Every finding on record at Royal Vista Care Center

Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) call light (a bedside button or cord that a patient presses to ask nurses and staff for help) was not broken.This deficient practice has potential for delay in meeting Resident 1's need for assistance and can lead to frustration, falls and accidents.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic neurological disease that causes sudden, repeated and unprovoked seizures), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/10/2026, the MDS indicated the resident is severely impaired in cognitive (the ability to understand and make decision) skills for daily decision making. The MDS also indicated the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 8/27/2026 at 9:55AM, Resident 1's call light was observed to be broken with no button. Resident 1's roommate stated Resident 1's call light has been broken since Resident 1 was admitted to the facility on [DATE]. During a concurrent observation in Resident 1's room and interview on 8/27/2026 at 10:29AM, Assistant Director of Nursing (ADON) stated Resident 1's call light is broken and should not be broken because the resident would not be able to call for assistance when needed. The ADON also stated the call lights should be checked monthly for maintenance to ensure all call lights are working properly. During an interview with Maintenance Director (MTD) on 8/28/2026 at 10:18AM, MTD stated the call light system was not checked for 08/2026. During a review of the facility's Invoice for maintenance of call lights, dated 7/20/2026, the invoice indicated the last time the call lights were checked was on 7/14/2026. During a review of the facility's Policy and Procedure (P&P) titled Call Light, dated 1/2025, the P&P indicated the call lights log checks monthly to ensure good working conditions. The P&P also indicated when call light is not in working order, nursing reports directly to maintenance, notates the maintenance log and notifies Administrator, DON/ADON and alerts patients/families. During a review of the facility's P&P titled Call Light System Maintenance and Response, dated 3/2026, the P&P indicated the facility will maintain all call light systems in working order and respond promptly.

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's behavioral of grabbing things and swinging of arms during care for one (1) of two (2) sampled residents (Resident 1). This deficient practice has the potential to delay in the necessary care and services for Resident 1's behavior and leading to harm to self or others.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic neurological disease that causes sudden, repeated and unprovoked seizures), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/10/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decision) skills for daily decision making. The MDS also indicated the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During an interview on 8/27/2026 at 10:29AM, Assistant Director of Nursing (ADON) stated Resident 1 gets agitated where the resident will start grabbing (staff and objects) and swinging his arms during care. During an interview on 8/27/2026 at 10:56AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 is non-compliant with care and is combative during care. LVN 1 also stated Resident 1 would grab and swing his arms when facility staff is providing care. LVN 1 further stated Resident 1 always had that behavior since admission. During a concurrent interview and record review on 8/27/2026 at 11:17AM, Resident 1's Care Plans, dated 8/6/2026 to 8/27/2026, were reviewed. ADON stated there was no care plan created to address the resident's behavior of grabbing things and swinging his arms during care. ADON added the facility should have created and initiated a resident-centered care plan to address the resident's behavior of grabbing things and swinging his arms should during care. ADON also stated the interventions in the care plan should include what is triggering the resident's agitation that way the staff can try to avoid those triggers and monitor the resident. ADON further stated if a care plan is not done, Resident 1 can potentially injure himself or others. During a concurrent observation and interview on 8/27/2026 at 1:25PM, Certified Nursing Assistant 1 (CNA 1) was observed changing Resident 1. Resident 1 was observed grabbing the bed rails tightly and swinging his arms during care. Resident 1 was also observed trying to grab CNA 1's hands/arms. CNA 1 stated Resident 1 had that behavior since the resident was admitted at the facility. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plan, dated 2/2025, the P&P indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P also indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (relates to the interrelation of social factors and individual thought, behavior, and mental health) and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was provided with treatment and services in accordance with the professional standards of practice (the established rules, guidelines, and expectations that define the level of competence, ethical conduct, and quality required from individuals working within a specific field) by failing to:Check Resident 1 every 2 hours for brief (adult diaper) change as indicated in the facility's P&P titled Incontinent (being unable to voluntarily control your bladder or bowels, leading to accidental leaks of urine or stool) Care Protocols. Address a change of condition (COC - a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, of functional domains) on 8/22/2026 when Resident 1's left upper arm skin discoloration was observed. These deficient practices have the potential to result in a delay in the necessary care and services for Resident 1.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic neurological disease that causes sudden, repeated and unprovoked seizures), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Admission/readmission Data Collection, dated 8/6/2026, the admission notes indicated the resident required extensive assistance with bed mobility, transfer, eating and toilet use. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/10/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decision) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 8/27/2026 at 9:55AM in Resident 1's room, Resident 1 was observed sleeping in bed. Resident 1's roommate stated, Resident 1 was changed and cleaned by the facility staff around 8am. During an observation on 8/27/2026 from 9:55 AM to 1:24 PM, Resident 1 brief was not checked/changed. During a concurrent observation and interview on 8/27/2026 at 1:25 PM, Certified Nursing Assistant 1 (CNA 1) was observed changing Resident 1's brief. CNA 1 stated Resident 1's brief was full of urine and Resident 1 urinates a lot. CNA 1 also stated the last time Resident 1 was changed was around 8 AM that morning. CNA 1 further stated the resident should be changed at least every 2 hours or as needed when soaked or soiled to prevent skin breakdown. During an interview on 8/27/2026 at 3 PM, Assistant Director of Nursing (ADON) stated residents should be checked if brief needs to be changed every 2 hours to prevent skin breakdown. During a review of the facility's P&P titled Incontinent Care Protocols, dated 1/2025, the P&P indicated a change of incontinent should be changed every 2 hours. 2. During a review of Resident 1's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review, dated 8/24/2026, the skin monitoring indicated Resident 1 has bruising on the left upper arm. During an interview on 8/27/2026 at 12:55 PM, CNA 1 stated Resident 1 has a bruise on the resident's left upper arm. Left arm was observed with purple center and yellow outer skin discoloration measuring 1.5inch x 1inch. During an interview on 8/27/2026 at 2:50 PM, CNA 1 stated, CNA 1 observed the bruise on Resident 1's left upper arm on 8/22/2026 during her 7 AM to 3 PM shift (unable to recall what time). CNA 1 also stated she did not report the skin discoloration to the licensed nurse and did not document it in Resident 1's Skin Monitoring: Comprehensive CNA Shower Review on 8/22/2026 (Saturday) because it was not Resident 1's shower day. CNA further stated on Monday 8/24/2026, the skin discoloration was reported in Resident 1's Skin Monitoring: Comprehensive CNA Shower Review sheet because it was Resident 1's shower day. During an interview on 8/27/2026 at 3 PM, ADON stated Resident 1's bruise should be investigated to find the root cause of the bruise, and it was not assessed, monitored and the doctor was not informed. During an interview on 8/27/2026 at 3:20 PM, Resident 1's Electronic Medical Record dated from 8/22/2026 to 8/27/2026, was reviewed. ADON stated there was no documented evidence about Resident 1's bruise on left arm noted on 8/22/2026 and that licensed nurse or Resident 1's physician was made aware of the COC. ADON also stated there is no 72-hour monitor for Resident 1's bruise noted on 8/22/2026 and on 8/24/2026. In addition, ADON stated, there was no care plan initiated to address Resident 1's bruise on left arm. During the same interview on 8/27/2026 at 3:20 PM, ADON stated Resident 1's bruise is considered a COC. ADON also stated CNA 1 should have reported Resident 1's bruise on 8/22/2026 and not wait until shower day on 8/24/2026 to the licensed nurse, so the bruise can be monitored and addressed. During a review of the facility's P&P titled Change of Condition, revised 2/2025, the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, and/or changes in the resident's physical/emotional/mental condition.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was given an initial fall risk assessment upon admission and to initiate a care plan after the resident had an actual fall while in the facility on 8/27/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to cause falls and/or injury to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic neurological disease that causes sudden, repeated and unprovoked seizures), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Admission/readmission Data Collection, dated 8/6/2026, the admission notes indicated resident was status post fall and required extensive assistance with bed mobility, transfer, eating and toilet use. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/10/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decision) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated the resident had a fall in the last month prior to admission, and the resident sustained a fracture related to a fall in the six (6) months prior to admission. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/27/2026 at 9:03AM, the SBAR indicated Resident 1 had an unwitnessed fall and abrasion (a scrape or the process of wearing something away by friction) was noted on the resident's back. During concurrent interview and record review on 8/27/2026 at 11:27AM, Resident 1's Medical Records dated from 8/6/2026 to 8/27/2026 were reviewed. Assistant Director of Nursing (ADON) stated Resident 1's medical records did not have documented evidence Resident 1 had a initial fall assessment done upon admission. \ The ADON further stated the fall risk assessment is to let the staff know if Resident 1 is at risk for falls or not. In addition, the ADON also stated if Resident 1 was at risk for falls, according to the fall risk assessment, a care plan with interventions would be implemented to address the risk of falls. During the same interview on 8/27/2026 at 11:27AM, Resident 1's Care Plans, dated 8/6/2026 to 8/27/2026, were reviewed. The ADON stated there are no Care Plans for Resident 1's risk for falls nor is there a care plan for the actual fall on 8/27/2026. During a review of the facility's P&P titled Fall, dated 1/27/2025, the P&P indicated the assessment data shall be used to identify underlying medical conditions that may increase the risk of falls. The P&P also indicated upon admission, the nursing staff and the physician will review a resident's record for a history of falls. The P&P further indicated that the staff and physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During a review of the facility's P&P titled Managing Falls and Fall Risk, dated 1/27/2025, the P&P indicated the staff with input of the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with history of falls. During a review of the facility's P&P titled Assessing Falls and Their Causes, dated 1/27/2025, the P&P indicated residents must be assessed upon admission and regularly afterward for potential risk of falls and relevant risk factors must be addressed promptly.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for three (3) of three sampled residents (Residents 1, 2 and 3) were followed in accordance with the facility's policy and procedure when:1. The facility staff failed to disinfect the shower chair used by Resident 1 before placing the shower chair back in the shower room for the next resident's use. 2. The facility staff used wet wipes meant for hygienic purposes to clean the shower chair used by Resident 2 instead of the Environmental Protection Agency (EPA, an independent federal agency tasked with protecting human health and the natural environment) approved disinfectant wipes.3. The facility staff used shampoo and water to clean the shower chair used by Resident 3 instead of an EPA approved disinfectant. These deficient practices had the potential to spread infection to all residents who utilize the shower chairs in the facility. Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in muscle mass, often due to an extended period of immobility) During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) on eating, shower, putting/taking off footwear, oral, toileting and personal hygiene and upper and lower body dressing. During an observation on 7/16/2026 at 8:30 AM, Certified Nursing Assistant 1 (CNA 1) was observed transporting Resident 1 to the shower room while the resident was seated on a shower chair. During an observation on 7/16/2026 at 8:46 AM, Resident 1 was observed being transported by CNA 1 back to the resident's room with the shower chair parked in the room. During an observation on 7/16/2026 at 9:07 AM, CNA 2 brought the shower chair back to the shower room without disinfecting it. During an interview on 7/16/2026 at 10:47 AM CNA 2 stated she should have disinfected the shower chair used by Resident 1 to prevent bacteria transferring from the resident to other residents. CNA 2 also stated shower chairs should be disinfected before and after residents' use. During an interview on 7/16/2026 at 11:08 AM, CNA 1 stated he did not disinfect the shower chair used by Resident 1. CNA 1 also stated the shower chair should be disinfected to prevent spread of any infection to other residents and to keep them clean and ready for use by another resident. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (a condition caused by brain injury that results in a varying degree of weakness, stiffness, and a lack of control in one side of the body) and ataxia (loss of muscle control). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS also indicated Resident 2 was dependent on toileting hygiene and shower and required substantial/maximal assistance (helper does more than half the effort) with putting on/taking off footwear. The MDS further indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with lower body dressing and required supervision (helper provides cues) with eating, oral and personal hygiene and upper body dressing. During an observation on 7/16/2026 at 9:22 AM, CNA 3 was observed coming out of the shower room with Resident 2 sitting on a shower chair. During an observation on 7/16/2026 at 9:28 AM, CNA 3 parked the shower chair used by Resident 2 outside Room A, entered Room A and came out with white wipes then proceeded to clean the shower chair with the white wipes. During a concurrent observation and interview on 7/16/2026 at 9:33 AM, CNA 3 brought the wipes container CNA 3 used to clean the used shower chair from Room A and then brought the shower chair to the women's shower room to park. CNA 3 brought out the wipes used to clean the used shower chair, and the wipes container did not indicate it was for disinfecting surfaces. CNA 3 stated she always uses those wipes used to clean the residents during perineal care (washing and cleaning private parts) when cleaning the shower chairs after use. CNA 3 also stated she should have used the EPA approved disinfectant wipes to remove any germs in the shower chair instead of the wet wipes for perineal care use. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, lack of coordination, and difficulty walking. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 3 was dependent on shower and required substantial/maximal assistance with toileting, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 3 required partial/moderate assistance with oral and personal hygiene and required supervision with eating. During an observation on 7/16/2026 at 9:54 AM, CNA 4 was seen with Resident 3 was seen bringing Resident 3 back to the resident's room from having a shower and seated on a shower chair with a mesh back rest. During a concurrent observation and interview on 7/16/2026 at 10:10 AM, CNA 4 was seen transporting the shower chair back to the shower room and saw CNA 4 rinse the shower chair with water inside the shower area. CNA stated she washed the used shower chair with shampoo and rinsed with hot water after. CNA 4 also stated the shower chairs should be disinfected with EPA disinfecting wipes before and after use to prevent spreading any type of skin infection to other residents. During an interview on 7/16/2026 at 12:08 PM, Infection Prevention Nurse (IPN) stated the staff should be cleaning and disinfecting the shower chairs before and after each resident use to prevent spread of bacteria from one resident to another. IPN further stated washing the shower chair with shampoo and hot water and wiping them with the wet wipes used to clean residents was not acceptable because it would not kill some of the bacteria on the surface of the shower chairs instead the staff should be disinfecting the shower chairs with EPA approved disinfectants. During an interview on 7/16/2026 at 12:25 PM, the Director of Nursing (DON) stated the staff should be disinfecting the shower chairs between each use to prevent infection because one resident can have bacteria and germs that could transfer to another resident. The DON also stated cleaning the shower chairs with shampoo and hot water was not enough because hot water might kill certain bacteria's but not others. The DON further stated using wet wipes to clean shower chairs does not have the ingredients that could kill bacteria from the surface of the shower chair instead disinfectant wipes should still be used. During a review of the facility's Policy and Procedure (P&P) titled, Resident Equipment Maintenance/Sanitary, dated 7/2025, the P&P indicated the facility was to ensure all equipment in the facility premises is kept clean. The P&P also indicated its purpose was to ensure all residents care equipment is safe and sanitary to protect the health and well-being of residents, staff and visitors. The P&P applies to all facility equipment used for resident care which included Hoyer lifts and shower chairs. During a review of the facility's Policy and Procedure (P&P) titled, Infection Control Policy: Porous Surfaces, dated 5/2025, the P&P indicated that the facility establishes infection prevention and control standards for cleaning, management of porous (a material or surface that has microscopic holes or spaces that allow liquids, air, or cells to pass through) and non-porous (a material that has no tiny holes or cracks, preventing liquids, air, or bacteria from absorbing into it) surfaces to reduce the risk of healthcare associated infections (HAI's, an infection a person gets while receiving medical treatment for a different issue) in accordance to California Title 22 and Centers for Disease Control (CDC, a major agency in the United States federal government dedicated to protecting public health and safety to detect, prevent, and respond to health threats, and injuries, providing data and guidance to communities worldwide) infection control guidance.

Based on observation, interview, and record review, the facility failed to develop a resident centered fall care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 4), who had a prior incidents of seizure activity. This deficient practice had the potential to result in physical injuries to Resident 4 from the facility's inability to recognize unique personal triggers or warning signs to provide environmental safety protocols specific to the resident's diagnosis of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 5/7/2021 and was readmitted to the facility on [DATE] with diagnoses that included lack of coordination, difficulty walking and epilepsy (seizure disorder). During a review of Resident 4's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 5/8/2026 at 5;30 PM, the SBAR indicated Resident 4 was found by Certified Nursing Assistant 5 (CNA 5) hunched over in a sitting position inside the restroom with vomit. The SBAR further indicated Resident 4 was transferred to the resident's bed where seizure activity continued for over six (6) minutes at which time, 911 (a universal emergency number) was called. During a review of Resident 4's Minimum Data Set (MDS, resident assessment tool), dated 5/18/2026, the MDS indicated Resident 4 had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 4 was dependent (helper does all the effort) on toileting hygiene and required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and upper body dressing and required supervision (helper provides cues) with eating. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 7/16/2026 at 3:33 PM, Resident 4 was seated on the wheelchair beside her bed with both unpadded bed rails (attached to the sides of a bed to help prevent a person from falling out and to assist with repositioning or getting in and out of bed) up. The ADON stated Resident 4 had a seizure incident in the bathroom this year on 5/8/2026 and was hospitalized . During a concurrent interview and record review on 7/16/2026 at 4 PM, Resident 4's Care Plan was reviewed with ADON. ADON stated Resident 4's care plan was not resident specific because it should have included interventions to prevent injuries during a seizure activity such as padded bed rails. During an interview on 7/17/2026 at 10:09 AM, the Director of Nursing (DON) stated Resident 4's Care Plan was not resident specific because it did not include interventions to prevent injuries during unwitnessed seizures which included use of padded bed rails, keeping the bed in low position and use of floor mats. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised February 2025, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, interview and record review on 5/7/2026 the facility failed to report an alleged abuse to the State Agency (SA) within two (2) hours after Resident reported an alleged abuse to the facility, for one of two sampled residents (Resident 1).This deficient practice led to delay of investigation and potentially put Resident 1 and other residents in the facility for ongoing and other abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and spinal stenosis (a narrowing of the spaces within your spine, which puts pressure on your spinal cord and nerve roots).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/24/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on taking off footwear and personal hygiene.During a concurrent observation and interview on 5/13/2026 at 10:10AM, Resident 1 was observed in his wheelchair and stated he was verbally abused on 5/7/2026. Resident 1 also stated Director of Staff Development (DSD) called him a Pinche Chimoso (fuckin noisy).During an interview on 5/13/2026 at 10:34AM, Restorative Nursing Assistant 1 (RNA 1) stated on 5/7/2026 at 2:50pm, Resident 1 told him the DSD called him Pinche Chimoso. RNA 1 also stated he did not report it because Resident 1 will report it.During an interview on 5/13/2026 at 1:25PM, Assistant Director of Nursing (ADON) stated if someone said Pinche Chimoso to a resident, the facility staff would need to report it because that is verbal abuse and would need to be reported within 2 hours, but it was not reported. During the same interview on 5/13/2026 at 1:25PM, the Policy and Procedure (P&P) titled Policy and Procedure for Prevention, Identification, and Reporting of Resident Abuse, revised 7/2025, was reviewed. ADON stated reporting of abuse should be within 2 hours.During an interview on 5/13/2026 at 3:10PM, Certified Nursing Assistant 3 (CNA 3) stated on 5/7/2026 at 2:15PM, DSD said Pinche Chimoso when she was walking by with Resident 1. CNA 3 also stated she did not report it until the next day.During an interview on 5/13/2026 at 3:30PM, Administrator stated the incident was reported on 5/8/2026.During a review of the facility's P&P titled Policy and Procedure for Prevention, Identification, and Reporting of Resident Abuse, revised 7/2025, the P&P indicated all staff are mandated reports and are required to immediately report any suspected or known instances of abuse. The facility's P&P indicated reporting suspected or known abuse: immediate actions (within 2 hours) and written report for all situation within 2 hours of all situation. The P&P also indicated abuse includes but not limited to verbal abuse.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of three (3) sampled residents (Residents 1 and 3) with suspected (believed to have due to signs and symptoms and/ or exposure to confirmed) and confirmed (a doctor had officially identified) cases of scabies (is a highly contagious skin infestation caused by tiny, burrowing mites) in accordance with the facility's policy and procedure by failing to:1. Perform contact tracing (method used to slow the spread of infectious diseases by identifying, notifying, and advising people who have been exposed to an infected person) on caregivers, and staff with direct contact with Resident 1 for six (6) weeks before 4/8/2026 and with Residents 3 within for 6 weeks before 3/6/2026. 2. Perform surveillance monitoring (an ongoing systematic tracking of infections to detect, stop, and prevent the spread of the disease) and screening of all residents and staff (unknown number of staff) with direct contact with Residents 1 and 3 for new signs of scabies mites' infestation (severe large-scale invasion of pests) within 6 weeks after the last suspected case on 4/8/2026. 3. Provide treatment for scabies on Resident 3 as soon the facility was made aware of Reisdent 3's scabies diagnosis. No treatment done from 3/7/2026 to 3/15/2026 (total of 9 days).4. Placed Resident 3 on contact isolation precautions (infection-control measures designed to prevent the spread of harmful germs transmitted by direct skin-to-skin contact or indirect contact with a patient's contaminated environment) from 3/6/2026 to 3/16/2026. These deficient practices had the potential to spread scabies infestation to residents, staff, and visitors in the facility. Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included lack of coordination, difficulty in walking and metabolic encephalopathy (a brain disease, disorder, or damage that affects brain function). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/13/2026, the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, hygiene and shower. It also indicated the resident required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 1's Dermatology (the branch of medicine focused on the health of the skin, hair, and nails) report dated 4/8/2026, the dermatology report indicated a diagnosis of suspected scabies at the resident's neck, trunk, back, and extremities. During a concurrent interview and record review on 4/28/2026 at 1:56 PM, Resident 1's Nurse' Progress Notes dated 4/8/2026 at 9:52 AM was reviewed. Wound Care Treatment Nurse 1 (TN 1) stated Resident 1's nurses progress notes indicated that Resident 1 was sent to the resident's dermatology appointment using the facility van accompanied by a CNA. TN 1 also stated Resident 1 returned to the facility from the dermatology appointment with a diagnosis of suspected scabies on the resident's neck, trunk, back, and extremities. 2. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included severe protein calorie malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 3's biopsy (a medical procedure that remove a small sample of tissue, cells, or fluid from the body to be examined under a microscope by a pathologist) report with a biopsy date of 2/27/2026 and a report date of 3/6/2026, the biopsy report on left upper chest skin site indicated a diagnosis of Arthropod assault reaction (an inflammatory skin reaction caused by bug bites or stings, such as from insects, spiders, ticks, or mites). The biopsy results also indicated Sarcoptes scabiei body parts (microscopic, eight-legged itch mites and their remains like legs, eggs, or poop have been found) are present in the stratum corneum (outer layer of the skin). During a review of Resident 3's nurses progress notes dated 3/6/2026 at 10:24 AM, the nurses progress notes indicated the staff was told by the dermatologist office that Resident 3's skin biopsy result was scabies. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS also indicated Resident 3 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on and taking off footwear. The MDS also stated Resident 3 required substantial/maximal assistance with oral and personal hygiene, and upper body dressing. During a concurrent observation and interview on 4/28/2026 at 2:32 PM, Resident 3 was in her room sitting on the wheelchair with Family 1 (FAM 1). FAM 1 stated Resident 3 went to see a dermatologist due to the rashes on the resident's body somewhere around late February or early March 2026 with the use of transport van. FAM 1 also stated he was notified by facility staff (unable to recall who) first week of March 2026 of the resident's scabies diagnosis. During a concurrent interview and record review on 4/28/2026 at 3 PM, Resident 3's skin biopsy report with a biopsy date of 2/27/2026 and report date of 3/5/2026was reviewed. Infection Prevention Nurse (IPN) stated Resident 3's medical records indicated the resident had confirmed scabies diagnosis based on the left upper chest skin biopsy on 3/6/2026 but the IP was not notified by the licensed staff who received the result from the dermatologist office. IPN also stated if she (IPN) only found out Resident 3 had a positive scabies result from an RN last 3/6/2026, IPN could have started the contact tracing and surveillance. IPN added, Resident 3 did not receive the Permethrin 5% external cream (used to treat scabies by causing paralysis and death in parasites) from 3/6/2026 until 3/15/2026. During the same concurrent interview and record review on 4/28/2026 at 3 PM with IPN, Resident 3's Physicians order dated 3/6/2026 to 3/16/2026 were reviewed. The physicians order did not indicate to place resident on contact isolation from 3/6/2026 to 3/16/2026. It also indicated to place the resident on contact isolation on 3/17/2026. IPN stated Resident 3 was not placed on contact precaution from 3/6/2026 until 3/16/2026. During a concurrent interview and record review with Registered Nurse 1 (RN 1) RN 1 on 4/28/2026 at 4:25 PM, the facility's Policy and Procedure titled, Scabies Prevention and Control, dated 3/2026 was reviewed. The P&P indicated contact tracing should be done 6 weeks from the confirmed case or suspected case, screening of staff for symptoms, and surveillance monitoring within 6 weeks after the last suspected or confirmed case of scabies. RN 1 stated surveillance, screening and monitoring of residents should have been done 6 weeks after the last suspected or confirmed case of scabies which was 4/8/2026. RN 1 also stated staff that had direct contact with both suspected and confirmed cases of scabies contact tracing should have been done for Resident 1 for six (6) weeks before 4/8/2026 and with Residents 3 within for 6 weeks before 3/6/2026 for the safety of the residents and staff and as a precautionary measure. RN 1 also stated facility's Policy and Procedure (P&P) on scabies prevention and control was not followed for Residents 1 and 3. During a concurrent interview and record review with the IPN on 4/28/2026 at 4:35 PM, the facility's P&P titled, Scabies Prevention and Control, dated 3/2026 was reviewed. The IPN stated she did not perform contact tracing, surveillance, and staff management as indicated in the facility's policy on scabies prevention and control for Resident 1 and 3. The IPN also stated she should have done 6 weeks 'of surveillance monitoring after the last case of scabies which was on 4/8/2026 and maintain a line list to see if the cases (suspected or confirmed) were going down and no additional residents or staff were being affected. IPN further stated contact tracing should be done to control transmission of scabies among residents, staff and visitors and to prevent outbreaks (sudden rise in the number of cases of a disease in a specific are, exceeding what is usually expected) from 6 weeks from when the suspected or confirmed case was known. IPN was unable to provide documentation of any surveillance, line list, screening of staff for symptoms, and contact tracing for Residents 1 and 2 based on the facility's policy. During an interview on 4/28/2026 at 4:48 PM, CNA 2 stated she took care of Resident 3 on 3/10/2026 and 3/11/2026 and was not notified by any of the licensed staff including IPN of the resident's scabies diagnosis. During an interview on 4/28/2026 at 4:52 PM, CNA 3 stated she had taken care of Resident 3 and helped CNA 2 provide care to Resident 3. CNA 3 also stated she was not informed by the IPN to monitor herself for any symptoms of scabies. During a review of the facility's Policy and Procedure (P&P) titled, Scabies Prevention and Control Policy, dated 3/2026, indicated its purpose was to prevent, identify, and control transmission of scabies among residents, staff, and visitors in accordance with California Department of Public Health (CDPH), Los Angeles County Department of Public Health (LACDPH), and Centers for Disease Control (CDC, a major agency in the United States federal government dedicated to protecting public health and safety to detect, prevent, and respond to health threats, and injuries, providing data and guidance to communities worldwide). The policy also indicated that the facility shall promptly identify, isolate, and treat suspected or confirmed scabies cases, prevent outbreaks, and report as required. The P&P further indicated that the facility would do the following including:1. Contact Tracing to include roommates, caregivers, and staff with direct contact within six (6) weeks. 2. Staff management which included screening staff for symptoms.3. Surveillance monitoring for 6 weeks after the last case and maintain line lists. During a review of the CDC's Public Health Strategies for Scabies Outbreaks in Institutional Settings, dated 12/18/2025, the strategies indicated suggestions for preventing, detecting, and responding to single or multiple cases of non-crusted scabies in an institution.1. Prevention- Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review to facilitate early identification of and response to potential outbreaks.2. Surveillance - establish surveillance. Have an active program for early detection of infested patients/residents and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings. Screen all new patients/residents and staff for scabies.3. Control & Treatment - establish appropriate procedures for infection control and treatment. Maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident. Use epidemiological data about the distribution of confirmed cases by building, room, floor, wing, occupation (for staff), dates of admission, and onset of scabies-like condition to determine levels of risk for patients/residents and staff. Identify and treat all people (e.g., staff, relatives, patients/residents) having prolonged, direct skin-to-skin contact with an infected person before they were treated.https://www.cdc.gov/scabies/php/public-health-strategy/

Based on observation, interview, and review, the facility failed to label and store drugs in locked compartments as indicated in the facility's Policy and Procedure (P&P) by failing to ensure: One unopened insulin (a hormone that works by lowering levels of sugar in the blood) pen was stored inside the refrigerator instead of inside Medication Cart 1 (MC 1) per manufacturer's guidelines. This deficient practice had the potential for loss of efficacy of the insulin medication. 2. One opened Ipratropium-Albuterol Solution (a medication that treats shortness of breath by opening the air passages in the lungs) foil packet, with an open date of 2/1/2026 and expired 7 days after opening, was removed from MC 1 as indicated in the facility's policy and procedure (P&P). 3. One opened Ipratropium-Albuterol Solution foil packet, which expires 7 days after opening, was labeled with the opened date and was removed from MC 1 as indicated in the facility's P&P. 4. One opened Albuterol Sulfate inhalation solution (medication used to treat shortness of breath) foil packet, with an opened date of 1/27/2026, which expired two weeks after opening, was removed from MC 1 as indicated in the facility's P&P. These deficient practices had the potential for loss of efficacy of the medications and unintentional medication administration of expired medications, which could potentially cause harm to the residents. 5. Expired syringes, needles and alcohol prepping pads were kept inside the medication storage room.This deficient practice had the potential for residents to have an adverse reaction in the event that the expired syringes, needles and alcohol prepping pads were used for the residents.Findings: 1. During the concurrent medication inspection and interview on 2/12/2026, at 11:38 AM, of MC 1, with Licensed Vocational Nurse 5 (LVN 5), one unopened Humalog insulin pen was observed in the top left drawer of MC 1. The insulin pen was placed in an individual clear plastic bag with a blue sticker that indicated, Refrigerate Until Opened. LVN 5 stated the insulin pen label indicated a sent date of 2/11/2026 and was most likely delivered by the pharmacy late in the evening of 2/11/2026 or early morning on 2/12/2026. LVN 5 stated the insulin pen was new and unused and should have been refrigerated after it was delivered. LVN 5 stated unused insulin can become ineffective which could cause the residents' blood sugar level to remain high or out of range if it is not stored in the refrigerator. to 4. During the same concurrent medication inspection and interview on 2/12/2026, at 12:09 PM, of MC 1, with LVN 5, the following medications were observed in the bottom right drawer of MC 1: One box of Ipratropium-Albuterol solution which contained an open foil packet with four plastic ampules of Ipratropium-Albuterol solution inside. The foil packet had a yellow date opened sticker on the back which was dated 2/1/2026. The label on the Ipratropium-Albuterol Solution box indicated an expiration date of 7 days after the open date. One box of Ipratropium-Albuterol solution that contained an open foil packet with four plastic ampules of Ipratropium-Albuterol solution inside. The foil packet had a yellow date opened sticker on the back which was not dated. One box of Albuterol Sulfate solution which contained an open foil packet of four plastic ampules of Albuterol Sulfate solution inside. The foil packet had a white date opened sticker on the back which was dated 1/27/2026. The label on the Albuterol Sulfate box indicated an expiration date of 2 weeks after the foil was opened. LVN 5 stated the Albuterol Sulfate foil packet with an opened date of 1/27/2026 expired and should have been discarded on 2/9/2026. LVN 5 stated the Ipratropium-Albuterol foil packet with an opened date of 2/1/2026 expired and should have been discarded on 2/8/2026. LVN 5 stated expired medications should not be stored in the medication cart and should be discarded in the medication storage room. LVN 5 stated it was important to date the foil packets with the opened date so facility staff know when the ampules will expire. LVN 5 stated the Ipratropium and Albuterol medications were ordered as needed for shortness of breath and could be ineffective and cause an undesired effect on the residents who are experiencing symptoms. LVN 5 stated medications carts were checked every shift by the licensed nurse assigned to the medication cart. LVN 5 stated it was the responsibility of the licensed nurses assigned to give medications to check and make sure the medications in the medication carts were not expired and were labeled with the opened dates. During an interview, on 2/12/2026, at 4:23 PM, with the Assistant Director of Nursing (ADON), the ADON stated new and unused insulin should always be stored in the refrigerator. The ADON stated it was the responsibility of the licensed staff receiving the insulin to place the insulin in the refrigerator. The ADON stated expired medications should immediately be discarded and not kept in the medication carts. The ADON stated administering expired medications could affect the efficacy of the medications and will not be effective. The ADON stated it was important to date the medications once they are opened and to follow the expiration dates on the medication boxes. During a review of the facility's P&P titled, Administering Medications, revised 9/2025, the P&P indicated, When opening a multi-dose container, the date opened is recorded on the container. During a review of the facility's P&P, titled, Medication Storage/Labeling, dated 7/2025, the P&P indicated the following: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The medication label includes, at a minimum: expiration date, when applicable and appropriate instructions and precautions. During a review of the facility's P&P, titled, Insulin Management and Administration, dated 7/2025, the policy indicated, Unopened insulin shall be refrigerated between 36 Fahrenheit (F- unit of measurement for temperature) and 46 F. 2. During a concurrent observation and interview on 2/12/2026 at 11:55 AM with the Assistant Director of Nursing (ADON) in the Medication Storage Room, one opened 3 milliliter (ML, measure of volume) syringe with capped needle was found in a box of sealed syringes. ADON stated this is not safe to have an opened syringe, because the staff can get injured. During a concurrent observation and interview on 2/12/2026 at 12:02 PM with ADON in the Medication Storage Room, there were 33 safety needles found with expiration date of 12/20/2025. ADON stated the syringes were expired for two (2) months. The needles might be dull or can cause possible reactions to the residents. Sterility was questionable because it was beyond expiration date. During a concurrent observation and interview on 2/12/2026 at 12:15 PM with ADON in the Medication Storage Room, one bag of alcohol prepping pads (10 pieces) was found with expiration date of 10/2023. ADON stated the alcohol pads will not be effective anymore, it will not be able to clean the injection site because they were expired. During a concurrent observation and interview on 2/12/2026 at 12:20 PM with ADON in the Medication Storage Room, there were 5-gallon size bags of expired needles and syringes with expiration dates of 7/31/2025 and 6/28/2025. ADON stated the staff were supposed to be cleaning the medication storage room and also should be checking the expiration dates before using the supply. Using expired supplies can possibly injure the residents or can cause infection because the staff does not know if they were still good to use. During a review of facility's P&P titled, Medication Storage/ Labeling, dated 7/2025, the P&P indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Medication Storage 2.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview, and record review, the facility failed to ensure three (3) of five sampled residents (Resident 7, 2 and 68) reviewed for unnecessary (any drug when used without adequate monitoring, and without adequate indication for use) psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were free from unnecessary psychotropic drugs as indicated in the facility's policy and procedure by failing to:1.Monitor and document the specific target behaviors of striking out and grabbing staff for the use of olanzapine (Zyprexa- an antipsychotic medication used to treat schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions) and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for Resident 7.This deficient practice had the potential to result in inaccurate evaluation in the effectiveness and/or ineffectiveness of the Resident 7's olanzapine medication and adjust the medication as necessary. 2. Ensure the specific number of Resident 2's bipolar disorder episodes manifested by changes in mood from happy to anger were monitored and documented in the resident's Medication Administration Record (MAR- is a report detailing the drugs administered to a resident by a healthcare professional at a treatment facility) for the use of Divalproex (also known as Depakote, a prescription medication used to treat manic episodes [a period of abnormally elevated, extreme changes in mood, behavior, activity and energy level] associated with bipolar disorder) ), as indicated in the physician's order.This deficient practice resulted in inadequate monitoring of Resident 2's mood changing episodes with the potential to result in inaccurate evaluations in the effectiveness of Resident 2's Divalproex and the risk of receiving an unnecessary medication.3.Ensure Resident 68's specific behavior was monitored for the use of quetiapine fumarate (Seroquel, antipsychotic medication that treats several kinds of mental health conditions including schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder) were documented on the MAR.This deficient practice had the potential to result to have inaccurate re-evaluation of Resident 68's need for psychotropic medications, which may lead to an overall negative impact on the resident's physical, mental, and psychosocial well-being.Findings: 1.During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included lobar pneumonia (a severe bacterial infection and inflammation of one or more lobes of the lung) , depression (a serious, common illness characterized by a persistent, intense, and long-lasting low mood, loss of interest in activities, and decreased energy), and dementia (a brain disorder that results in memory loss, poor judgment and confusion). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 7 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 7 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, putting on/taking off footwear, roll left and right, and sit to lying. The MDS indicated Resident 7 was dependent (helper does all of the effort) with eating, oral/toileting hygiene, shower/bathe self, sit to stand, and toilet transfer. During a review of Resident 7's Order Summary Report, dated 2/12/2026, the Order Summary Report indicated a physician order, with a start date of 12/29/2025, for the following: Zyprexa oral tablet 2.5 milligrams (mg- unit of measurement) give 1 tablet by mouth at bedtime for psychosis (a mental state characterized by a loss of contact with reality often involving seeing or hearing things and false beliefs) manifested by (m/b) striking out and grabbing staff. Monitor behavior episodes of striking out and grabbing staff and tally with hashmarks for each episode on the MAR every shift. During a review of Resident 7's Care Plan, dated 12/29/2025, the care plan indicated Resident 7 had periods of striking out or grabbing staff. The care plan indicated an intervention to monitor and record episodes of behavior per facility policy/protocol. During an interview on 2/11/2026, at 9:29 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7 had a history of aggressive behavior towards staff. CNA 1 stated Resident 7 would scratch, spit, and hit the CNAs who assisted the resident with dressing and diaper change. CNA 1 stated she informed the Licensed Vocational Nurses (LVN) each time Resident 7 demonstrated aggressive behavior but was not sure if it was documented in Resident 7's records. CNA 1 stated she did not know that Resident 7 was being monitored for the resident's aggressive behavior. During an interview on 2/11/2026, at 12:35 PM, with Director of Social Services (DSS 1), DSS 1 stated Resident 7 only demonstrated aggressive behavior towards the staff at night. DSS 1 stated Resident 7's behavior of hitting staff should be monitored and documented in Resident 7's electronic or physical medical records. During an interview on 2/11/2026, at 12:47 PM, with LVN 1, LVN 1 stated Resident 7's mood varied from day to day. LVN 1 stated Resident 7 had days where the resident was aggressive and tried to bite, hit, or scratch staff and days where the resident was calm. LVN 1 stated Resident 7 has the aggressive behavior towards staff at least once a week. LVN 1 stated CNAs also informed LVN 1 each time Resident 7 had an episode of aggressive behavior. LVN 1 also stated Resident 7 had an order to monitor the resident's behavior or hitting and grabbing staff. LVN 1 stated, he has not documented Resident 7's aggressive behavior towards staff in the resident's MAR as ordered because LVN 1 forgets. LVN 1 stated it was important to monitor and document Resident 7's aggressive behavior towards staff because it was used by the physician to determine the need to continue, stop, or change Resident 7's Zyprexa medication. During a concurrent interview and record review on 2/11/2026, at 3:26 PM, with the Assistant Director of Nursing (ADON), Resident 7's MAR from 1/1/2026 to 1/31/2026 and 2/1/2026 to 2/28/2026 was reviewed. The ADON stated Resident 7 was ordered for Zyprexa due to the resident's behavior of striking out and grabbing staff. The ADON stated Resident 7's had an order to monitor Resident 7's behavior of striking out and grabbing staff and Resident 7's MAR from 1/1/2026 to 1/31/2026 and 2/1/2026 to 2/28/2026 did not indicate Resident 7 had any aggressive behavior towards staff. ADON stated LVN 1 and the licensed nurse assigned to Resident 7 should have documented the aggressive behavior that LVN 1 witnessed and CNAs report of aggressive behavior in Resident 7's MAR. ADON also stated it was important to monitor Resident 7's behavior to see if the Zyprexa was effective or needed to be discontinued. ADON stated not monitoring and documenting Resident 7's behavior could cause Resident 7's physician to discontinue or incorrectly adjust the resident's Zyprexa dose even if Resident 7 still had episodes of aggressive behavior. ADON stated Resident 7's care plan for her behavior of striking out or grabbing staff was not followed. During a review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Use dated 6/2025, the P&P indicated that psychotropic medications management includes adequate monitoring for efficacy and adverse consequences. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder and depression. During a review of Resident 2's MDS, dated 1/14/2026, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 needed partial/moderate assistance (helper does less than half the effort) for eating, oral and personal hygiene, and dependent with toileting, self-showering/bathing and lower body dressing. During a review of Initial Psychiatric (relating to mental illness or its treatment) Evaluation, dated 1/21/2026, the Initial Psychiatric Evaluation indicated Resident 2 had bipolar disorder with episodes of agitation/sadness/mood swings and a current medication of Depakote DR 250 mg. During a review of Resident 2's Order Summary Report, dated 2/10/2026, the Order Summary Report indicated: Divalproex Sodium oral tablet delayed release (DR) 250 mg, give 1 tablet by mouth two times a day for mood stabilizer/ bipolar disorder manifested by changes in mood from happy to anger, ordered on 1/9/2026. Monitor behavior episodes of mood stabilizer/ bipolar disorder manifested by changes in mood from happy to anger and tall with hashmarks for each episode on the MAR every shift, ordered on 1/9/2026. During a review of Resident 2's Resident Has Periods of: Bipolar Disorder, care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) dated 1/8/2026, the care plan indicated the intervention for nursing staff to monitor and record episode(s) of behavior per facility policy/protocol. During a concurrent interview and record review on 2/12/2026 at 2:41 PM with the Assistant Director of Nursing (ADON), Resident 2's MAR, dated 2/1/2026 – 2/28/2026, was reviewed. The MAR indicated to monitor behavior episodes of mood stabilizer/ bipolar disorder manifested by changes in mood from happy to anger and tall with hashmarks for each episode on the MAR every shift for divalproex with only yes or no documented. The MAR did not indicate documented tally hashmarks. ADON stated the MAR should have been tallied to monitor the episodes of Resident 2's behavior of changes with mood and it was not. ADON stated it is important to allow staff to document the number of times/ tally the number of the episode occurred every shift as indicated in the ordered instead of a yes or no to ensure complete and correct monitoring of Resident 2's behavior and so that Resident 2's doctor will know how many episodes the resident is having and if adjustments to the medication is needed and to also evaluate its effectiveness. During an interview on 2/12/2026 with LVN 3, LVN 3 stated nursing staff documentation should be tallied when monitoring Resident 2's bipolar disorder behavioral symptoms to accurately know how the resident's mood is. During a record review of the facility's policy titled, Antipsychotic Medication Use, dated 5/2025, the policy indicated the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others and that staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. During a review of the facility's policy titled Policy on Unnecessary Medications, dated 7/2025, the policy indicated: Residents shall be free from unnecessary medications. The purpose is to prevent the use of unnecessary medications, including psychotropic drugs and other medications without adequate clinical indication, to ensure appropriate monitoring and gradual dose reduction when required. The policy applied to all licensed nurses, physicians, nurse practitioners, physician assistants, consultant pharmacists, and all staff involved in medication administration, monitoring, and documentation. 3. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 68's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), psychosis and dementia. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 68 was dependent on toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/taking off footwear, tub/ shower transfer, walk 10, 50, and 150 feet During a review of Resident 68's Order Summary dated 2/11/2026. The OS indicated Depakote (also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features) Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG Give 1 capsule by mouth every 12 hours for mood disorder manifested by aggressive towards others by hitting ordered on 10/27/2025 During a concurrent interview and record review on 2/11/2026 at 3:53 PM with MDS Coordinator (MDS 1), the physician's order (PO) for quetiapine fumarate dated 10/3/2025 was reviewed. The PO indicated quetiapine fumarate (Seroquel) 25 MG Give 1 tablet by mouth at bedtime for psychosis manifested by aggressive behavior. MDS 1 stated the PO was incomplete because the manifested behavior by aggressive behavior was not specific to what type of behavior such as Resident 68 was hitting himself or the staff, yelling, verbal, or physical aggression. During a concurrent interview and record review on 2/11/2026 at 3:58 PM with MDS 1, Resident 68's Order Summary dated 2/11/2026 was reviewed. The PO indicated the following: 1. Monitor behavior episodes of: psychosis manifested by aggressive behavior and tally with hashmarks for each episode on the MAR every shift for Quetiapine ordered on12/30/2025. 2. Monitor behavior episodes of: mood disorder manifested by aggressive towards others by hitting and tally with hashmarks for each episode on the MAR every shift for Depakote ordered pm 12/30/2025. MDS 1 stated the PO for behavior monitoring was incomplete because there was no specific aggressive behavior to monitor such as Resident 68was hitting himself or the staff, yelling, verbal, or physical aggression for the use of Quetiapine. MDS 1 also statedmonitoring aggressive behavior orders were almost the same for both quetiapine and Depakote medications. MDS 1 also stated each medication should have a different and specific behavior that needs to be monitored and documented so the staff can check if which medication was effective for Resident 68. During a concurrent interview and record review on 2/11/2026 at 4:19 PM with MDS 1, Resident 68's Care Plan (CP) for behavior problem dated 10/22/2025 was reviewed. TH CP intervention indicated to monitor/document observed behavior and attempted interventions in resident record. MDS 1 stated the CP intervention was not specific, incomplete and not person centered. MDs 1 stated the care plan should include interventions for behavior monitoring specifically for Resident 68's antipsychotic drug use, and also to check the effectiveness of the medications. During a concurrent interview and record review on 2/11/2026 AT 4:21 PM with MDS 1, the facility's P&P titled, Antipsychotic Medication Use, dated 5/2025 was reviewed. The P&P indicated, the nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. MDS 1 stated the P&P was missing the monitoring of the specific behavior of the resident using the anti-psychotic medication, it should be included the policy, and not only the adverse and side effects of medications.

Based on interview and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a nursing facility) was completed and was accurate for two (2) of two (2) sampled residents (Resident 38 and 68) reviewed for PASRR, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 38 and 68 and had the potential for not receiving the necessary and appropriate level of treatment and evaluation in the facility.Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and unspecified intellectual disabilities. During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 38 was dependent (helper does all the effort) with oral, toileting, and personal hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 38 was independent (resident completes the activity by themselves with no assistance from helper) with eating. During a review of Resident 38's Medical Records, Residents 38's medical records did not indicate there was a PASARR 1 screening on 8/8/2025 re-admission. During a concurrent interview and record review on 2/10/2026 at 3:58 PM, the Director of Nursing (DON) stated PASARR 1 screening should have been completed when Resident 38 was readmitted back on 8/8/2025 to ensure the resident will be provided with the right care and the right kind of treatment and was appropriately placed. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review Reports (PASRR), updated on 1/2025, the P&P indicated that the facility must ensure PASARR screening requirements which included pre-admission completion of PASARR process was completed prior to any admission, regardless of the payer source (Medicaid, Medicare, or private pay). 2. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 68's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), psychosis (a mental disorder characterized by a disconnection from reality) and dementia (a progressive state of decline in mental abilities) During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 68 was dependent on toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/taking off footwear, tub/ shower transfer, walk 10, 50 and 150 feet During a review of Resident 68's PASARR dated 10/3/2025, the PASARR indicated Level 1 was negative. The PASARR indicated Resident 68 was not diagnosed with serious mental illness and was not taking any psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications. During a review of Resident 68's Order Summary (OS) dated 2/11/2026. The OS indicated Resident 68 was prescribed on 10/3/2025, Quetiapine (antipsychotic medication that treats several kinds of mental health conditions including schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) 25milligram (MG, unit of mass) by mouth at bedtime for psychosis manifested by aggressive behavior. During a concurrent interview and record review on 2/10/2026 at 12:19 PM with DON, the PASRR dated 10/3/2025 was reviewed. The DON stated PASARR indicated Resident 68 was not diagnosed with serious mental illness and was not taking any psychotropic medications. The DON stated Resident 68's latest PASARR was dated 10/3/2025 from General Acute Hospital (GACH). The DON stated PASARR was incorrectly filled out because it should have indicated that Resident 68 had a diagnosis of psychosis and was taking Quetiapine. During an interview on 2/11/2026 at 12:22 PM with the DON, the DON stated if the PASRR was incorrectly done, the facility will not be able to provide the right level of care that Resident 68 possibly need. During review of the facility's P&P titled, PASARR Compliance Policy, updated on 1/2025, the P&P indicated, 1. Preadmission Screening (PAS) Requirements Admissions from Hospitals: The facility must only accept residents from General Acute Care Hospitals (GACH) if the PASRR Level I Screening has been completed and verified via the online system. 2. Level I Screening Process Negative Results: If the screening is negative, the PAS RR process is complete, and the individual may be admitted (pending other medical requirements). 3. Resident Review (RR) for Current Residents Significant Change in Status: Staff must initiate a new Level I Screening as a Resident Review whenever a current resident experiences a significant change in their physical or mental condition. Indicators for RR: This includes new symptoms of SMI or ID/DD, or a change in physical health that could alter the need for specialized mental. health services.

Based on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Resident 3 and 38) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) were provided care and services to maintain good grooming and personal hygiene by failing to:1. Ensure Resident 38's nails were trimmed and not long and jagged (an uneven, rough, or broken free-edge fingernails). This deficient practice resulted in multiple scattered reddened scratch marks on Resident 38's right arm.2. Ensure shower was provided for Resident 3 in accordance with residents' shower requests. This deficient practice had the potential to result in a negative impact on Resident 3's quality of life and self-esteem.Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), muscle disorders, and lack of coordination. During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 38 was dependent (helper does all the effort) with oral, toileting, and personal hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 38 was independent (resident completes the activity by themselves with no assistance from helper) with eating. During a concurrent observation and interview on 2/9/2026 at 10:42 AM, Resident 38 was observed in the hallway sitting in a wheelchair with multiple scattered reddened scratch marks on the right forearm and long, untrimmed, jagged nails on both hands. Resident 38 stated that he scratched his arm with his nails. During an interview on 2/11/2026 at 9:50 AM, the Assistant Director of Nursing (ADON) stated Resident 38's nails should be trimmed by the Certified Nursing Assistants (CNAs) or charge nurses to prevent the injuries from the resident scratching himself. During an interview on 2/12/2026 at 2:33 PM, CNA 3 stated CNAs and Restorative Nursing Assistants (RNAs) are assigned to do nail trimming for the residents. CNA 3 also stated long nails could easily get dirty and could break the residents' skin and if the nails are dirty, it could potentially cause infection. CNA 3 further stated Resident 38 could bleed if he scratches his skin too much. During an interview on 2/12/2026 at 2:37 PM, Registered Nurse 1 (RN 1) stated residents sometimes scratch themselves and if they have long and jagged nails, the residents could break their skin, injure themselves and potentially bleed, especially if they take blood thinners (medications that help prevent dangerous blood clots from forming). During an interview on 2/12/2026 at 2:59 PM, CNA 4 stated the CNA assigned to the resident should cut the nails if they are long to prevent the residents' from injuring themselves. During a review of the facility's Policy and Procedure (P&P) titled, Resident Nail Care, dated 6/2025, the P&P indicated that the facility shall ensure that the residents receive appropriate fingernail and toenail care as part of routine personal hygiene. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 7/2025, the P&P indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 3's diagnoses included spinal stenosis (happens when the space inside the backbone is too small) lumbar (lower back bone) region, peripheral vascular disease (reduced circulation of blood to arms or legs due to a narrowed or blocked blood vessel), and diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS indicated Resident 3 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunks or limbs, and provides more than half the effort) in shower/ bathe self, putting on and taking off footwear and walk 50 feet. Resident 3 also needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in lower body dressing, personal hygiene, roll left and right, sit to lying, lying-to-sitting on the side of the bed, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer and walk 10 feet. During an observation in Resident 3's room and interview on 2/9/2026 at 8:24 AM, Resident 3 was observed awake and lying in bed. Resident 3 stated that he has been trying to request a shower for two weeks, on both the morning and evening shifts, but his request has not been granted. Resident 3 stated that, according to the staff, they cannot give him a shower because they are only allowed to give showers at certain times. Resident 3 stated, They give me a bed bath every two days, but this does not work for my hair. I want to wash my hair. It makes me feel uncomfortable. It is different when you take a shower—I feel fresher, and it makes me feel better. During a concurrent interview and record review on 2/11/2026 at 8:48 AM with the ADON, Resident 3's current Care Plan (CP) was reviewed. The ADON stated there was no CP formulated for Resident 3's ADLs, which would include shower and/or bed bath. The ADON stated since there was no CP, there were no interventions, which means the facility staff did not address Resident 3's ADL needs. During a concurrent interview and record review on 2/11/2026 at 12:01 PM with the ADON, Resident 3's Shower and Bathing Flow Sheet (SBFS) dated 1/13/2026 to 2/9/2026 was reviewed. The ADON stated there was no documentation whether a shower or bed bath was provided to Resident 3 on 1/13/2026, 1/21/2026,1/27/2026 to 1/31/2026, 2/4/2026 to 2/6/2026, 2/8/2026, and 2/9/2026. The ADON stated since there was no documentation, it means Resident 3 was not provided with a shower or bed bath on the said dates. During a concurrent interview and record review on 2/11/2026 at 12:30 PM with Director of Staff Development (DSD), the CNA Shower Review Form (CSRF) dated 1/27/2026 to 2/9/2026 was reviewed. The DSD stated there was no documentation on 1/27/2026, 1/31/2026, 2/3/2026, 2/5/2026, and 2/9/2026 indicating whether Resident 3 received a shower or a bed bath. The DSD stated if Resident 3 refused a shower, the staff should have documented the refusal, endorsed it to the charge nurse, and charted it in the nurses' progress notes. During an interview on 2/11/2026 at 12:31 PM with DSD, the DSD stated if a resident is unable to shower for several days, it can make the resident feel depressed. The DSD stated if a resident requests a shower, the CNA should provide it on any shift. The DSD stated Resident 3 has the right to shower in the morning or at any time he requests. The DSD added, It is part of the residents' rights. The resident (Resident 3) has the right to take a shower whenever he requests one. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 7/2025, the P&P indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) by failing to ensure:1. All personnels in the kitchen wore hair and or beard nets.2. Multiple food items were stored in a manner that prevents foodborne illness (illness that comes from eating contaminated food) for residents.3. Staff personal items were not placed inside the kitchen refrigerator. 4. Kitchen staff did not touch the rim of multiple glasses of water with bare hands during tray line preparation. These deficient practices have the potential to result in foodborne illness in a population of 80 residents who consume the food prepared by the facility every day.Findings:1. During an observation on 2/9/2026 at 7:35 AM, [NAME] 1 (CK 1) was observed without a hair net and was wearing a hat while his hair on the back of his head was exposed. During a concurrent observation and interview on 2/9/2026 at 8:11 AM, the Dietary Service Supervisor (DSS) was seen without a beard net, exposing his facial hair. DSS stated hair and beard nets should be used inside the kitchen to keep hair out of the food and prevent food contamination. During a tray line (behind the scenes check on how the facility kitchen staff prepare meal trays) observation on 2/11/2026 at 12:08 PM, Dietary Service Aid 1 (DSA 1) was seen without a hair net and was wearing a hat with his hair exposed at the back of his head while preparing rice soups for the residents. During an interview on 2/11/2026 at 3:18 PM, DSA 1 stated hair nets are used to prevent the hair from falling on the residents' food and contaminate the food. DSA 1 also stated he thought wearing only a hat without a hair net was acceptable. During a review of the facility's Policy and Procedure (P&P) titled, Hair Net, dated on 7/2025, the P&P indicated that the facility would enforce strict hair restraint standards to prevent food contamination. The P&P also indicated that all food service personnel, including cooks, dietary aides, and dishwashers must wear effective hair restraints when preparing, handling, or serving non prepackaged food or clean utensils. The P&P further indicated that staff with beards or mustaches that are not closely cropped and neatly trimmed must wear a beard net or restraint. The P&P also indicated that restraints must be put on before entering the kitchen area and the dietary manager or designee would perform daily sanitation inspection to ensure all staff adhere to proper attire and hair restraint standards. 2. During an observation on 2/9/2026 at 7:40 AM, a beef patty box was observed inside refrigerator #2 without a use by date on the box. During an observation on 2/9/2026 at 7:48 AM in freezer #2, the following items were found:A large metal tray of green gelatin with mandarin oranges unlabeled with preparation date and use by dateA large metal tray of plain green gelatin unlabeled with preparation date and use by dateExpired container of pumpkin soup prepared on 11/15/2025 with use by date of 12/15/2025Expired chorizos inside a large clear container with preparation date of 1/1/2026 and use by date of 2/1/2026 During an observation on 2/9/2026 at 7:53 AM in refrigerator #1, a clear container with 10 cucumbers with use by date of 2/3/2026 During an observation on 2/9/2026 at 7:58 AM in freezer #1, the following items were found:A bowl of uncovered ice cream undatedThree gallons of vanilla ice cream - unlabeled and no use by dateOpened box of dinner rolls unlabeledOpened bags of French fries (2 bags) unlabeledUnknown food item inside the plastic bag with use by date of 8/5/2025 During an observation on 2/9/2026 at 8 AM in refrigerator #3, the following items were found:Six pieces of Vanilla Greek Yogurts 32 ounce (oz) unlabeled1 gallon of an open container of milk (2) without an open date and use by dateOpened silk almond milk 32 fluid oz (2) with no open date and use by dateA clear pitcher of cranberry juice with use by date of 2/5/2026A clear pitcher of thickened water with use by date of 2/5/2026Chocolate flavored syrup (24 oz) with use by date of 12/2025Opened thick and easy hydrolyte thickened water 46 fluid oz (2) with no open date and use by date During a concurrent observation and interview on 2/9/2026 at 8:06 AM, CK 1 stated the facility had multiple expired and unlabeled food items inside refrigerators and freezers. CK 1 stated that expired food items should have been discarded and not used to prevent the residents from potentially getting sick. During a concurrent interview on 2/9/2026 at 8:11 AM, the DSS stated food items should be labeled to keep track of when the food items would expire. The DSS also stated residents could get food borne illness (an illness caused by eating or drinking contaminated, spoiled food/drinks leading to symptoms of nausea, vomiting, and stomach cramps) if expired items are consumed. During a review of the P&P titled, Food Labeling and Storage, dated 10/2024, the P&P indicated that all food items removed from the original packaging or prepared in-house must be labeled with the common name of the food and the date of preparation/opening. The P&P also indicated on use-by dates that perishable, ready to eat foods must be marked with a discard date not to exceed 7 days from the date of opening or preparation. The P&P further indicated on resident-specific food that any personal food brought in by family must be labeled with the residents' name, date received, and discard date. 3. During an observation on 2/9/2026 at 7:53 AM in refrigerator #1, a bag of strawberries belonging to CK 1 were found inside the refrigerator. During an interview on 2/9/2026 at 8:11 AM, the DSS) stated staff personal items should not be stored inside the kitchen refrigerator to avoid cross contamination. 4. During a tray line observation on 2/11/2026 at 11:12 AM, DSA 2 prepared multiple batches of water in small cups and grabbed each around the mouthpiece without gloves while placing plastic cover on each of the cups. During an interview on 2/12/206 at 10:28 AM, DSA 3 stated it was important to wear gloves when filling up water cups and to keep everything clean for the residents. During a review of the P&P titled, Food Handling and Safety, dated 10/2024, the P&P indicated that the facility ensures resident safety through strict temperature control, sanitation, and adherence to physician-ordered diets.

Based on observation, interview, and record review, the facility failed to follow the standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) in accordance with the facility's policy and procedure when:1.a Licensed Vocational Nurse 2 (LVN 2) failed to change gloves and perform hand hygiene during medication administration to Resident 2.1.b LVN 3 failed to sanitize medication tray (equipment includes durable plastic, divided trays designed to organize, transport, and dispensing pills and syringes in clinical or home settings) after putting in the dirty lancet (a small, disposable, double-edged needle or blade used to prick the skin-usually on the finger-to obtain a tiny blood sample for checking blood sugar levels) and failed to perform hand hygiene in between tasks during medication administration to Resident 2.2. The facility failed to ensure the facility linens (bed sheets, pillowcases and blankets) were washed and dried at the appropriate temperatures and time lengths, as indicated in the facility's policies. These deficient practices have potential to contaminate clean items and can place the residents at risk for infection. Findings: 1.a During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]with the diagnoses that included encephalopathy (a disturbance of brain function), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on / taking off footwear, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer, car transfer, walk 10, 50 and 150 feet. During an observation on 2/10/2026 at 4:24 PM with LVN 2 in the hallway near the nurse station, Resident 2 was sitting in the wheelchair facing the nurse station. LVN 2 was wearing a glove while placing the medications into Resident 2's mouth when one (1) medication fell and rolled onto the floor. LVN 2 picked up the medication tablet from the floor and discarded the medication in the biohazard container. LVN 2 then dispensed another medication from medication cart into the medicine cup without changing her (LVN 2) disposable gloves, picked up the medication from the medicine cup and put the medication inside Resident 2's mouth. During an interview on 2/10/2026 at 4:27 PM with LVN 2, LVN 2 stated she picked up the medication on the floor, wasted it, and replaced it with a new one. LVN 2 stated she forgot to change her gloves, and it is considered dirty. LVN 2 stated she should have removed the dirty gloves, performed hand hygiene before putting on a new pair of gloves and before administering the new medication because Resident 2 might get an infection. During an interview on 2/12/2026 at 2:30 PM with Infection Preventionist Nurse (IPN), IPN stated when LVN 2 picked up medication from the floor, LVN 2 should have changed her (LVN 2) gloves, and perform hand hygiene before getting/ preparing the new medication for Resident 2. IPN also stated if LVN 2 did not change her (LVN 2) gloves and put the medication inside Resident 2's mouth, then Resident 2 could get sick from the bacteria on the floor. 1.b During an observation on 2/11/2026 at 9:32 AM with LVN 3 inside Resident 2's room, LVN 3 checked Resident 2's blood sugar and discarded the dirty lancet inside the medication tray. LVN 3 then used the same medication tray to store the medicine cups without sanitizing the medication tray during medication preparation. During an observation on 2/11/2026 at 9:34 AM with LVN 3 in the hallway, LVN 3 picked up medication cup on floor with his bare hands and threw it away in the trashcan. LVN 3 then started to prepare Resident 2's medication without performing hand hygiene. During an interview on 2/12/2026 at 2:20 PM with LVN 3, LVN 3 stated he did put the dirty/ used lancet in the medication tray and did not sanitize the medication tray after LVN 3 checked Resident 2's blood sugar. LVN 3 did not clean the medication tray before putting the medicine cups with Resident 2's medications. LVN 3 stated they should clean the medication tray because it was dirty and for infection control. During an interview on 2/12/2026 at 2:45 PM with IPN, IPN stated LVN 3 should have disinfected the medication tray before putting in the medicine cups with Resident 2's medications. LVN 3 should have done hand hygiene after picking up anything on the floor and before preparing the medication of the resident because Resident 2 can get exposed to bacteria. During review of the facility's policy and procedure (P&P) titled, Hand washing/ Hand Hygiene updated on 1/2025, the P&P indicated, this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The P&P also indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. The P&P indicated hand hygiene is indicated after contact with blood, body fluids, or contaminated surfaces. During review of the facility's P&P titled, Administering Medications updated on 9/2025, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. The P&P also indicated under implementation, staff will follow established facility infection control procedures (e.g., handwashing, and gloves, etc.) for the administration of medications, as applicable. 2. During a concurrent observation and interview on 2/11/2026 at 12:58 PM with the Maintenance Director (MTD) and Laundry Staff (LS) 1, in the facility's laundry room, a poster titled Brand 1- Wash Formula Chart, was observed. The poster indicated the following linen types and formula/card numbers: Whites number 1 Heavy whites number 2 Colors number three (3), no bleach Heavy colors number four (4), no bleach Rags and mops number five (5) Rewash number six (6) LS 1 stated he used this poster when loading linens into the washer machines to know which cycle to select. MTD stated the formula/card number means the cycle number on the washer machine and the poster is used by laundry staff to determine the appropriate cycle number based off linen types indicated on the chart. During a concurrent observation and interview on 2/11/2026 at 1:02 PM with the MTD and LS 1 in the facility's laundry room, LS 1 was observed loading Washer Machine 1 with colored linen, set on cycle 3 and then started. LS 1 was then observed loading Washer Machine 2 with white linens, set on cycle 1 and then started the washer cycle. LS 1 was unable to state the water temperatures for the washer cycles 1 and 3. MTD was unable to state the set temperatures for cycles 1 and 3 and further stated the cycle temperatures were already programmed in the washer machines settings. During a concurrent interview and record review on 2/12/2026 at 12:22 PM with the MTD, the facility's document titled Automated Laundry Systems, undated, was reviewed. The document indicated the recommended washer machine temperatures of 120 to 140 degrees Fahrenheit (F) for cycles 1 and 2 and 85 to 105 degrees F for wash cycles 3 through 6. The document also indicated a Brand 2 recommended temperatures of 120 to 140 degrees F for white and heavy soiled colorfast items, 85 to 105 degrees F most loads and 65 to 75 degrees F for very bright colored linens with light soil only and water below 65 degrees is not recommended for washing. The MTD stated Brand 2 is the supplier of the washer machine and the recommended temperatures on this document are the temperatures that were set for cycle number for the facility Washer Machines 1 and 2. During a concurrent interview and record review on 2/12/2026 at 12:30 PM with the MTD, the facility's policy titled Washer and Dryer, dated 1/2025, was reviewed. The policy indicated the purpose of the policy for laundry is to align with federal standards and linens should be exposed to water at a minimum of 160 degrees F for at least 24 minutes during the wash cycle to ensure disinfection with the standard hot water method. The MTD stated the facility washer machines use standard hot water method and per facility policy, the washer cycles 1 through 6 do not meet the minimum temperature requirement of 160 degrees F. MTD added the washer machine temperatures should follow the current facility policy for Washer and Dryer to make sure linens are cleaned and disinfected. During a continuous concurrent observation and interview on 2/11/2026 from 1:05 PM to 1:50 PM with LS 1, MTD and the Maintenance Supervisor (MS), in the facility's laundry area, LS 1 was observed loading the Dryer 1 with white linen and Dryer 2 with colored linen, then started the drying cycle for Dryers 1 and 2. LS 1 stated Dryer 1 contained sheets and pillowcases and Dryer 2 contained blankets. LS 1 stated he monitors the dryer temperatures by a gauge located outside of the drying machines to make sure the temperature reached 180 degrees F. During the same observation and interview on 2/11/2026 from 1:05 PM to 1:50 PM with LS 1, the MTD and MS, in the facility's laundry area, Dryer 1's load cycle was observed running at a temperature of 160 degrees F from 1:34 PM to 1:41 PM (7 minutes) and Dryer 2's load cycle ran at a temperature of 150 degrees F from 1:31 PM to 1:43 PM (12 minutes). LS 1 was observed removing the linens from Dryers 1 and 2 into a large bin. LS 1 stated he was going to start folding the linens that LS 1 got from Dryers 1 and 2. During a concurrent interview and record review on 2/11/2026 at 1:52 PM with MTD, the facility's document titled Brand 1- Laundry Drying Procedures, (undated), was reviewed. The Laundry Drying Procedures indicated for sheets and pillowcases to be dried at 160 to 170 degrees F for 12 to 15 minutes and blankets were to be dried at 150 to 170 degrees for 25 to 30 minutes. The MTD stated per facility protocol, staff need to follow the drying times and temperature range indicated in the Laundry Drying Procedures. MTD also stated the linens that were dried in Dryers 1 and 2 did not run at the appropriate temperatures for the full indicated time frame and LS 1 should have let it complete the required amount of time before removing the linens from Dryers 1 and 2. MTD further stated it was important to follow the drying times and dry time temperature ranges for health reasons, to prevent mold and bacteria accumulation on the linen and to make sure it is dried and disinfected properly for the residents. During an interview on 2/11/2026 at 3:02 PM with the Infection Preventionist Nurse (IPN), the IPN stated it was important for the facility's linen to be washed and dried at appropriate temperatures and time lengths to ensure whatever bacteria is present is killed and the linen will be sanitized and bacteria free. During a review of the facility's policy titled Policies and Practices – Infection Control, revised 10/2018, the policy indicated the intention to maintain a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for influenza (the flu- a contagious respiratory virus) and pneumococcal (a serious, often fatal infection caused by Streptococcus pneumoniae bacteria) vaccinations per facility policy. This failure had the potential for Residents 72 and 4 (or their responsible party [RP]) to accept or decline the influenza and/or pneumococcal vaccinations without the proper understanding of risks and benefits to make an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).Findings:1. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] with diagnoses that included fusion of the spine (a surgical procedure that permanently connects two or more vertebrae [a small bone in the spine] in the spine), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and difficulty in walking. During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 72 has intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 72 was assessed to need set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) and with toileting and personal hygiene and showering/bathing self. During a review of Resident 72's physical medical charts dated from 8/1/2025 to 2/11/2026, the medical chart did not indicate documentation that Resident 72 was provided education or a VIS form regarding the influenza vaccine. During an interview on 2/11/2026 at 10:32 AM with the Infection Preventionist Nurse (IPN), IPN stated the facility protocol is to provide the residents and/or RP with VIS forms to educate the residents or the resident's RP on the risks and benefits and then let them decide if they consent to or will decline the offered influenza and pneumococcal vaccinations. IPN also stated per facility protocol, once the VIS form is provided, it would be documented in the resident's electronic medical chart under the immunizations section or documented in a progress note. During a concurrent interview and record review on 2/11/2026 at 10:39 AM with the IPN, Resident 72's electronic medical record, from 8/1/2025 to 2/11/2026 and Resident 72's Vaccine Consent Form, dated 10/1/2026, were reviewed. The electronic medical chart and the Vaccine Consent Form both did not indicate Resident 72 was provided with education or VIS form for influenza vaccine, prior to obtaining the consent for the flu and pneumococcal vaccine. IPN stated there was no documentation in the medical record or on the consent to ensure Resident 72 was provided education or a VIS form for the influenza vaccination and there should be documentation that it was provided, so it was not done. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was readmitted to the facility on [DATE] with diagnoses that included acute (sudden) and chronic (long lasting) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), COPD and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 4 was dependent (helper does all the effort) with toileting hygiene, shower/bathing self, partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene and supervision or touching assistance with eating. During a review of Resident 4's physical medical charts dated from 7/4/2025 to 2/11/2026, the medical chart did not indicate documentation that Resident 4's RP was provided education or a VIS form regarding the influenza and pneumococcal vaccines. During a concurrent interview and record review on 2/11/2026 at 10:48 AM with IPN, Resident 4's electronic medical record, from 7/4/2025 to 2/11/2026 and Resident 4's Vaccine Consent Form, (undated), were reviewed. The electronic medical record and the Vaccine Consent Form both did not indicate Resident 4 and/or the RP were provided a VIS form for the influenza and pneumococcal vaccines. IPN stated there is no documentation in Resident 4's medical record or the consent form regarding any provided education or VIS forms for the pneumococcal and flu vaccine and there should be documentation if provided. During an interview on 2/11/2026 at 10:59 AM with IPN, IPN stated it was important to ensure residents and/or the RP are provided education and the VIS forms regarding offered vaccines (influenza and pneumococcal) to ensure family/residents are educated for their own understanding of what they are receiving, to know the side effects, and to help with their (the resident or RP) decision to consent of decline the vaccine. The IPN also stated that without ensuring the residents/family are provided education and the VIS forms, the facility cannot ensure family/residents are fully informed of the offered vaccinations. During a review of the facility's policy and procedure (P&P) titled Influenza Vaccination Program, dated 2/2026, the P&P indicated the purpose of the vaccination program is to prevent transmission of disease within the facility and to provide qualified residents the opportunity to receive the influenza vaccine while at the facility. The P&P also indicated the influenza vaccine will be offered October through March and for staff to provide the Resident with the appropriate Vaccine Information Sheet before obtaining a consent from the resident or representative. During a review of the facility's P&P titled Pneumococcal Vaccination Program, dated 2/2026, the P&P indicated the purpose of the vaccination program is to prevent transmission of disease within the facility and to provide qualified residents the opportunity to receive the pneumococcal vaccine while at the facility and for staff to provide the Resident with the appropriate Vaccine Information Sheet before obtaining a consent from the resident or representative. During a review of the facility P&P titled Vaccination Program, (undated), the P&P indicated the policy purpose of recognizing the major impact and mortality of both influenza, pneumococcal and Covid- 19 disease (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) on the elderly and other individuals at risk and the effectiveness of vaccines for reducing health care costs and in preventing illness, hospitalization, and death. The P&P also indicated to provide the resident (RP) with a VIS prior to the consenting and/or administering of the influenza, pneumococcal and/or Covid vaccinations.

Based on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for the Covid-19 (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine per the facility's policy and procedure. This failure had the potential for Residents 72 and 4 (or their responsible party [RP]) to accept or decline the Covid-19 vaccine without the proper understanding of risks and benefits to make an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).Findings:1. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] with diagnoses that included fusion of the spine (a surgical procedure that permanently connects two or more vertebrae [a small bone in the spine] in the spine), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and difficulty in walking. During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 72 has intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 72 was assessed to need set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) and with toileting and personal hygiene and showering/bathing self. During a review of Resident 72's physical medical charts dated from 8/1/2025 to 2/11/2026, the medical chart did not indicate documentation that Resident 72 was provided education or a VIS form regarding the Covid-19 vaccine. During an interview on 2/11/2026 at 10:32 AM with the Infection Preventionist Nurse (IPN), the IPN stated the facility protocol is to provide the residents and/or RP with VIS forms to educate them on the risks and benefits and then let them decide if they consent to or will decline the offered Covid vaccinations. The IPN also stated per facility protocol, once the VIS form is provided, it would be documented in the resident's electronic medical chart under the immunizations section or documented in a progress note. During a concurrent interview and record review on 2/11/2026 at 10:39 AM with the IPN, Resident 72's electronic medical record, from 8/1/2025 to 2/11/2026 and Resident 72's Vaccine Consent Form, dated 10/1/2026, were reviewed. The electronic medical chart and the Vaccine Consent Form both did not indicate Resident 72 was provided with education or VIS form for Covid-19 vaccine. IPN stated there was no documentation in the medical record or on the consent to ensure Resident 72 was provided education or a VIS form for the Covid-19 vaccination and there should be documentation if it was provided. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was readmitted to the facility on [DATE] with diagnoses that included acute (sudden) and chronic (long lasting) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), COPD and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 4 was dependent (helper does all the effort) with toileting hygiene, shower/bathing self, partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene and supervision or touching assistance with eating. During a review of Resident 4's physical medical charts dated from 7/4/2025 to 2/11/2026, the medical chart did not indicate documentation that Resident 4's RP was provided education or a VIS form regarding the Covid-19 vaccine. During a concurrent interview and record review on 2/11/2026 at 10:48 AM with IPN, Resident 4's electronic medical record, from 7/4/2025 to 2/11/2026 and Resident 4's Vaccine Consent Form, (undated), were reviewed. The electronic medical record and the Vaccine Consent Form both did not indicate Resident 4 and/or the RP were provided a VIS form for the covid vaccine. IPN stated there is no documentation in Resident 4's medical record or the consent form regarding any provided education or VIS forms for the Covid-19 vaccine and there should be documentation if provided. During an interview on 2/11/2026 at 10:59 AM with IPN, IPN stated it was important to ensure residents and/or the RP are provided education and the VIS forms regarding offered vaccines (including Covid-19) to ensure family/residents are educated for their own understanding of what they are receiving, to know the side effects, and to help with their (the resident or RP) decision to consent of decline the vaccine. The IPN also stated that without ensuring the residents/family are provided education and the VIS forms, the facility cannot ensure family/residents are fully informed of the offered vaccinations. During a review of the facility's policy and procedure (P&P) titled Covid Vaccination Program, dated 2/2026, the P&P indicated the purpose of the vaccination program is to prevent transmission of disease within the facility and to provide qualified residents the opportunity to receive the Covid vaccine while at the facility. The P&P also indicated for staff to provide the Resident with the appropriate Vaccine Information Sheet before obtaining a consent from the resident or representative. During a review of the facility P&P titled Vaccination Program, (undated), the P&P indicated the policy purpose of recognizing the major impact and mortality of both influenza, pneumococcal and Covid disease on the elderly and other individuals at risk and the effectiveness of vaccines for reducing health care costs and in preventing illness, hospitalization, and death. The P&P also indicated to provide the resident (RP) with a VIS prior to the consenting and/or administering of the influenza, pneumococcal and/or Covid vaccinations.

Based on observation, interview, and record review the facility failed to ensure its medication error rate was less than five (5) percent (%). 18 medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 36 opportunities (observed administered medications) for error which yielded a facility medication error rate of 50% for four (4) of 4 sampled residents (Residents 38, 2, 82, and 67) observed for medication administration (med pass). Licensed Vocational Nurse 4 (LVN 4) failed to correctly administer Combivent Respimat (medication used to treat and prevent tightening of the airway in adults) for Resident 38 as indicated in the package insert (a document included in the package of a medication that provides information about the medication and its use). 2a. LVN 3 failed to administer 16 medications within 60 minutes of scheduled time of 9 AM to Resident 2. 2b. LVN 3 failed to ensure three medications were not crushed and administered to Resident 2.3. LVN 6 failed to administer Vitamin C ascorbic acid 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) to Resident 67 on 2/11/2026.These deficient practices had the potential to result in harm to Residents 38, 2, and 67 by not administering medications as prescribed by the physician in order to meet their individual medication needs.Findings: 1.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), chronic obstructive pulmonary disease (COPD- a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and essential hypertension (high blood pressure). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by himself) with eating. The MDS indicated Resident 38 was dependent (helper does all of the effort) with oral hygiene, upper/lower body dressing, personal dressing, sit to lying, sit to stand, and tub/shower transfer. During a review of Resident 38's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician order for Combivent Respimat Inhalation Aerosol Solution 20-100 micrograms (mcg- unit of measurement), 1 inhalation, inhale orally two times a day for prevention related to COPD, ordered on 8/9/2025. During a review of Resident 38's Medication Administration Record (MAR), from 2/1/2026 to 2/28/2026, the MAR indicated Resident 38 was scheduled to receive Combivent Respimat Inhalation Aerosol Solution 20-100 mcg at 5 PM. During a review of the package insert (the paper inside a medication box) for Combivent Respimat, the package insert, under instructions for use, indicated to do following: Breathe out slowly and fully Close your lips around the mouthpiece without covering the air vents Point the inhaler to the back of your throat While taking a slow, deep breath through your mouth, press the dose-release button (a grey button located on the side of the inhaler that releases a soft mist or puff of medication) and continue to breathe in Hold your breath for 10 seconds or for as long as comfortable During an observation of the medication pass on 2/10/2026, at 4:33 PM, LVN 4, LVN 4 placed Resident 38's Combivent inhaler in Resident 38's mouth. LVN 4 held the inhaler in Resident 38's mouth and pressed the dose-release button on Resident 38's inhaler. LVN 4 instructed Resident 38 to take a deep breath and counted to five (5) while Resident 38 inhaled and exhaled five times. LVN 4 did not instruct Resident 38 to hold his breath after inhaling the medication. During an interview, on 2/10/2026, at 4:35 PM, with LVN 4, LVN 4 stated Resident 38's was ordered for one (1) inhalation of Combivent to help Resident 38 breathe better. LVN 4 stated Resident 38 take took 5 breaths while she held the inhaler to Resident 38's mouth. LVN 4 stated Resident 38 did not receive his Combivent medication correctly. During an interview, on 2/11/2026, at 3:54 PM, with the Assistant Director of Nursing (ADON), the ADON stated Resident 38's Combivent was for his COPD and was ordered to open Resident 38's airway and help him breathe. The ADON stated Resident 38 should have been instructed by LVN 4 to hold his breath for at least 5 seconds after inhaling his Combivent medication. The ADON stated it was important that Resident 38 held his breath after he inhaled his Combivent to receive the full effect of the medication. The ADON stated LVN 4 did not administer Resident 38's medication correctly. The ADON stated not administering Resident 38's Combivent correctly could cause Resident 38 to go into respiratory distress and can lead to hospitalization. 2a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. The admission record indicated Resident 2's diagnoses included encephalopathy, DM, and dementia (a progressive state of decline in mental abilities) During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent in toileting hygiene, shower/ bathe self, lower body dressing, putting on / taking off footwear, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer, car transfer, walk 10, 50 and 150 feet. During a review of Resident 2's Order Summary Report, dated 2/10/2026, the Order Summary Report indicated a physician order for the following medications: Divalproex sodium (medication used to treat bipolar disorder [bpd-mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) oral tablet delayed release 250 milligrams (mg- unit of measurement) give 1 tablet by mouth two times a day for mood stabilizer/bpd manifested by (m/b) changes in mood from happy to anger do not crush, ordered on 1/9/2026. Gabapentin (medication used to treat nerve pain) oral capsule 300 mg give 1 capsule by mouth three times a day for nerve pain, ordered on 1/8/2026. Aspirin EC (a medication used as prophylaxis [action to prevent disease] for cerebrovascular accident [CVA or stroke- a medical emergency where blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients]) oral tablet delayed release 81 mg give 1 tablet by mouth one time a day for deep vein thrombosis (DVT- a condition where a blood clot forms in a deep vein) prophylaxis (ppx- action to prevent disease) do not crush, ordered on 1/8/2026. Eliquis (medication used to reduce the risk of stroke and blood clots) oral tablet 2.5 mg give 1 tablet by mouth two times a day for DVT ppx, ordered on 1/8/2026. Acetaminophen (medication used to treat mild to moderate pain) oral tablet 500 mg give 2 tablets by mouth one time a day for mild pain (1-3)/pain management, ordered on 1/14/2026. Hydralazine Hydrochloride (medication used to treat moderate to severe hypertension and heart failure), oral tablet 10 mg give 1 tablet by mouth four times a day for hypertension hold if SBP less than 110, HR less than 60, ordered on 1/8/2026. Losartan potassium oral tablet 50 mg give 2 tablets by mouth one time a day for hypertension hold if SBP less than 110, HR less than 60, ordered on 1/8/2026. Metformin Hydrochloride (medication used to control high blood sugar levels) oral tablet 500 mg give 2 tablets by mouth two times a day for DM management give with food, ordered on 2/4/2026. Pacerone (medication used to maintain normal heart rhythm) oral tablet 200 mg give 1 tablet by mouth two times a day for arrythmia (irregular or abnormal heartbeat), ordered on 1/8/2026. Sertraline Hydrochloride (medication used to treat depression) oral tablet 100 mg give 1 tablet by mouth one time a day for depression m/b verbalized sadness/withdraw from activities, ordered on 1/9/2026. Vitamin C (vitamin for immune [resistance to an infection] function) oral tablet give 500 mg by mouth one time a day to support wound healing of stage 3 pressure injury, ordered on 1/12/2026. Zetia (medication that lowers the bad cholesterol [a waxy, fat-like substance found in the cells of the body) oral tablet 10 mg give 1 tablet by mouth one time a day for hyperlipidemia (a condition in which there are high levels of fat particles in the blood), ordered on 1/8/2026. Zinc sulfate oral tablet give 50 mg by mouth one time a day to support wound healing of stage 3 pressure injury, ordered on 1/12/2026. Metoprolol succinate ER (medication used to lower high blood pressure) oral tablet extended release 24-hour 50 mg give 1 tablet by mouth every 12 hours for hypertension hold if SBP less than 110, HR less than 60 with food, ordered on 1/15/2026. Multivitamin-minerals oral tablet give 1 tablet by mouth one time a day to support wound healing of stage 3 pressure ulcer injury (a deep wound where the skin is broken and fat is visible), ordered on 1/12/2026. Amlodipine besylate (medication used to lower high blood pressure) oral tablet 5 mg give 1 tablet by mouth two times a day for hypertension hold if systolic blood pressure (SBP- pressure in the arteries when the heart contracts and pumps blood out) less than 110, heart rate (HR) less than 60, ordered on 1/8/2026. During a review of Resident 2's MAR, from 2/1/2026 to 2/28/2026, the MAR indicated Resident 2 was scheduled to receive the following medications at 9 AM: Divalproex sodium oral tablet delayed release 250 mg Gabapentin oral capsule 300 mg Aspirin EC oral tablet delayed release 81 mg Eliquis oral tablet 2.5 mg Acetaminophen oral tablet 500 mg Hydralazine HCl oral tablet 10 mg Losartan potassium oral tablet 50 mg Metformin HCl oral tablet 500 mg Pacerone oral tablet 200 mg Sertraline HCl oral tablet 100 mg Vitamin C oral tablet give 500 mg Zetia oral tablet 10 mg Zinc sulfate oral tablet Metoprolol succinate ER oral tablet extended release 24 hour 50 mg Multivitamin-minerals oral 1 tablet Amlodipine besylate oral tablet 5 mg During an observation of the medication pass, on 2/11/2026, from 10:02 AM to 10:10 AM, LVN 3 administered the following medications to Resident 2: Hydralazine HCl oral tablet 10 mg, 1 tablet by mouth Metformin HCl oral tablet 500 mg, 2 tablets by mouth Multivitamin-minerals oral tablet, 1 tablet by mouth Eliquis oral tablet 2.5 mg, 1 tablet by mouth Zinc sulfate oral tablet, 50 mg by mouth Losartan potassium oral tablet 50 mg, 2 tablets by mouth Sertraline HCl oral tablet 100 mg, 1 tablet by mouth Metoprolol succinate ER oral tablet extended release 24 hour 50 mg, 1 tablet by mouth Gabapentin oral capsule 300 mg, 1capsule by mouth Zetia oral tablet 10 mg, 1 tablet by mouth Vitamin C oral tablet, 500 mg by mouth Acetaminophen oral tablet 500 mg, 2 tablets by mouth Amlodipine besylate oral tablet 5 mg, 1 tablet by mouth Aspirin EC oral tablet delayed release 81 mg, 1 tablet by mouth Divalproex sodium oral tablet delayed release 250 mg, 1 tablet by mouth Pacerone oral tablet 200 mg, 1 tablet by mouth During an interview, on 2/12/2026, at 1:40 PM, with LVN 3, LVN 3 stated Resident 2's 9 AM medications were allowed to be given as early as 8 AM but no later than 9:59 AM. LVN 3 stated the Resident 2's hydralazine HCl, metformin HCl, multivitamin-minerals, Eliquis, zinc sulfate, losartan potassium, sertraline HCl, metoprolol succinate ER, gabapentin, Zetia, vitamin C, acetaminophen, amlodipine besylate. Aspirin EC, divalproex sodium, and Pacerone were administered after 10 AM. LVN 3 stated Resident 2's medications were given late because she had a lot of medications scheduled for 9 AM. LVN 3 also stated Resident 2's late medication administration was caused by the need to replace the blood pressure cuff (the device wrapped around the arm to measure blood pressure) and check Resident 2's blood sugar before medication pass. LVN 3 stated it was important for Resident 2 to receive her hydralazine, losartan potassium, metoprolol succinate, and amlodipine besylate medications on time to because Resident 2's SBP ran in the high 150s and needed her medications to maintain her blood pressure in the normal range. LVN 3 stated it was important for Resident 2 to receive her metformin on time because she had DM and needed her metformin to maintain her blood sugar in the normal range. LVN 3 stated not giving Resident 2 her metformin on time could cause her to have symptoms of hyperglycemia like shaking and sweating. LVN 3 stated not giving Resident 2's medications on time could cause her to display side effects like unstable mood, pain, irregular heartbeat, and placed Resident 2 at risk for developing a DVT. LVN 3 stated it was important to administer medications as scheduled to prevent giving them too close together which could cause the residents to receive too much medication. During an interview, on 2/12/2026, at 4:10 PM, with the ADON, the ADON stated medications can be administered 1 hour before and 1 hour after the scheduled administration time. The ADON stated 9 AM medications were considered late if administered after 10 AM. The ADON stated it was important to give medications on time to ensure the right time space was given in between the medications. The ADON also stated not administering medications on time can affect the therapeutic levels (medication concentration in the blood) of the medications. The ADON stated LVN 3 should have given Resident 2's 9 AM medications as ordered because they were significant medications. The ADON stated Resident 2 can experience symptoms such as hypertension, high blood sugar, depression, depression, blood clots, pain, and abnormal heartbeat if the therapeutic levels of her medications were low. The ADON stated LVN 3 did not follow the policy for medication administration. 2.b) During a review of Resident 2's Order Summary Report dated 2/11/2026, the order summary report indicated: divalproex sodium 250 mg delayed release oral tablet **DO NOT CRUSH. Give 1 tablet by mouth twice a day for mood stabilizer, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) manifested by changes in mood from happy to anger. aspirin 81 mg oral tablet EC delayed release *** DO NOT CRUSH. Give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, a blood clot in a vein located deep within your body, usually in your leg) prophylaxis. metoprolol tartrate 50 mg oral tablet Extended Release ***DO NOT CRUSH. Give 1 tablet every 12 hours for hypertension. Hold if systolic blood pressure (SBP) less than (<)110, heart rate (HR) <60 with food. During an interview on 2/12/2026 at 1:40 PM with LVN 3, LVN 3 stated there were three medications for Reisdent 2 that indicated do not crush on the label. LVN 3 stated he did not know that those 3 medications (divalproex, aspirin and metoprolol) cannot be crushed. LVN 3 stated, LVN 3 crushed the medications and did not inform the Registered Nurse Supervisor (RNS), the facility's pharmacy or Resident 2's doctor. During an interview on 2/12/2026 at 2:04 PM with LVN 3, LVN 3 stated when medications indicate delayed release it means once it was swallowed, it was slowly dissolved and absorbed in the body. LVN 3 also stated if the delayed release medications were crushed, it affects the slow effect of the medication and it becomes rapid release which can affect Resident 2's mood, which could result to depressive symptoms, affect the resident's the blood pressure, blood consistency and Resident 2 can become unstable. LVN 3 stated Resident 2's physician's order for divalproex, aspirin and metoprolol were not followed. During an interview on 2/12/2026 at 4:10 PM with the DON, the DON stated when medications have an instruction of do not crush, the medications will not be absorbed properly. The DON stated the licensed nurses need to call the doctor or pharmacy to change the form, or if not able to, call the doctor to change the medications. The DON stated if a medication is labeled as delayed release, it means that once it is swallowed, it dissolves slowly in the body. If it is crushed, it disrupts the delayed or slow-release mechanism, causing the medication to be released too quickly. This can affect the resident's depression treatment and lead to instability. 3. During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident MDS, dated [DATE], the MDS indicated Resident 67 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 67 was dependent on oral, toileting and personal hygiene, shower/bathing self, dressing and was set up or clean up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 67's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated Vitamin C oral tablet 500 mg, give one (1) tablet by mouth one time a day for supplement. It also indicated an order for [NAME] Vita Rx oral table, give one tablet by mouth one time a day. During a concurrent record review, observation of medication pass (process of administering scheduled/ prescribed medications to residents), on 2/11/2026 at 8:11 AM with Licensed Vocational Nurse 6 (LVN 6), Resident 67's MAR, dated 2/1/2026 through 2/28/2026, was reviewed. The MAR indicated to administer [NAME]-Vite Rx oral table 1 m, to give 1 tablet by mouth one time a day for supplement at 9 AM and Vitamin C oral tablet 500 mg, give 1 tablet by mouth one time a day for supplement at 9 AM. LVN 6 was observed grabbing a bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles, separated by dose) labeled Rena Vite 1 mg, removed 1 tablet and placed it into a medication cup labeled Rena Vite. LVN 6 was then observed, reading the MAR for Vitamin C, grabbing a bubble pack labeled Rena Vite 1 mg for a second time, removed 1 tablet and placed it into a medication cup labeled Vitamin C. During the same observation of medication pass and interview on 2/11/2026 at 8:11 AM with LVN 6, LVN 6 stated she put the Rena Vite in the cup labeled Vitamin C, but it was the wrong medication prepared. LVN 6 stated she should have checked the medication bubble pack more than once to ensure the prepared medication was Vitamin C and not Rena Vite, because Rena Vite had already been prepared for Resident 67. LVN 6 stated it was important to follow the facility policy and ensure that the right medication is prepared to prevent administering extra or double dose if Rena Vite and/ or administering the wrong medication to the residents. LVN 6 added, if the wrong medication is administered to residents, they would not receive their medications as ordered and needed. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 9/2025, the P&P indicated medications are administered in a safe manner, as prescribed and the nurse administering the medication will check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure two (2) of four sampled residents (Residents 38 and Resident 2) were free from significant medication errors (error which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: Correctly administer Combivent Respimat (medication used to treat and prevent tightening of the airway in adults) for Resident 38 as indicated in the package insert (a document included in the package of a medication that provides information about the medication and its use) This deficient practice had the potential for Resident 38 to experience shortness of breath and difficulty breathing. 2. Ensure the extended-release formulation of divalproex, metoprolol, and Aspirin were not crushed, compromising the slow release of the medications for Resident 2. This deficient practice had the potential for harm to Resident 2 due to the potential side effects from medications administered not according to its extended-release formulation.Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), chronic obstructive pulmonary disease (COPD- a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and essential hypertension (high blood pressure). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by himself) with eating. The MDS indicated Resident 38 was dependent (helper does all of the effort) with oral hygiene, upper/lower body dressing, personal dressing, sit to lying, sit to stand, and tub/shower transfer. During a review of Resident 38's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician order for Combivent Respimat Inhalation Aerosol Solution 20-100 micrograms (mcg- unit of measurement), 1 inhalation, inhale orally two times a day for prevention related to COPD, ordered on 8/9/2025. During a review of Resident 38's Medication Administration Record (MAR), from 2/1/2026 to 2/28/2026, the MAR indicated Resident 38 was scheduled to receive Combivent Respimat Inhalation Aerosol Solution 20-100 mcg at 5 PM. During a review of the package insert (the paper inside a medication box) for Combivent Respimat, the package insert, under instructions for use, indicated to do following: Breathe out slowly and fully Close your lips around the mouthpiece without covering the air vents Point the inhaler to the back of your throat While taking a slow, deep breath through your mouth, press the dose-release button (a grey button located on the side of the inhaler that releases a soft mist or puff of medication) and continue to breathe in Hold your breath for 10 seconds or for as long as comfortable During an observation of the medication pass on 2/10/2026, at 4:33 PM, Licensed Vocational Nurse 4 (LVN 4), LVN 4 placed Resident 38's Combivent inhaler in Resident 38's mouth. LVN 4 held the inhaler in Resident 38's mouth and pressed the dose-release button on Resident 38's inhaler. LVN 4 instructed Resident 38 to take a deep breath and counted to five while Resident 38 inhaled and exhaled five times. LVN 4 did not instruct Resident 38 to hold his breath after inhaling the medication. During an interview, on 2/10/2026, at 4:35 PM, with LVN 4, LVN 4 stated Resident 38's was ordered for one (1) inhalation of Combivent to help Resident 38 breathe better. LVN 4 stated Resident 38 take took five breaths while she held the inhaler to Resident 38's mouth. LVN 4 stated Resident 38 did not receive his Combivent medication correctly. During an interview, on 2/11/2026, at 3:54 PM, with the Assistant Director of Nursing (ADON), the ADON stated Resident 38's Combivent was for his COPD and was ordered to open Resident 38's airway and help him breathe. The ADON stated Resident 38 should have been instructed by LVN 4 to hold his breath for at least 5 seconds after inhaling his Combivent medication. The ADON stated it was important that Resident 38 held his breath after he inhaled his Combivent to receive the full effect of the medication. The ADON stated LVN 4 did not administer Resident 38's medication correctly. The ADON stated not administering Resident 38's Combivent correctly could cause Resident 38 to go into respiratory distress and can lead to hospitalization. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. The admission record indicated Resident 2's diagnoses included encephalopathy, DM, and dementia (a progressive state of decline in mental abilities) During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent in toileting hygiene, shower/ bathe self, lower body dressing, putting on / taking off footwear, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer, car transfer, walk 10, 50 and 150 feet. During a review of Resident 2's Order Summary Report dated 2/11/2026, the order summary report indicated: divalproex sodium 250 mg delayed release oral tablet **DO NOT CRUSH. Give 1 tablet by mouth twice a day for mood stabilizer, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) manifested by changes in mood from happy to anger. 2. aspirin 81 mg oral tablet EC delayed release *** DO NOT CRUSH. Give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, a blood clot in a vein located deep within your body, usually in your leg) prophylaxis. 3. metoprolol tartrate 50 mg oral tablet Extended Release ***DO NOT CRUSH. Give 1 tablet every 12 hours for hypertension. Hold if systolic blood pressure (SBP) less than (<)110, heart rate (HR) <60 with food. During an interview on 2/12/2026 at 1:40 PM with LVN 3, LVN 3 stated there were three medications for Reisdent 2 that indicated do not crush on the label. LVN 3 stated he did not know that those 3 medications (divalproex, aspirin and metoprolol) cannot be crushed. LVN 3 stated, LVN 3 crushed the medications and did not inform the Registered Nurse Supervisor (RNS), the facility's pharmacy or Resident 2's doctor. During an interview on 2/12/2026 at 2:04 PM with LVN 3, LVN 3 stated when medications indicate delayed release it means once it was swallowed, it was slowly dissolved and absorbed in the body. LVN 3 also stated if the delayed release medications were crushed, it affects the slow effect of the medication and it becomes rapid release which can affect Resident 2's mood, which could result to depressive symptoms, affect the resident's the blood pressure, blood consistency and Resident 2 can become unstable. LVN 3 stated Resident 2's physician's order for divalproex, aspirin and metoprolol were not followed. During an interview on 2/12/2026 at 4:10 PM with the DON, the DON stated when medications have an instruction of do not crush, the medications will not be absorbed properly. The DON stated the licensed nurses need to call the doctor or pharmacy to change the form, or if not able to, call the doctor to change the medications. The DON stated if a medication is labeled as delayed release, it means that once it is swallowed, it dissolves slowly in the body. If it is crushed, it disrupts the delayed or slow-release mechanism, causing the medication to be released too quickly. This can affect the resident's depression treatment and lead to instability. During a review of the facility's policy and procedure (P&P), titled, Administering Medications, revised 9/2025, the P&P indicated the following: 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for four (4) of four sampled residents (Residents 38, 2, 82, and 67) reviewed and observed for medication administration, in accordance with the facility's policy and procedure (P&P) by failing to:Correctly administer Combivent Respimat (medication used to treat and prevent tightening of the airway in adults) for Resident 38 as indicated in the package insert (a document included in the package of a medication that provides information about the medication and its use) This deficient practice had the potential for Resident 38 to experience shortness of breath and difficulty breathing. 2a. Administer 16 medications within 60 minutes of scheduled time of 9 AM for Resident 2.This deficient practice had the potential for a decline in Resident 2's overall health status and decrease the therapeutic levels for Resident 2's 16 medications which could cause Resident 2's mood, pain, blood pressure, heart rhythm, diabetes mellitus (DM- is a metabolic disease, involving inappropriately elevated blood glucose levels) symptoms to worsen or not be properly managed. 2b. Ensure the delayed or extended-release (designed to release active ingredients slowly into the bloodstream over an extended period, providing a steady, consistent dose rather than an immediate spike and drop) formulation of divalproex (medication used to treat bipolar disorder [bpd-mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]), metoprolol (medication used to lower high blood pressure) and aspirin (a medication used as prophylaxis [action to prevent disease] for cerebrovascular accident [CVA or stroke- a medical emergency where blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients]) were not crushed, compromising the slow release of the medication for Resident 2.This deficient practice had the potential for harm to Resident 2 due to the potential side effects from medication administered not according to its extended-release or delayed release formulation. 3.Ensure Licensed Vocational Nurse 2 (LVN 2) used two (2) resident identifiers (unique, person-specific data points used to accurately identify, locate, or verify the identity of a resident such as in a long-term care facility. These identifiers are crucial for patient safety, typically requiring at least two unique identifiers such as full name, date of birth , or medical record number to distinguish the residents) prior administering medication to Resident 82 on 2/11/2026.This deficient practice had the potential to result in ineffectively managing Residents 82 medical condition and placing the resident for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare professional, patient, or consumer) and compromised resident safety.4. Failed to ensure Licensed Vocational Nurse 6 (LVN 6) prepared the correct medication of Vitamin C ascorbic acid 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) for Resident 67 during medication administration. On 2/11/2026, LVN 6 prepared Rena Vite (a medication with a combination of B vitamins used to treat or prevent vitamin deficiency) to administer to Resident 67 instead of the resident's Vitamin C. This failure had the potential for Resident 67 to receive double dose of Rena Vite and a missed prescribed dose of Vitamin C.Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), chronic obstructive pulmonary disease (COPD- a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and essential hypertension (high blood pressure). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 38 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 38 was independent (resident completes the activity by himself) with eating. The MDS indicated Resident 38 was dependent (helper does all of the effort) with oral hygiene, upper/lower body dressing, personal dressing, sit to lying, sit- to- stand, and tub/shower transfer. During a review of Resident 38's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician order for Combivent Respimat Inhalation Aerosol Solution 20-100 micrograms (mcg- unit of measurement), 1 inhalation, inhale orally two times a day for prevention related to COPD, ordered on 8/9/2025. During a review of Resident 38's Medication Administration Record (MAR), from 2/1/2026 to 2/28/2026, the MAR indicated Resident 38 was scheduled to receive Combivent Respimat Inhalation Aerosol Solution 20-100 mcg at 5 PM. During a review of the Combivent Respimat Inhalation Aerosol Solution's package insert (a document included in the package of a medication that provides information about that drug and its use, and how to administer the drug) for Combivent Respimat, the medication package insert, indicated the following instructions for use: Breathe out slowly and fully. Close your lips around the mouthpiece without covering the air vents. Point the inhaler to the back of your throat. While taking a slow, deep breath through your mouth, press the dose-release button (a grey button located on the side of the inhaler that releases a soft mist or puff of medication) and continue to breathe in. Hold your breath for 10 seconds or for as long as comfortable. During an observation of the medication pass on 2/10/2026, at 4:33 PM, Licensed Vocational Nurse 4 (LVN 4), LVN 4 placed Resident 38's Combivent inhaler in Resident 38's mouth. LVN 4 held the Combivent inhaler in Resident 38's mouth and pressed the dose-release button on Resident 38's inhaler. LVN 4 instructed Resident 38 to take a deep breath and counted to five while Resident 38 inhaled and exhaled five times. LVN 4 did not instruct Resident 38 to hold his breath after inhaling the medication. During an interview, on 2/10/2026, at 4:35 PM, with LVN 4, LVN 4 stated Resident 38's was ordered for one (1) inhalation of Combivent to help Resident 38 breathe better. LVN 4 stated Resident 38 took five breaths while she held the inhaler into Resident 38's mouth. LVN 4 stated Resident 38 did not receive his Combivent medication correctly per the Combivent package insert. During an interview, on 2/11/2026, at 3:54 PM, with the Assistant Director of Nursing (ADON), ADON stated Resident 38's Combivent was for the resident's COPD and was ordered to open Resident 38's airway and help him breathe. ADON stated Resident 38 should have been instructed by LVN 4 to hold his (Resident 38) breath for at least 5 seconds after inhaling the Combivent medication. ADON stated it was important that Resident 38 held his breath after the resident inhaled his Combivent to receive the full effect of the medication. ADON also stated LVN 4 did not administer Resident 38's medication correctly. and that not administering Resident 38's Combivent correctly could cause Resident 38 to go into respiratory distress and can lead to hospitalization. 2a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. The admission record indicated Resident 2's diagnoses included encephalopathy, DM, and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent on toileting, hygiene, shower/ bathe self, lower body dressing, taking off footwear, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer, car transfer, walk 10, 50 and 150 feet. During a review of Resident 2's Order Summary Report, dated 2/10/2026, the Order Summary Report indicated a physician order for the following 16 medications: Divalproex sodium oral tablet delayed release 250 milligrams (mg- unit of measurement) give 1 tablet by mouth two times a day for mood stabilizer/bpd manifested by (m/b) changes in mood from happy to anger do not crush, ordered on 1/9/2026. Gabapentin (medication used to treat nerve pain) oral capsule 300 mg give 1 capsule by mouth three times a day for nerve pain, ordered on 1/8/2026. Aspirin EC oral tablet delayed release 81 mg give 1 tablet by mouth one time a day for deep vein thrombosis (DVT- a condition where a blood clot forms in a deep vein) prophylaxis (ppx- action to prevent disease) do not crush, ordered on 1/8/2026. Eliquis (medication used to reduce the risk of stroke and blood clots) oral tablet 2.5 mg give 1 tablet by mouth two times a day for DVT ppx, ordered on 1/8/2026. Acetaminophen (medication used to treat mild to moderate pain), oral tablet 500 mg give 2 tablets by mouth one time a day for mild pain (1-3)/pain management, ordered on 1/14/2026. Hydralazine HCl (medication used to treat moderate to severe hypertension and heart failure) oral tablet 10 mg give 1 tablet by mouth four times a day for hypertension hold if SBP less than 110, HR less than 60, ordered on 1/8/2026. Losartan potassium (medication used to lower high blood pressure) oral tablet 50 mg give 2 tablets by mouth one time a day for hypertension hold if SBP less than 110, HR less than 60, ordered on 1/8/2026. Metformin HCl (medication used to control high blood sugar levels) oral tablet 500 mg give 2 tablets by mouth two times a day for DM management give with food, ordered on 2/4/2026. Pacerone (medication used to maintain normal heart rhythm) oral tablet 200 mg give 1 tablet by mouth two times a day for arrythmia (irregular or abnormal heartbeat), ordered on 1/8/2026. Sertraline HCl (medication used to treat depression) oral tablet 100 mg give 1 tablet by mouth one time a day for depression m/b verbalized sadness/withdraw from activities, ordered on 1/9/2026. Vitamin C (vitamin for immune [resistance to an infection] function), oral tablet give 500 mg by mouth one time a day to support wound healing of stage 3 pressure injury, ordered on 1/12/2026. Zetia (medication that lowers the bad cholesterol [a waxy, fat-like substance found in the cells of the body), oral tablet 10 mg give 1 tablet by mouth one time a day for hyperlipidemia (a condition in which there are high levels of fat particles in the blood), ordered on 1/8/2026. Zinc sulfate (vitamin for immune function), oral tablet and give 50 mg by mouth one time a day to support wound healing of stage 3 pressure injury, ordered on 1/12/2026. Metoprolol succinate ER oral tablet extended release 24- hour 50 mg give 1 tablet by mouth every 12 hours for hypertension, ordered on 1/15/2026. Multivitamin-minerals oral tablet and give 1 tablet by mouth one time a day to support wound healing of stage 3 pressure ulcer injury (a deep wound where the skin is broken and fat is visible), ordered on 1/12/2026. Amlodipine besylate (medication used to lower high blood pressure) oral tablet 5 mg give 1 tablet by mouth two times a day for hypertension, ordered on 1/8/2026. During a review of Resident 2's MAR, from 2/1/2026 to 2/28/2026, the MAR indicated Resident 2 was scheduled to receive the following 16 medications at 9 AM: Divalproex sodium oral tablet delayed release 250 mg Gabapentin oral capsule 300 mg Aspirin Enteric- Coated (Aspirin EC) oral tablet delayed release 81 mg Eliquis oral tablet 2.5 mg Acetaminophen oral tablet 500 mg Hydralazine HCl oral tablet 10 mg Losartan potassium oral tablet 50 mg Metformin HCl oral tablet 500 mg Pacerone oral tablet 200 mg Sertraline HCl oral tablet 100 mg Vitamin C oral tablet Zetia oral tablet 10 mg Zinc sulfate oral tablet Metoprolol succinate ER oral tablet extended release 24- hour 50 mg Multivitamin-minerals oral 1 tablet Amlodipine besylate oral tablet 5 mg During an observation of the medication pass, on 2/11/2026, from 10:02 AM to 10:10 AM, LVN 3 administered the following 16 medications to Resident 2: Hydralazine HCl oral tablet 10 mg, 1 tablet by mouth Metformin HCl oral tablet 500 mg, 2 tablets by mouth Multivitamin-minerals oral tablet, 1 tablet by mouth Eliquis oral tablet 2.5 mg, 1 tablet by mouth Zinc sulfate oral tablet, 50 mg by mouth Losartan potassium oral tablet 50 mg, 2 tablets by mouth Sertraline HCl oral tablet 100 mg, 1 tablet by mouth Metoprolol succinate ER oral tablet extended release 24- hour 50 mg, 1 tablet by mouth Gabapentin oral capsule 300 mg, 1capsule by mouth Zetia oral tablet 10 mg, 1 tablet by mouth Vitamin C oral tablet, 500 mg by mouth Acetaminophen oral tablet 500 mg, 2 tablets by mouth Amlodipine besylate oral tablet 5 mg, 1 tablet by mouth Aspirin EC oral tablet delayed release 81 mg, 1 tablet by mouth Divalproex sodium oral tablet delayed release 250 mg, 1 tablet by mouth Pacerone oral tablet 200 mg, 1 tablet by mouth During an interview, on 2/12/2026, at 1:40 PM, with LVN 3, LVN 3 stated Resident 2's 9 AM medications were allowed to be given as early as 8 AM but no later than 9:59 AM. LVN 3 stated Resident 2's 16 medications: hydralazine HCl, metformin HCl, multivitamin-minerals, Eliquis, zinc sulfate, losartan potassium, sertraline HCl, metoprolol succinate ER, gabapentin, Zetia, vitamin C, acetaminophen, amlodipine besylate, aspirin EC, divalproex sodium, and Pacerone that were scheduled to be given at 9 AM, were administered to the resident after 10 AM. LVN 3 stated Resident 2's medications were given late because the resident had a lot of medications scheduled for 9 AM. LVN 3 also stated Resident 2's late medication administration was caused by the need to replace the blood pressure cuff (the device wrapped around the arm to measure blood pressure) and check Resident 2's blood sugar before medication pass. LVN 3 stated it was important for Resident 2 to receive her hydralazine, losartan potassium, metoprolol succinate, and amlodipine besylate medications on time because Resident 2's systolic blood pressure (SBP- pressure in the arteries when the heart contracts and pumps ran in the high 150s and the resident needed her medications to maintain her blood pressure in the normal range. During the same interview, on 2/12/2026, at 1:40 PM, LVN 3 stated it was important for Resident 2 to receive her metformin on time because the resident had DM and needed her metformin to maintain her blood sugar in the normal range. LVN 3 stated not giving Resident 2 her metformin on time could cause her to have symptoms of hyperglycemia (which the level of glucose in the blood is higher than normal) like shaking and sweating. LVN 3 stated not giving Resident 2's medications on time could cause her to display side effects like unstable mood, pain, irregular heartbeat, and placed Resident 2 at risk for developing a DVT. LVN 3 stated it was important to administer medications as scheduled to prevent giving the medications too close together which could cause the residents to receive too much medication and drug interactions (a change in the way a medication works in the body caused by the presence of another substance, such as other drugs). During an interview, on 2/12/2026, at 4:10 PM with ADON, ADON stated medications can be administered 1 hour before and 1 hour after the scheduled administration time. ADON stated 9 AM medications were considered late if administered after 10 AM. ADON stated it was important to give medications on time to ensure the proper timing was given in between the medications or the next dose of the same medication. ADON also stated, not administering medications on time can affect the therapeutic levels (medication concentration in the blood, maximizing the effectiveness while minimizing the side effects) of the medications. ADON stated LVN 3 should have given Resident 2's 9 AM medications as ordered because they were significant medications (medications that pose a high risk of causing substantial patient harm, injury, or death if misused, dosed incorrectly, or administered not as ordered by the physician). ADON stated Resident 2 can experience symptoms such as hypertension, high blood sugar, depression, depression, blood clots, pain, and abnormal heartbeat if the therapeutic levels of her medications were low. ADON stated LVN 3 did not follow the policy for medication administration. During a review of the facility's policy and procedure (P&P), titled, Administering Medications, revised 9/2025, the P&P indicated the following: 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. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication. Medications are administered within 1 hour of their prescribed time, unless otherwise specified. 2.b) During a review of Resident 2's Order Summary Report dated 2/11/2026, the order summary report indicated: divalproex sodium 250 mg delayed release oral tablet **DO NOT CRUSH. Give 1 tablet by mouth twice a day for mood stabilizer, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) manifested by changes in mood from happy to anger. aspirin 81 mg oral tablet EC delayed release *** DO NOT CRUSH. Give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, a blood clot in a vein located deep within your body, usually in your leg) prophylaxis. metoprolol tartrate 50 mg oral tablet Extended Release ***DO NOT CRUSH. Give 1 tablet every 12 hours for hypertension. Hold if systolic blood pressure (SBP) less than (<)110, heart rate (HR) <60 with food. During an observation on 2/11/2026 at 9:52 AM with LVN 3, LVN 3 crushed all the 9 AM medications for Resident 2. During an interview on 2/12/2026 at 1:40 PM with LVN 3, LVN 3 stated there were three medications for Resident 2 that indicated do not crush on the label. LVN 3 stated he did not know that those 3 medications (divalproex, aspirin and metoprolol) cannot be crushed. LVN 3 stated, LVN 3 crushed the medications and did not inform the Registered Nurse Supervisor (RNS), the facility's pharmacy or Resident 2's doctor. During an interview on 2/12/2026 at 2:04 PM with LVN 3, LVN 3 stated when medications indicate delayed release it means once it was swallowed, it was slowly dissolved and absorbed in the body. LVN 3 also stated if the delayed release medications were crushed, it affects the slow effect of the medication and it becomes rapid release which can affect Resident 2's mood, which could result to depressive symptoms, affect the resident's the blood pressure, blood consistency and Resident 2 can become unstable. LVN 3 stated Resident 2's physician's order for divalproex, aspirin and metoprolol were not followed. During an interview on 2/12/2026 at 4:10 PM with the DON, the DON stated when medications have an instruction of do not crush, the medications will not be absorbed properly. The DON stated the licensed nurses need to call the doctor or pharmacy to change the form, or if not able to, call the doctor to change the medications. The DON stated if a medication is labeled as delayed release, it means that once it is swallowed, it dissolves slowly in the body. If it is crushed, it disrupts the delayed or slow-release mechanism, causing the medication to be released too quickly. This can affect the resident's depression treatment and lead to instability. During review of the facility's P&P titled, Administering Medications updated on 9/2025, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. The P&P also indicated, medications are administered in accordance with prescriber orders, including any required time frame. 3) During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was admitted to the facility on [DATE]. The admission record indicated Resident 82's diagnoses included spinal stenosis (happens when the space inside the backbone is too small) lumbar (lower back bone) region, acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypoxia (a dangerous condition that happens when your body doesn't get enough oxygen) and hypertension( high blood pressure) During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 82 was dependent (helper does all of the effort, resident does not effort to complete the activity) in toileting hygiene, shower/ bathe self, putting on / taking off footwear, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, and tub/ shower transfer. During a review of Resident 82's electronic Medication Administration Record (MAR, is a report detailing the drugs administered to a resident by a healthcare professional at a treatment facility) for the month of February 2026. The MAR indicated the following medications were administered at 5:00PM: Atorvastatin 20 MG for hyperlipidemia (a condition characterized by abnormally high levels of lipids [fats] in the blood). Bethanechol 25 MG for urinary retention (a condition in which you cannot empty all the urine from your bladder). Calcium & Phosphorus with Vitamin D (supplement). Docusate Sodium 250 MG for bowel management. Meclizine 25 MG for nausea and vomiting. During an observation on 2/10/2026 4:33 PM with LVN 2 by the door of Resident 82's room, Resident 82 was sitting on her wheelchair. LVN 3 handed the medicine cup containing all five (5) medications (Atorvastatin, Bethanechol, Calcium Phosphorous with Vitamin D, docusate sodium and meclizine to Resident 82. LVN 3 did not verify Resident 82's identity by asking the resident's full name, date of birth , or medical record number before giving the medication. Resident 82 was not properly informed of the 5 medications being administered to the resident before Resident 82 took the medications with a cup of water. During an interview on 2/10/2026 at 4:35 PM with LVN 2 stated she only used one (1) identifier only the resident's MAR. LVN 2 stated she did not verify Resident 82's identity by asking the resident for at least two identifiers such as the resident's name, date of birth or medical record number before administering the medications because LVN 2 knew the resident already. LVN 2 stated she also did not look at Resident 82's armband (patient identification wristband- a secure, durable, and typically waterproof band worn around the wrist or ankle by individuals admitted to nursing homes, or long-term care facilities. It functions as a critical safety device that links a person to their medical records, ensuring accurate identification to reduce medical errors) to verify Resident 2's identity. LVN 2 stated she should have used two (2) patient identifiers such as checking the armband and asking the resident's name because it was part of the five (5) rights of medication administration. During an interview on 2/12/2026 At 2:38 PM with Infection Preventionist Nurse (IPN), IPN stated the licensed nurse needed to verify two (2) resident identifiers by asking the resident's name and verifying the armband and then explain each medication to the resident so that the resident know what medications the resident was taking. IPN also stated f the licensed nurse did not inform the resident, they were not educating and getting consent from the Resident. During review of the facility's P&P titled, Administering Medications updated on 9/2025, the P&P indicated, the individual administering medications verifies the resident's identity before giving the resident his/her medications. The P&P also indicated methods of identifying the residents include: a. checking identification band b. checking photographs attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. 4. During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident MDS, dated [DATE], the MDS indicated Resident 67 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 67 was dependent on oral, toileting and personal hygiene, shower/bathing self, dressing and was set up or clean up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 67's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated Vitamin C oral tablet 500 mg, give one (1) tablet by mouth one time a day for supplement. It also indicated an order for [NAME] Vita Rx oral table, give one tablet by mouth one time a day. During a concurrent record review, observation of medication pass (process of administering scheduled/ prescribed medications to residents), on 2/11/2026 at 8:11 AM with Licensed Vocational Nurse 6 (LVN 6), Resident 67's MAR, dated 2/1/2026 through 2/28/2026, was reviewed. The MAR indicated to administer [NAME]-Vite Rx oral table 1 m, to give 1 tablet by mouth one time a day for supplement at 9 AM and Vitamin C oral tablet 500 mg, give 1 tablet by mouth one time a day for supplement at 9 AM. LVN 6 was observed grabbing a bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles, separated by dose) labeled Rena Vite 1 mg, removed 1 tablet and placed it into a medication cup labeled Rena Vite. LVN 6 was then observed, reading the MAR for Vitamin C, grabbing a bubble pack labeled Rena Vite 1 mg for a second time, removed 1 tablet and placed it into a medication cup labeled Vitamin C. During the same observation of medication pass and interview on 2/11/2026 at 8:11 AM with LVN 6, LVN 6 stated she put the Rena Vite in the cup labeled Vitamin C, but it was the wrong medication prepared. LVN 6 stated she should have checked the medication bubble pack more than once to ensure the prepared medication was Vitamin C and not Rena Vite, because Rena Vite had already been prepared for Resident 67. LVN 6 stated it was important to follow the facility policy and ensure that the right medication is prepared to prevent administering extra or double dose if Rena Vite and/ or administering the wrong medication to the residents. LVN 6 added, if the wrong medication is administered to residents, they would not receive their medications as ordered and needed. During a review of the facility's policy titled Administering Medications, dated 9/2025, the policy indicated medications are administered in a safe manner, as prescribed and the nurse administering the medication will check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure three (3) of four (4) sampled residents (Resident 2, 3, and 42) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were provided necessary treatment and services in accordance with the facility's policy and procedure (P&P) and physician's order by failing to ensure:1. Resident 2's low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) and use of heel and elbow protectors (specialized cushioned sleeves or pads designed to reduce pressure, friction, and shear on bony prominences to prevent skin breakdown, pressure ulcers, and abrasions) were implemented as ordered and as indicated in the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs).2. Resident 3's LALM was set according to the residents' weight. Resident 3, who weighed 199 pounds (lbs, unit of measurement for weight), was observed with the LALM weight setting at 270 lbs.3. Resident 42's LALM was set up according to the resident's weight. Resident 42, who weighed 140 lbs, was observed with the LALM weight setting at 240 lbs.This deficient practice placed Resident 2 at risk for deterioration of pressure ulcer and Residents and 42 to develop a pressure ulcer.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life] to elevated periods of emotional highs), and depression. During a review of Resident 2's Admission/readmission Data Collection, dated 1/8/2026, the Admission/readmission Data Collection indicated Resident 2 had right heel and left heel non blanchable (refers to an area on the skin that remains red and does not turn white when pressed) redness and a sacrococcyx (the area where the sacrum [base of the spine] connects with the coccyx [tailbone]) stage three (3) pressure ulcer (injury that extends through the skin into deeper tissue and fat). During a review of Resident 2's Order Summary Report, the Order Summary Report indicated Resident 2 may have LALM every day for wound management, ordered 1/9/2026. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding ) skills for daily decision making. The MDS indicated Resident 2 needed partial/moderate assistance (helper does less than half the effort) for eating, oral and personal hygiene, and dependent (helper does all the effort) with toileting, self-showering/bathing and lower body dressing. The MDS also indicated Resident 2 had two (2) stage one pressure ulcers (intact skin that is discolored and does not turn white [blanch] when pressed) and one stage 3 pressure ulcer with treatments of a pressure reducing device for bed and pressure ulcer/injury care. During a review of Resident 2's Weekly Pressure Ulcer Records, dated 2/6/2026, the Weekly Pressure Ulcer Records indicated that Resident 2 had stage 3 pressure sores on the sacrum and on the left and right heels, with LALM identified as the pressure relieving intervention. During a review of Resident 2's Left Heel Non Blanchable Redness care plan, initiated 1/9/2026, the care plan indicated the staff interventions included were to provide pressure reduction mattress and heel/elbow protectors. During a review of Resident 2's Right Heel Non Blanchable Redness care plan, initiated 1/9/2026, the care plan indicated the staff interventions included were to provide pressure reduction mattress and heel/elbow protectors. During a review of Resident 2's Sacro-coccyx Pressure Injury Stage 3 care plan, initiated 1/9/2026, the care plan indicated the staff interventions included were to provide pressure reduction mattress and heel/elbow protectors. During an observation on 2/10/2026 at 8:18 AM at Resident 2's bedside, Resident 2 was observed lying in bed with a low air loss pump at the foot of the bed, powered off. During a concurrent observation and interview on 2/10/2026 at 12:30 PM with Licensed Vocational Nurse 3 (LVN 3) at Resident 2's bedside, Resident 2's bed was observed without a LALM. A low air loss pump that was powered off was observed at the foot of Resident 2's bed. LVN 3 stated the current mattress on Resident 2's bed was a regular mattress, not a LALM and the last time he saw Resident 3 with a LALM on her bed was on 2/7/2026. LVN 3 stated per the MD order, Resident 2 should have a LALM and all nurses should be checking to make sure it is on and working. LVN 3 further stated he did not and should have checked to ensure Resident 2 had a LALM and/or that the pump was powered on during his shift. LVN 3 stated it was important for Resident 2 to have a LALM to help with would healing. During an interview and record review on 2/10/2026 at 12:52 PM with the Assistant Director of Nursing (ADON), Resident 2's medical record was reviewed. Resident 2's medical record failed to indicate any documentation of why Resident 2's LALM was not implemented as ordered. The ADON stated nursing staff should be inspecting the LALM to ensure it is working properly and implemented as ordered. The ADON stated the staff should document reasons if LALM was not implemented such as resident's refusal or LALM malfunctions. The ADON also stated it was important to implement the LALM to prevent worsening of resident's pressure wounds or development of new pressure wounds. During a concurrent observation, interview and record review on 2/10/2026 at 1:38 PM with the Treatment Nurse 1 (TN 1) at Resident 2's bedside, Resident 2 was observed sitting in her wheelchair without any heel or elbow protectors on. TN 1 stated Resident 2 did not and should be using elbow and heel protectors. TN 1 stated heel and elbow protectors are nursing interventions and should be implemented unless Resident 2 refused. Resident 2's medical record was reviewed and failed to indicate any documentation of Resident 2 refusing heel and/or elbow protectors. TN 1 stated it was important for staff to implement the use of heel and elbow protectors and the LALM to help with Resident 2's wound healing. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 3's diagnoses included spinal stenosis (happens when the space inside the backbone is too small) lumbar (lower back bone) region, peripheral vascular disease (reduced circulation of blood to arms or legs due to a narrowed or blocked blood vessel), and diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS indicated Resident 3 needed partial/ moderate assistance for lower body dressing, personal hygiene, roll left and right, sit to lying, lying-to-sitting on the side of the bed, sit-to stand, and chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer and walk 10 feet. The MDS also indicated Resident 3 was at risk for pressure ulcers and was using pressure relieving devices for bed. During a review of Resident 3's Braden Scale Assessment (BSA, tool use to check a resident's risk for developing pressure sores), dated 11/26/2025, indicated Resident 3 was at high risk for developing pressure ulcers. During an observation and interview on 2/9/2026 at 8:33 AM in Resident 3's room, Resident 3 was observed awake and lying on a LALM which was set at 270 lbs. Resident 3 stated he was using the LALM because he used to have a pressure ulcer on his right buttock which was resolved for few months now. Resident 3 stated his estimated weight was 197 lbs. During a concurrent observation and interview on 2/10/2026 at 12 PM with the Assistant Director of Nursing (ADON) in Resident 3's room, Resident 3 was observed awake and lying on a LALM. ADON stated Resident 3's LALM was set at 210 lbs. The ADON stated the LALM should be set based on Resident's weight of 197 lbs. During a concurrent interview and record review on 2/10/2026 at 12: 03 PM with ADON, Resident 3's physician's order, dated 9/29/2025, and weight for the month of December 2025 were reviewed. The physician's order indicated LALM skin management per resident request every shift. Resident 3's weight on 12/1/5/2025 indicated 199 lbs. The ADON added that if the LALM setting was too high, it would be too firm and could cause skin breakdown because it would place pressure on Resident 3's pressure points, such as the hips and sacral area, causing him to lie on bony prominences. The ADON also stated that staff should check the LALM every shift to ensure it is set up correctly. During a concurrent interview and record review on 2/10/2026 at 12: 15 PM with the Director of Nursing (DON), Resident 3's care plan for skin management, dated 12/4/2025, was reviewed. The DON stated Resident 3's care plan did not and should have included the use of LALM to ensure that it was properly implemented. 3. During a review of Resident 42's admission Record, the admission Record indication Resident 42 was admitted to the facility on [DATE] with diagnoses that included epilepsy (brain activity that causes sudden, uncontrolled electrical disturbance in the brain and sometimes loss of awareness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mental disorder (a significant long-lasting disturbance in thinking, emotion, mood or behavior that impair daily functioning). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was assessed to have moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 42 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with eating, oral/toileting hygiene, shower/bathe self, upper/lower body dressing, personal hygiene, roll left and right, sit to lying, and chair/bed-to-chair transfer. The MDS also indicated Resident 42 was at risk for developing pressure ulcers/injuries. During a review of Resident 42's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated Resident 42 may have low air loss mattress for wound management every shift, with a start date of 2/10/2026. During a review of Resident 42's Braden Scale, dated 12/9/2025, the Braden Scale indicated Resident 42 had a score of 11 which indicated Resident 42 was at high risk for developing pressure injuries. During a review of Resident 42's Weight and Vitals Summary from 2/1/2026 to 2/28/2026, the Weight and Vitals Summary indicated Resident 42 weighed 140 lbs. on 2/6/2026. During an observation in Resident 42's room on 2/9/2026, at 10:52 AM, Resident 42 was observed in bed with the LALM mattress setting at 240 lbs. During an interview, on 2/10/2026, at 1:11 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 42 had sensitive skin and a history of pressure ulcers and skin breakdown. CNA 1 stated Resident 42's LALM was to prevent her from developing pressure ulcers. CNA 1 stated licensed nurses were responsible for adjusting Resident 42's LALM setting. CNA 1 stated she did not know what Resident 42's LALM setting was supposed to be. During an interview on 2/10/2026, at 1:04 PM, with Treatment Nurse 1 (TN 1), TN 1 stated Resident 42 used a LALM for wound prevention and management because Resident 42 had a history of pressure ulcers and skin breakdown. TN 1 stated the LALM setting should be based on Resident 42's weight. TN stated if Resident 42's weight was 140 lbs. then her LALM setting should have been set to 120 lbs. TN stated it was the responsibility of licensed nurses to make sure Resident 42's LALM was in the correct setting every shift. TN stated it was important for the LALM to be in the proper setting to get the benefits of wound prevention and management. During an interview, on 2/11/2026, at 3:34 PM, with the ADON, the ADON stated Resident 42 required maximum assistance with turning and positioning in bed. The ADON stated Resident 42 had a history of pressure ulcers and was ordered to use a LALM for wound management. The ADON stated Resident 42's LALM was used to prevent pressure points while Resident 42 was in bed. The ADON stated Resident 42's LALM setting at 240 lbs. was wrong. The ADON stated Resident 42's LALM setting should have been set according to Resident 42's weight of 140 lbs. The ADON stated it was the responsibility of the TN and licensed nurses to check the setting of the LALMs during their rounds. The ADON stated the facility's P&P should indicate the setting the residents' LALM needed to follow. During a review of the facility's P&P, titled, Low Air Loss Support Surface Policy, revised 7/2025, the P&P indicated the following: The facility will establish clinical and documentation standards for the use of Low Air Loss LAL support surfaces to prevent and treat pressure injuries in accordance with CMS (Centers for Medicare & Medicaid Services), Medicare (health insurance program for people age [AGE] or older), Medi-Cal (California's free or low-cost health care program), and California SNF (skilled nursing facility) requirements. Under Nursing responsibilities: to ensure proper mattress setup and function During a review of the Operation Manual for the Protekt Aire 4000DX/4600DX/5000DX pump, the Operation Manual indicated, under Weight/Pressure set up, the Users can adjust air mattress to a desired firmness according to a patient's weight or the suggestion from a health care professional.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as a high risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the Director of Activities (DOA) wheeled Resident 1 outside of the activity room to take care of other residents and left Resident 1 unattended while sitting in a wheelchair (WC) at the hallway (outside the activity room). This deficient practice resulted in Resident 1 fell in the hallway outside the activity room on 1/18/2025 around 11:13 AM. Resident 1 sustained redness on the right side of resident's forehead. On 1/24/2025 (6 days after the fall), Resident 1 complained of pain on the resident's right ribs (slender curved bones protecting the lungs). Resident 1 underwent a Xray (a quick, painless test that captures images of the inside of the body) on 1/25/2025 and the result showed that Resident 1 had a fracture (a break in a bone) on the resident's eighth (8th) and ninth (9th) ribs. Findings: During a review of Resident 1's Admission Record, it indicated the resident was admitted to the facility on [DATE] with diagnoses that included: dementia, cerebral infarction, lack of coordination and repeated falls. During a review of Resident 1's Admission Fall Risk Assessment (AFRA) dated 1/17/2025, it indicated, Resident 1 is chair bound (unable to walk and dependent on a chair/ wheelchair to move around) and has a high risk for potential falls. During a review of Resident 1's Care Plan (CP) dated 1/17/2025, the CP indicated Resident 1 was at risk for falls due to history of falls. The CP did not indicate interventions such as facility staff actions or strategies to prevent resident from falling while the resident is in the wheelchair, such as monitoring and/ or supervising the reisdent while in wheelchair. During a review of Resident 1's Change of Condition (CoC) dated 1/18/2025 at 11:13 AM, it indicated Resident 1 fell outside the activity room while trying to turn his WC and the resident's right hand slipped causing the resident to fall on the floor. The COC also indicated the resident was observed having redness to the right side of the forehead. During a review of Resident 1's CoC dated 1/24/2025 at 7:44 PM, COC indicated the resident has hemiparesis (weakness to one side of body) and complained of pain on the right side of his ribs. During a review of Resident 1's physician's order, dated 1/24/2025, it indicated Resident 1 may have Xray of the right ribs due to pain. During a review of Resident 1's Radiology Report (Xray of ribs) dated 1/25/2025, it indicated Resident 1 had right 8th and 9th rib fractures. During a review of Resident 1's CoC dated 1/25/2025 at 11:09 PM, it indicated the resident's Xray result indicated the resident sustained fractures to the 8th and 9th rib and Tylenol (acetaminophen - medicine for mild pain) and ice were ordered for pain. During a review of Resident 1's Medication Administration Record (MAR) dated 1/1/2025 to 1/31/2025, it indicated Resident 1 received acetaminophen on 1/18/2025 at 11:28 AM for a pain (location of pain not indicated) level of two (2) out of 10 (mild pain). The MAR also indicated Resident 1 received acetaminophen on 1/26/2025 at 5:56 AM for a pain (location of pain not indicated) level of four (4) out of 10 (moderate pain). During an interview on 1/29/2025 at 8:04 AM with the DOA, DOA stated on 1/18/2025, DOA wheeled Resident 1 outside of the activity room and left Resident 1 at the hallway unattended to take care of other residents that were inside of the activity room. DOA also stated, DOA heard a sound coming from the hallway outside of the activity room and turned finding Resident 1 on the floor. DOA stated, Resident 1 is at high risk for falling and that means the resident must be constantly monitored, and the resident needs someone with him at all times especially when the resident is in the wheelchair. DOA stated on 1/18/2025, DOA did not tell another staff member to watch Resident 1 while DOA attends to other residents. DOA stated, Resident 1 should not have been left unattended by facility staff on 1/18/2025 and the fall could have been prevented. During an interview on 1/29/2025 at 8:26 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 1/18/2025, CNA 1 saw Resident 1 being wheeled out of the activity room by the DOA and left unattended in the hallway outside of the activity room. CNA 1 also stated, CNA 1 walked past Resident 1, then heard a thump, turned around and saw Resident 1 on the floor of the hallway outside of the activity room. During an interview on 1/29/2025 at 10:24 AM with RN 1, RN 1 stated Resident 1 is confused, has right sided weakness and is unable to use the WC by himself. RN 1 stated, on 1/18/2025 RN 1 was called to assess Resident 1 after the resident fell in the hallway outside of the activity room and saw redness on Resident 1's forehead. RN 1 also stated, Resident 1 had multiple falls before being admitted at the facility and was assessed to be at high risk for falling. RN 1 stated Resident 1 needs to always be monitored/ supervised because the resident is at risk for falling. RN 1 stated, Resident 1's fall and injury could have been prevented if the resident was monitored/ supervised by facility staff last 1/18/2025 while in the activity room. During a record review on 1/29/2025 at 11:46 AM with the Director of Nursing (DON), the facility's P&P titled, Fall Risk Assessment updated 1/27/2025 was reviewed. The P&P indicated: 1. The nursing staff, in conjunction with others will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. 2. Upon admission the nursing staff and physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction) and worsening of existing pressure ulcers for two of four residents (Residents 11 and 17) observed for pressure ulcers in a total of 18 sampled residents. 1. For Resident 11, the facility failed to: (a) Ensure the resident did not lie on her back directly on the pressure ulcer. (b) Implement the plan of care to turn and reposition the resident in bed every two hours. (c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. (d) Follow the staff in service training to prevent skin breakdown by positioning the resident every two hours off bony prominence area of the body. (e) Monitor staff implementation of the in service training in preventing pressure ulcer development. These failures resulted in Resident 11 developing an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) may be present on some parts of the wound bed which often includes undermining and tunneling) to her sacrococcyx (sacral (a triangular shaped bone at the bottom of the spine) coccyx (tailbone)). 2. For Resident 17, the facility failed to: (a) Implement the plan of care to offload the resident's heels (take off pressure from the heels, to suspend) when in bed. (b) Implement the physician's orders [REDACTED]. resident's feet to provide pressure relief and ventilation to feet) for pressure ulcer management. (c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. (d) Follow the staff in service training to prevent skin breakdown by positioning the resident every two hours off bony prominence area of the body. (d) Monitor staff implementation of the in service training in preventing pressure ulcer development. These failures resulted in Resident 17 developing an avoidable, unstageable pressure ulcer (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black) in the wound bed) to her left lateral (side) heel. Findings: 1. A review of the Admission/Readmission Data Collection form dated 6/14/16, indicated Resident 11 was admitted to the facility without a pressure ulcer. Resident 11's [DIAGNOSES REDACTED]. A review of the Change of Condition SBAR (situation background assessment recommendation) indicated Resident 11 was assessed on 7/21/16, with a 3 centimeter (cm) in length (L) by 3 cm in width (W) unstageable pressure ulcer to her coccyx. On 7/29/16, the wound doctor's notes indicated the resident's pressure ulcer had progressed to 3.5 cm (L) x 3 cm (W) unstageable sacrococcyx pressure ulcer. On 8/30/16, the sacrococcyx pressure ulcer had progressed to 4.5 cm (L) x 4.5 cm (W) Stage IV pressure ulcer. A review of the Nursing Home to Hospital Transfer Form, dated 1/23/17, indicated Resident 11 was transferred to acute hospital with Stage IV sacrococcyx pressure ulcer. The resident was transferred to acute hospital due to an abnormal blood test results. A review of the Nursing Admission/Readmission Data Collection form dated 1/30/17, indicated Resident 11 was readmitted to the facility with 7 cm (L) x 8.5 cm (W) x 3.8 cm (depth) Stage IV pressure ulcer to her sacrococcyx. A review of the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate a resident's risk of developing a pressure ulcer) indicated Resident 11 scored 15 on 6/14/16 and 11 on 1/30/17. A total score of 10 12 indicates a high risk for pressure ulcer development, and 15 to 18 indicates at risk for pressure ulcer development. A review of the initial and quarterly Minimum Data Set (MDS a standardized assessment and care planning tool) dated 6/21/16 and 3/24/17, indicated Resident 11 was assessed with [REDACTED]. During multiple observations on 4/5/17 at 7:45 a.m., 8:45 a.m., 9:50 a.m., 10:55 a.m., 11:52 a.m., 12:50 p.m., 1:48 p.m., 2:50 p.m., 3:55 p.m., 4:25 p.m.; and 4/6/17 at 6:15 a.m., 7:35 a.m., 8:55 a.m., 9:20 a.m., Resident 11 was observed lying on her back in bed with a [DEVICE] (draws out fluid from the wound and increases blood flow to the area) attached to her sacrococcyx pressure ulcer. The resident had left sided weakness due to [MEDICAL CONDITION] ([MEDICAL CONDITION] an interruption of the blood supply to part of the brain) and was nonverbal. On 4/6/17 at 9:30 a.m., CNA 1 (Certified Nursing Assistant 1) was interviewed in the presence of ADON (Assistant Director of Nursing). CNA 1 stated he was the regular caregiver of Resident 11. He was aware the resident had a pressure ulcer to her sacrococcyx. He had an in service training regarding turning and repositioning the resident every two hours in bed to prevent skin breakdown. CNA 1 stated he was unable to turn and reposition Resident 11 every two hours because he was busy taking care of another resident. CNA 1 stated when the resident was lying on the site of pressure ulcer it would get bigger due to pressure. CNA 1 stated no one told him not to reposition Resident 11 on her back. During the treatment observation on 4/6/17 at 11:15 a.m., TN 1 (Treatment Nurse 1) measured the pressure ulcer. Resident 11 was observed with 10 cm (L) x 9.2 cm (W) and 1.5 cm in depth Stage IV pressure ulcer to her sacrococcyx. The pressure ulcer had 4 cm undermining from 10 to 2 o'clock. The wound bed had small amount of yellow slough (dead tissue). TN 1 cleansed the sacrococcyx pressure ulcer with Normal Saline (sterile mixture of salt and water), applied foam dressing and clear tape, and attached the canister [DEVICE] to the pressure ulcer. On 4/6/17 at 9:45 a.m., the medical record of Resident 11 was reviewed with MDS 1 (Minimum Data Set Nurse 1). The initial Care Plan for pressure ulcer prevention, dated 6/15/16, indicated Resident 11 was at risk for skin breakdown due to poor mobility, incontinence of bowel and bladder and fragile skin. The Care Plan interventions included turning and repositioning Resident 11 every two hours and as needed while in bed. The Care Plan interventions for unstageable coccyx pressure ulcer dated 7/21/16, unstageable sacrococcyx pressure ulcer dated 7/29/16, and Stage IV sacrococcyx pressure ulcer dated 8/30/16 and 1/30/17, were not revised to indicate which specific side the resident's body should be turned and repositioned every two hours while in bed to prevent further skin breakdown and to promote healing of the pressure ulcer. MDS 1 stated, I thought repositioning and turning the resident every two hours in bed was enough. He stated when Resident 11 was lying directly on the pressure ulcer it will not heal due to pressure. On 4/6/17 at 2:45 p.m., an interview with the DON (Director of Nursing) and TN 1 was conducted while reviewing with them the medical record of Resident 11. The DON stated the facility had a written repositioning schedule to turn and reposition, at least every two hours, residents with pressure ulcer and or residents who required assistance in bed mobility. The DON stated Charge Nurse and DSD (Director of Staff Development) were responsible for monitoring the residents repositioning schedule every two hours. TN 1 stated she did not know Resident 11 should not be repositioned on her pressure ulcer. They both stated staff did not have a written or visual monitoring system to ensure a resident with a pressure ulcer was not turned and repositioned directly on a pressure ulcer every two hours while in bed. On 4/7/17 at 11:15 a.m., the DSD was interviewed in the presence of the DON. The In Service meeting minutes dated 3/9/17, indicated to turn and reposition the resident every two hours off bony prominence area of the body to prevent skin breakdown. CNA 1 attended the in service training on 3/9/17. The DSD stated she in serviced the CNAs not to reposition the resident directly on the pressure ulcer. The in service training on 3/9/17 did not indicate the CNAs were educated for proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. The DSD stated she was responsible for spot checking the CNAs if the residents were being turned and repositioned every two hours in bed on all shifts. The DSD stated spot checking of the CNAs should be done every day. She did not spot check CNA 1 to see if Resident 11 was not repositioned on her sacrococcyx pressure ulcer. The DSD stated the last time she spot checked the CNAs was on 3/31/17. According to Medical Surgical Nursing Ninth Edition pages 186 187, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. 2. A review of the Admission/Readmission Data Collection dated 9/24/15, indicated Resident 17 was admitted to the facility without a pressure ulcer. Resident 11's [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], indicated Resident 17 was assessed with [REDACTED]. A review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/24/15, indicated Resident 17 scored 14 which indicated the resident was at moderate risk of developing pressure ulcer. A review of the Change of Condition SBAR dated 1/27/17, indicated Resident 17 was assessed with [REDACTED]. On 2/28/17, the wound doctor notes indicated the resident's pressure ulcer had progressed to 1.1 cm (L) x 2.8 cm (W) unstageable left lateral heel pressure ulcer. On 4/5/17 at 1:50 p.m., Resident 17 was observed lying on her back in bed. TN 1 lifted the blanket and the resident's heels were observed resting on the mattress. The resident's legs were observed contracted (shortening and hardening of the muscles and tendons often leading to deformity and rigidity of the joints). Her right leg was crossed over the left leg. Her left heel was observed with a dressing. Resident 17 stated her left heel hurts like hell. Further observation on 4/5/17 at 2:55 p.m., and 4:05 p.m., the resident's heels were still resting on the mattress and there was no foot cradle (a frame placed over the body of a bed to keep sheets and blankets off the resident's feet to provide pressure relief and ventilation to the feet) on bed. On 4/6/17 at 7:40 a.m., 8:50 a.m., and 2:00 p.m., Resident 17's heels were also observed resting on the mattress. The foot cradle was on the resident's bed. On 4/6/7 at 2:10 p.m., the treatment observation was conducted in the presence of the Assistant Director of Nursing. Resident 17 was observed with an unstageable pressure ulcer to her left lateral heel. TN 1 measured the resident's pressure ulcer 1.5 cm (L) x 2 cm (W) . The wound bed had 100 percent yellow green slough. TN 1 cleansed the left lateral heel pressure ulcer with Normal Saline, applied Santyl ointment ([MEDICATION NAME] ointment), and covered the pressure ulcer with dry dressing. During an interview on 4/6/17 at 2:28 p.m., CNA 2 stated Resident 17 was totally dependent in bed mobility. She was aware the resident had a pressure ulcer to her left heel. CNA 2 stated no staff member informed her to float Resident 17's left heel on a pillow while in bed. She was informed by a licensed staff (forgot her name) to only put a pillow under the resident's leg for comfort. CNA 2 stated she was not in serviced on how to properly position a resident with pressure ulcer of the heel. CNA 2 stated when the resident's left heel pressure ulcer was resting on the mattress the wound will get bigger and the resident will have pain. She did not know Resident 17 had a doctor's order to apply a foot cradle on bed until 4/6/17. CNA 2 stated she was the regular caregiver for Resident 17. During a record review and concurrent interview with DON and MDS 1 on 4/6/17 at 3:40 p.m., the initial Care Plan for pressure ulcer prevention for Resident 17, dated 9/25/15, indicated Resident 17 was at risk for pressure ulcer related to immobility and incontinence. The Care Plan interventions included positioning the resident with pillows to maintain proper body alignment whenever necessary and to provide pressure relieving device (unspecified). Resident 17 developed deep tissue injury pressure ulcer to her left lateral heel on 1/27/17, and the wound had progressed to unstageable pressure ulcer on 2/28/17. The Care Plan intervention, dated 1/27/17 and 2/28/17, indicated the heels were to be floated when Resident 17 was in bed. On 2/10/17, the physician ordered a foot cradle to be applied on Resident 17's bed for pressure ulcer management. The DON stated that the Charge Nurse and DSD were responsible in monitoring the care given to Resident 17 to ensure the resident's left lateral pressure ulcer was floated on the pillow while in bed. MDS 1 stated that Resident 17 had a foot cradle on bed but he did not know who removed the resident's foot cradle. On 4/7/17 at 11:15 a.m., the staff in service training records for pressure ulcer prevention were reviewed with DSD and DON. The In Service Meeting Minutes dated 4/18/16, 7/1/16, 7/20/16, and 3/9/17 did not contain information staff were educated about proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. There were no lesson plans for the staff in service training of pressure ulcer prevention conducted on the above dates. In addition, the facility had a total of 42 CNAs, however, the DSD stated all CNAs did not receive the training because all of them were not working on the days of the in service. The DSD stated she did not reschedule the in service training because she got busy. The DSD stated she was aware that the lesson plans were to be done and attached to the in service training sign in sheets but failed to do so.

Based on observations, interviews and record reviews, the facility failed to prevent and provide treatment and services for one of 20 sampled Residents (Resident 3) who had a history of [REDACTED]. As a result, Resident 3 developed two pressure ulcers and was not provided with treatment to promote healing of the pressure ulcers for nine days that lead to worsening and/or non-healing of the pressure ulcer. Findings: During multiple observations on June 20, 2013 at 6:10 p.m., June 21, 2013 at 12:30 p.m. and 3:27 p.m., Resident 3's heels were resting on the mattress. Resident 3's admission face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated June 12, 2013, indicated the resident was able to understand and be understood, required total assistance to reposition self in bed and for activities of daily living. The section for skin condition indicated the resident was at risk of developing pressure ulcers and had one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The location of the pressure ulcer was not specified) According to the resident's initial nursing admission assessment dated [DATE], Resident 3's skin had a Stage 4 pressure ulcer to the left heel. On June 22, 2013 at 10:30 a.m., a skin assessment was conducted on Resident 3 by the treatment nurse 1 and in the presence of the certified nursing assistant (CNA) 3. The body check revealed the resident had redness that was non-blanchable (abnormal redness) to the right heel. The left heel was observed to have a dark purplish discoloration near an already existing and identified Stage 4 pressure ulcer. Treatment Nurse described the dark purplish discoloration as a deep tissue injury that measured 1.7 inches in length by 0.6 inches in width. A review of the Braden Scale, used for predicting pressure ulcer risk dated June 11, 2013, indicated that Resident 3's score was noted as 13, which represents a moderate risk for pressure ulcer development (very high risk total score < 9, high risk total score 10-12, moderate risk total score 13-14, at risk total score 15-18). A review of the pressure ulcer care plan last reevaluated on June 2013, indicated to conduct daily body checks to monitor for skin injury, to monitor for skin redness and to notify physician promptly. Additionally a subsequent care plan for altered skin integrity pressure ulcer last reevaluated on May 24, 2013, indicated for the left heel Stage 4 pressure ulcer the staff was to float the heels while the resident was in bed. A review of the resident's weekly skin data collection dated June 13, 2013, indicated the resident developed redness on the right and left heels heels (pressure ulcer stage was not specified). However, there was no documentation that the physician had been notified of the change in the resident's skin condition. During an interview with CNA 3 on June 22, 2013 at 10:40 a.m., she stated the resident is to have pillows under her heels; however, the resident kicks them off. During a review of Resident 3's clinical record and an interview with Treatment Nurse 1 on June 22, 2013, at 2:07 p.m., she stated she was unable to find a recent skin assessment that documented the progression of the redness of the pressure ulcers of left heel by a licensed nurse nor that the physician was notified of the pressure ulcers to the two heels. In addition, she stated no treatment had been given to the resident for the two pressure ulcers, since it was identified by the Treatment Nurse 2 on June 13, 2013. The resident had the two pressure ulcers for nine days however; no treatment was obtained or provided. During an interview with the Treatment Nurse 2 on June 22, 2013 at 2:41 p.m., she stated she did not report the resident's pressure ulcer of the left and right heel to the physician nor did she document them in the resident's clinical record. The facility's policy and procedure titled, "Wound Care" dated October 2010, indicated any change in the resident's condition needs to be documented in the resident's medical record.