45 (a.m.). (I) walked in (my dad's) room. He was out of it. Nurse came in, (LN 1). I felt his leg, it was cold. I touched his leg, it was ice cold. This ain't right. She, (LN 1), said, I didn't know he had a blood clot (before). During an interview with the DON on 1/17/18 at 4:15 p.m., she stated her expectation of the nursing staff in response to a resident change of condition was to assess, communicate with the doctor, follow orders, and document in the clinical record. During a concurrent interview and record review or Resident 1's clinical record with the Director of Nursing (DON) on 4/5/18 at 10:20 a.m., the DON confirmed Resident 1's clinical record contained no documented evidence of licensed nursing assessments or physician notification on 11/18/17 prior to 12:14 p.m. During a phone interview with the facility administrator (ADM) on 4/5/18 at 11:10 a.m., he confirmed there was no nursing documentation in the clinical record of Resident 1 on 11/18/17 prior to 12:14 p.m. A review of Resident 1's clinical record, Resident Progress Notes: (Resident 1), dated 11/18/17 at 12:14 p.m., indicated the licensed nurse (LN 2) .contacted (hospital) on-call .(ambulance company) contacted .ED (emergency department) contacted and report given to (personal name) RN. A review of Resident 1's clinical record, Discharge & Transfer --Hospital Transfer Form, dated 11/18/17 at 12:20 p.m., indicated the form was completed by LN 2. During an interview with LN 1 on 3/14/18 at 12:30 p.m., when asked who gives report to the ambulance company when transferring someone to the hospital, stated, It is always a nurse. It could be me, it could be a charge nurse, it could never be a CNA. A review of Resident 1's clinical record, (ambulance company) Patient Care Report, dated 11/18/17, indicated, .STAFF SAID THEY NOTICED PT (patient) HAD A COLD, MOTTLED EXTREMITY AT ABOUT 0630. A review of Resident 1's clinical record, (hospital) Encounter-Level Documents, dated 11/18/17, indicated, Since 0630 (6:30 a.m.), (right) lower leg blue/cold. A review of Resident 1's clinical record, (hospital) Consult/H&P (history & physical), dated 11/18/17, indicated Resident 1's right leg .has been cold/blue since at least 0600 this morning. Ultrasound imaging (internal images of the arteries and veins) indicated Resident 1 had a blood clot in his right leg. Due to the extent of ischemia, above knee amputation (removal of a limb) /or palliative care (reduction in the discomfort of symptoms rather than a cure) were recommended. A review of Resident 1's clinical record, (hospital) Discharge Summaries - DISCHARGE SUMMARY, dated 11/21/17, documentation referred to Resident 1 by indicating, Vascular (blood supply) surgery evaluated him and rushed him to OR (operating room); where he underwent right above knee amputation. The facility policy and procedure titled Charting and Documentation revised (MONTH) 2008, indicated, 1. All observations .must be documented in the resident's clinical records .3. All incidents, accidents, or changes in the resident's condition must be recorded. The facility-provided document titled Job Description(:) Charge Nurse revised 3/1/14, indicated under Essential Job Functions the Licensed Vocational Nurse is to: Perform physical observations of new admissions and current residents as indicated by change in condition or as required by regulation .Based on observation of the resident's condition, develop or revise the plan of care with interventions and time measurable objectives to assist resident to attain or maintain highest practicable physical, mental, and psychosocial well being . Immediately .consult with the resident's physician .when .a significant change in the resident's physical, mental or psycho social status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility.