Every finding on record at Sacramento Post-Acute

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:Several kitchenware found not in sanitary manners and stored away in the clean and ready-to-use storage areas;The arrangement of the raw meat stored in the walk-in refrigerator were not in a food safety manner;The ice machine was not clean; andOne microwave designated for residents' food was not clean and not well maintained.These failures had the potential to result in food contamination which could cause illness for 71 medically [NAME] residents who received food prepared from the facility kitchen. The census was 89.Findings:1. During the kitchen observations on 2/17/26 at 9:03 a.m. and 9:06 a.m., the following items found issues and stored in the clean and ready-to-use storage areas:Two full sheet metal pans stacked wetTwo half sheet metal pans stacked wetFive quarter (1/4) sheet metal pans stacked wetOne muffin baking pan with brown substancesA concurrent interview with Dietary Manager (DM), DM confirmed and stated the sheet pans were wet and should be air-dried before stored away to prevent the moisture to promote bacteria growth. DM confirmed and stated the brown substances on the muffin baking pan were food crumbs and stated they should be clean before stored away. DM stated the dietary staff who put away the sheet pans and dishes should check them before they were stored away. A review of the facility P&P titled, Dishwashing, dated 2023, indicated, . 1. Gross food particles shall be removed by careful scraping and pre-rinsing in running water, 5. Dishes are to be air dried in racks before stacking and storing.A review of the facility P&P titled, Sanitation, dated 2023, indicated, .All utensils.equipment shall be kept clean.2. During an observation in the walk-in refrigerator on 2/17/26 at 9:08 a.m., it was noted there were several containers and pans of thawing raw meat stored at the same level on the bottom level of the storage rack, including: a container of raw bacon, a container of raw chicken, a container of raw pork, a container of raw ground beef. In addition, there were a pan of raw sausage patties and a pan of raw bacon stacked together and placed on top of all containers of the raw meat.A concurrent review of the undated poster posted on the refrigerator titled, Proper Food Storage in Refrigerators and Freezers, showed there were five levels of storage as followed:First level (Top Level): produce, cooked and ready-to-eat foodsSecond level: Fish, eggs, (cook temperature of 145 degrees Fahrenheit [F])Third level: raw beef, raw pork (cook temperature of 145 degrees F)Fourth level: raw ground meats (i.e. hamburger, sausage) (cook temperature of 155 degrees F)Fifth level (bottom level): raw poultry (chicken, turkey, duck) (cook temperature of 165 degrees F)A concurrent interview with the Registered Dietitian (RD) and the DM, they confirmed and stated the arrangement of the raw meat stored in the refrigerator was not correct and they needed to be rearranged properly.According to 2022 Food and Drug Administration (FDA) Food Code, Annex 5, indicated, .food storage areas for proper storage, separation, segregation, and protection form contamination.raw animal foods should be separated by cooking temperatures such that food requiring a higher cooking temperature, like chicken, should be stored below or away from foods requiring a lower temperature, like pork and beef.3. A concurrent observation of the ice machine and interview of the Maintenance Director (MD) was conducted on 2/17/26 at 10:41 a.m. The MD stated he was responsible for the cleaning and sanitizing of ice machine monthly and the last cleaning and sanitizing was completed on 2/1/26. The MD dissembled the top (machinery) part of the ice machine; it was noted there were white powdery substances on the water curtain (a plastic cover rest on the ice making panel to redirect the ice to the ice storage bin) and the substances could not be removed when wiping the paper towel. The MD confirmed and stated the white substances were calcium deposit and hard to remove. Then it was noted there were significant black substances found on the bottom of the evaporator unit (a unit where to make ice). The black substances were able to remove by wiping the paper towel and were rough to touch. The MD confirmed the findings and agreed the ice machine was not clean. the MD stated he usually used brushes to clean the rims of the ice making panel and the bottom of the evaporator during the monthly cleaning and sanitizing. He stated he might not be cleaning and scrubbing enough. The MD stated he was aware of the bottom surface of the evaporator was rough because of the calcium buildup. He further stated the rough surface would easily hold the dirt and bacteria. MS stated there was no water filter installed for the ice machine.During an interview with the RD on 2/19/26 at 11:16 a.m., the RD stated the ice was food and the ice machine should be clean and well maintained.A review of [Manufacturer's Name] Ice Machine Installation, Operation and Maintenance Manual, dated 11/18, indicated, .If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. In addition, during cleaning with cleaner solution, .use a nylon brush or cloth to thoroughly clean the following ice machine areas: side walls, base (area above the water trough), evaporator plastic parts - including top, bottom and sides, and bin or dispenser. During sanitizing with sanitizer solution, .use a spray bottle to liberally apply the solution. When sanitizing, pay particular attention to the following areas: side walls, base (area above the water trough), evaporator plastic parts - including top, bottom and sides, and bin or dispenser.According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae).In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits.4. During an observation of the microwave designated for residents' food located in the utility room at the subacute station on 2/17/26 at 1:40 p.m., it was noted the interior of the microwave had orange and red splashes on the top and there was interior metal coating lining chipping off.During an interview with the MD on 2/17/26 at 1:50 p.m., the MD confirmed and agreed the microwave was not clean. He stated the janitor was scheduled to clean the microwave twice a day and the nurses would clean it as needed if splashes or spills occurred.During a follow-up interview with the MD on 2/18/26 at 8:01 a.m., the MD stated and agreed the interior lining material of the microwave was chipping. He further stated the microwave needed to be replaced.A review of facility policy and procedures titled, Sanitization, dated 2001, indicated, All utensils.equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.

Based on observation, interview, and record review, the facility failed to follow infection control and prevention practices for a census of 89. when:Two certified nursing assistants (CNAs) did not follow the Enhanced Barrier Precautions (EBP-infection control measures that require staff to wear gowns and gloves during high-contact care, such as dressing, transferring, or changing linen) required during resident's care;Five packs of adult briefs and three elongated packs of vinyl plank flooring covered with whitish-to-brownish substances were inside the dusty floor of the linen storage room [ROOM NUMBER]; A resident's indwelling urinary catheter (IUC, flexible tube inserted through the urethra into the bladder to continually drain urine into an external collection bag) urine drainage bag was sagging and touching the floor; and, Two residents' respiratory equipment were touching the floor. These failures had the potential to increase the risks of cross-contamination, airborne contaminants, and spread infectious diseases to a vulnerable population Findings: 1.a. During an observation on 2/17/26 at 2:09 p.m. in room [ROOM NUMBER], room [ROOM NUMBER]A had a purple dot stuck to his name (means the resident is on precautions) and an EBP signage which required complete Personal Protective Equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) must be worn during resident's high contact care which included transferring. CNA 4 transferred Resident 3A from his bed to his wheelchair and did not wear the complete EBP-PPE required. During a concurrent observation and interview on 2/17/26 at 2:09 p.m., CNA 4 confirmed he did not use the EBP-PPE required when he transferred Resident 3A from his bed to his wheelchair. CNA 4 stated he should have followed the EBP-PPE to prevent the spread of infection from one resident to another. 1.b. During another observation on 2/18/26 at 10:30 a.m. in room [ROOM NUMBER], room [ROOM NUMBER]A had a purple dot stuck to his name and an EBP signage. which required complete PPE must be worn during high contact care which included changing soiled linens. CNA 3 changed the soiled pillowcases, bed sheets and cover sheets and did not wear the required EBP-PPE. During a concurrent observation and interview on 2/18/26 at 10:30 a.m., CNA 3 confirmed she removed the soiled linens in room [ROOM NUMBER]A and did not wear the required EBP-PPE. CNA 3 stated she should have been more careful and followed the required PPE when changing soiled linens, but she did not. During an interview on 2/18/26 at 4:29 p.m. with the Infection Prevention Nurse (IPN), the IPN stated she expected the staff to follow the PPE requirements with residents on EBP. The IPN stated not following the EBP- PPE as required could lead to increase spread of infections and staff contamination. 2. During an observation on 2/18/26 at 1:20 p.m., the following were found inside the linen storage #2: (1) Six big packs of adult brief stored on the floor, and (2) three elongated packages of vinyl plank flooring materials covered with whitish to creamy-like substances were found in the dusty floor. During a concurrent observation and interview on 2/18/26 at 1:20 p.m. with the Director of Nursing (DON), the DON confirmed the findings inside the linen storage area #2. The DON stated the adult brief should be stored off the floor and the three packs of vinyl plank flooring materials should not be stored in the linen storage area #2. The DON also stated the floor of the linen storage should be kept clean to prevent environmental contaminants which could cause musty odor, molds and pests. The DON stated nothing else should be stored in the linen storage area except clean and organized linens. 3. During an observation on 2/20/26 at 8:36 a.m., one resident from room [ROOM NUMBER]B had his urine drainage bag sagged with urine and was touching the floor while the resident wheeled himself out of his room down to the hallway going to the front door. During a concurrent observation and interview on 2/20/26 at 8:36 a.m., with the Assistant Director of Nursing (ADON), the ADON confirmed the findings for the resident wheeling out of his room with the urine bag on the floor. The ADON stated the resident on IUC should have been checked if the urine bag was emptied before allowing the resident to wheel himself out of his room. The ADON emptied the catheter urine bag and confirmed the content of the bag measured 300 milliliters of urine. The ADON stated the urinary bag must never touch the floor. The ADON stated the dirty floors harbor pathogens which could contaminate the urinary bags, and the contaminated bags could spread to other surfaces including the resident's bed. During an interview on 2/20/26 at 11:45 a.m., with the Director of Nursing (DON, the DON stated, urinary bags must never touch the floor for infection control. A review of the facility's infection prevention signages posted by the residents' doors, the EBP – PPE indicated: providers and staff must wear gloves and gown for the following high contact resident care activity such as.transferring.changing linens . During a review of the facility's policy and procedure (P&P) titled, ENHANCED BARRIER PRECAUTIONS, dated 12/24, the EBP indicated, Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms (MDROs- bacteria or other germs that have developed resistance to multiple, or all, types of commonly used antibiotics or antifungal medications. These superbugs are difficult to treat, often spreading rapidly in healthcare settings, and can cause serious infections like pneumonia, bloodstream infections, or wound infections) to residents . 4. During an observation on 2/17/26 at 9:06 a.m. in room [ROOM NUMBER] B and room [ROOM NUMBER] B room, room [ROOM NUMBER] B and 27 B residents received tracheostomy humidification equipment (THE, respiratory equipment that provides moisturized air to the lungs through Tracheostomy Corrugated Tubing Collection System [TCT, an aerosol drainage bag attached to the plastic breathing tube of a patient with a tracheostomy] to keep lung secretions thin and avoid mucus plugs. room [ROOM NUMBER] B and 27 B TCT was found on the floor. During a concurrent observation and interview on 2/18/26 at 2:15 p.m. with the Respiratory Therapy Supervisor (RTS) in room [ROOM NUMBER] B, the RTS confirmed that the TCT was touching the dirty floor. During an interview on 02/18/26 at 4:40 p.m. with the IPN, the IPN indicated it was not the expectation for TCT to touch the floor and stated the TCT on the floor could have the possibility to harbor dirty organisms that could be transferred to the residents. During an interview on 2/19/26 at 9:01 a.m. with LN 9, LN 9 stated she expected TCT to be hung to avoid germs and patient illness. During an interview on 2/20/26 at 10:40 a.m. with the DON, the DON stated she expected the TCT not to be on the floor and that it was an infection control issue and could be stepped on. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2022, Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment.). Such devices should be free from all microorganisms although small numbers of bacterial spores are permissible .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5% for two of 23 sampled residents (Resident 76 and Resident 11) when:1. Licensed Nurse (LN) 5 applied a medication patch not in accordance with the Physician's Orders (POs) for Resident 76;2. A medication was not available for timely administration for Resident 76 by LN 5; and3.LN 5 administered the wrong dose of a medication to Resident 11. These failures resulted to three errors identified out of 29 opportunities for error during the observation of medication administration with the facility's medication error rate of 10.34%.Findings:1. During a medication administration observation on 2/17/26 at 7:57 a.m., LN 5 applied a lidocaine transdermal patch (a patch that delivers pain relieving medication through the skin) 5% to Resident 76's left knee.During a reconciliation of Resident 76's POs on 2/17/26 at 1 p.m., the PO indicated: Lidocaine External Patch 5% apply to the right knee once daily for knee pain and remove as scheduled.During a review of Resident 76's Medication Administration Record (MAR) on 2/17/26, the MAR indicated the transdermal patch was applied to Resident 76's left knee.During an interview on 2/17/26 at 1:20 p.m. with LN 5, LN 5 confirmed that the PO required the lidocaine patch to be applied to Resident 76's right knee, not the left knee. LN 5 stated that she should have contacted the physician to update the order.During an interview on 2/19/26 at 1:03 p.m. with the Director of Nursing (DON), the DON stated that licensed nurses were expected to follow physician orders.2. During an observation of medication administration on 2/17/26 at 7:57 a.m., LN 5 prepared and administered Resident 76's medications, which did not include losartan (a medication used to treat high blood pressure).During a reconciliation of Resident 76's PO on 2/17/26 at 1 p.m., dated 3/24/25, the PO indicated: Losartan Oral Tablet 25 mg. Give 25 mg by mouth one time a day for HTN (hypertension-high blood pressure).A review of Resident 76's MAR dated 2/17/26 indicated the resident did not receive his scheduled dose of losartan on 2/17/26.During an interview on 2/17/26 at 8:07 a.m. with LN 5, LN 5 stated that Resident 76's losartan was not available for administration.During an interview on 2/19/26 at 1:03 p.m., the DON stated that LNs were expected to follow physician orders and ensure all medications were available during medication administration.3. During an observation of medication administration on 2/18/26 at 9:38 a.m., LN 5 administered one tablet of Vitamin D (cholecalciferol, a medication used to prevent and treat Vitamin D deficiency) 10 mcg (microgram, a unit of weight) to Resident 11.During a reconciliation of Resident 11's current POs, dated 8/27/25, the PO indicated: Cholecalciferol Tablet [Vitamin D 3] 1000 UNIT [1000 unit = 25 mcg] Give one tablet by mouth one time a day for supplement.During an interview on 2/18/26 at 10:28 a.m. with LN 5, LN 5 stated that two and a half tablets of Vitamin D 3 should have been administered to Resident 11 in accordance with the PO to ensure the correct dosage. LN 5 further stated that administering too little or too much could cause adverse symptoms in the resident.During an interview on 2/19/26 at 1:03 p.m. with the DON, the DON stated that licensed nurses were expected to follow PO.During a review of the facility's policies & procedures (P&P) titled Medication Administration, dated 4/2023, the P&P indicated: Medications are administered in a safe and timely manner, and as prescribed. The P&P further stated: Policy Interpretation and Implementation. 10. The individual administering the medication checks 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 provide a clean environment for the residents and visitors for a census of 89, when one of one garbage dumpster, located outside the facility, was not closed securely with the dumpster lid.This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility.Findings:During an observation of the dumpster area outside the kitchen on 2/17/26 at 7:59 a.m., noted one of one garbage bin was not securely covered by the lid.During an interview with the Dietary Manager (DM) on 2/17/26 at 8:44 a.m., the DM confirmed and stated the garbage bin should be closed securely to prevent pest and rodent infestation. DM stated the maintenance department usually checked the garbage bin and surrounding area every morning and afternoon.During a second observation of the dumpster area outside the kitchen on 2/17/26 at 4:00 p.m., noted the same garbage bin was not securely covered by the lid and observed there were bags of trash inside the garbage bin.During an interview with the Maintenance Director (MD) on 2/18/26 at 8:01 a.m., the MD stated the maintenance department was responsible for monitoring the dumpster area. He stated the garbage bin needed to be closed with the lid.A review of facility policy and procedure titled, Sanitization, dated 2001, indicated, 14. Garbage and refuse containers.waste is properly contained in dumpsters/compactors with lids.According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 5-501.15 Outside Receptacle, (A) Receptacles and waste handling units for refuse.used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and record review, the facility failed to ensure that prescription medications were labeled and that expired medications were not available for a census of 89, when:1. Multiple unlabeled prescription medications were found in the medication room and the treatment cart; and2. Expired wound dressings containing silver were found inside the treatment cart. These failures had the potential to compromise resident safety by increasing the risk of medication errors and the use of ineffective medications.Findings: 1. During an inspection on 2/17/26 at 8:55 a.m. in one out of two medication rooms with Licensed Nurse 7 (LN 7), the following meds were observed stored among other active medications without a resident specific pharmacy label:a. Lidocaine Injection (medication used to treat swelling, bruising, or pain at the injection site) 200mg/20 mL (milliliters, a unit of volume);b. Triamcinolone acetonide (medication used to reduce inflammation, swelling, itching, and redness) 200mg/5mL injectable suspension; andc. Folic acid (vitamin B9, primarily treats and prevents folate deficiency anemia by helping the body produce healthy red blood cells) 1 mg, a prescription box (100 tablet size).During an interview on 2/17/26 at 8:55 a.m. with LN 7, LN 7 stated all the medications were missing the residents' labels. During an interview on 2/17/26, at 9:06 a.m. with the Director of Nursing (DON), the DON indicated that prescription medications must have a label from the pharmacy including the resident's name. The DON further explained that without the resident's name, it was impossible to identify the owner of the medication, and therefore, it should be discarded.During an inspection on 2/17/26 at 2:15 p.m. of the skilled treatment cart with LN 6, the following prescription tubes had missing resident-specific labels: a. Nystatin (antifungal medication used to treat yeast infections of the skin) ointment 100,000U (units, unit of measure), a 30 g (gram, unit of measure) tube;b. Triamcinolone acetonide (used to relieve skin inflammation, itching, redness, and swelling) cream 0.5% (percentage, unit of measure), a 15 g tube;c. Collagenase Santyl (used to remove dead tissue) ointment 250 u, two 30 g tubes; andd. Mupirocin (used to treat bacterial skin infections) ointment 2%, a 22 g tube.During an interview on 2/17/26 at 2:15 p.m. with LN 6, LN 6 stated that the ointments needed to be discarded when the resident was discharged or sent home with the resident if orders were still active. During an interview on 2/19/26 at 1:03 p.m. with the DON, the DON stated that prescription medications should have a pharmacy label with the resident's name and that LNs were expected to remove and discard expired medications/products from the treatment carts.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/23, the P&P indicated, Medication labeling.2. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. The P&P further indicated, Medication Labeling.8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.2. During an inspection on 2/17/26 at 2:15 p.m. of the skilled treatment cart with LN 6, four expired pieces of Advanced Antimicrobial Ag (Silver) Advantage dressing for wound care were observed stored among other active medications.During an interview on 2/17/26, at 2:15 p.m. with LN 6, LN 6 confirmed that four pieces of Advanced Antimicrobial Ag (Silver) Advantage dressing had expired on 1/1/26. LN 6 mentioned that the wound dressings should have been discarded and removed from the treatment cart. LN 6 further stated that using an expired dressing might be less effective for wound healing.During an interview on 2/19/26 at 1:03 p.m. with the DON, the DON stated that prescription medications should have a pharmacy label with the resident's name and that LN was expected to remove and discard expired medications/products from the treatment carts.During a review of the facility's P&P titled, Medication Storage in the Facility dated 2/23, the P&P indicated, Medication Storage.3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure that one of the 23 sampled residents (Resident 76) received treatment and care in accordance with professional standards of practice, when Licensed Nurse 5 (LN 5) did not notify the physician about the unavailability of Resident 76's blood pressure medication.This failure prevented the physician from providing alternative orders and placed the resident at risk for uncontrolled blood pressure, which had the potential to cause stroke or other adverse effects such as headaches, dizziness, and fatigue.Findings:A review of Resident 76's admission record indicated that Resident 76 was admitted to the facility in 2/2025 with diagnoses which included stroke and high blood pressure.During a medication pass observation and interview on 2/17/26 at 7:57 a.m. with LN 5, LN 5 stated that Resident 76's losartan (a medication used to lower blood pressure) was not available to administer.A review on 2/17/26 at 1 p.m. of the reconciliation of the Physician's Orders for Resident 76's medications dated 3/24/25, indicated: Losartan Potassium Oral Tablet 25 mg. Give 25 mg by mouth one time a day for HTN (hypertension-high blood pressure).A review of Resident 76's Medication Administration Record (MAR) dated 2/17/26 indicated Resident 76 did not receive his scheduled dose of losartan on 2/17/26.During an interview on 2/19/26 at 12:15 p.m. with the Medical Doctor (DR), the DR stated the LN never notified her about the missed losartan dose and that she expected nurses to inform her if a medication was unavailable so she could determine whether alternative orders were needed.During an interview on 2/19/26 at 1:03 p.m. with the Director of Nursing (DON), the DON stated that nurses were expected to inform the physician if a medication was not available so the physician could decide whether to administer the medication upon its arrival or adjust the administration time accordingly.A review of the facility's Policies and Procedures (P&P) titled Medication Administration, dated 3/2023, indicated: Medications are administered in a safe and timely manner, and as prescribed.A review of the facility provided P&Ps indicated that they did not include guidance for nursing staff to follow when a medication was unavailable, such as steps for timely physician notification or actions to ensure continuity of care.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 38), when Resident 38's Bowel and Bladder Toileting Program (B&BTP) was not implemented with focused measurable objectives. This failure had the potential to negatively impact Resident 38's quality of life, and the care and services received.A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility in early 2026, as his own responsible party, with a diagnosis of benign prostatic hyperplasia (BPH, prostate enlargement which causes bladder dysfunction occurring in men), and a stool incontinence. A review of Resident 38's Order Summary Report, indicated physician orders on 1/27/26 for a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine); and on 1/30/26 for a [B&BTP], with no end date. A review of Resident 38's Care Plan Report, initiated 1/27/26, indicated there was no care plan focus, goal, or intervention for the B&BTP. During an interview on 2/17/26 at 9:45 a.m., with Resident 38, Resident 38 stated when in the gym for exercises, felt embarrassed with his stool incontinence, and had not fully participated due to the urinary catheter bag and tubing. Resident 38 stated frustration with staff's lack of communication and concern related to his B&B care. During a concurrent interview and record review on 2/19/26 at 10:25 a.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed there was no care plan focus for a B&BTP for Resident 38. LN 3 stated a care plan was important to monitor progress, for re-evaluation, and for quality of care. During a concurrent interview and record review on 2/20/26 at 10:15 a.m., with the Director of Nursing (DON), the DON confirmed there was no care plan focus for a B&BTP for Resident 38. The DON stated her expectations were for staff to carry out the physician's orders, provide communication, and to develop the care plan. The DON stated these procedures were important to meet the needs and rights of the residents. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 2/2021, the P&P indicated, .be informed of, and participate in, his.care planning and treatment. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, .is consistent with the resident's rights to participate.reflects problem areas and conditions.Assessments.are ongoing and care plans are revised.

Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve his or her ability to carry out the activities of daily living for one of 23 sampled residents (Resident 61), when the eye patch (specialized, often concave, devices used to cover, protect, or treat an eye abnormality) was not worn during lunch time as ordered by the physician. This failure had the potential to result in the decline of Resident 61's functional independence during meals. Findings:During a review of Resident 61's admission Record (AR) dated 6/9/14, the AR indicated, he had diagnoses which included ptosis (droopy eye caused by weak eye muscles which may block vision) of left eyelid, glaucoma (a common eye disease that causes slow and silent vision loss), and left facial droop.During a review of Resident 61's Physicians Order (PO) dated 11/24/25, the PO indicated, Restorative Nursing Assistant [RNA, specialized training in restorative care] for dining program: Patient to wear eye patch on his left eye during lunch time or as tolerated.During a review of Resident 61's Care Plan (CP) dated 2/19/26 titled, At risk of decline in self-feeding task d/t [due to] incoordination. Goal: to improve self-feed with use of eye patch d/t incoordination .Intervention: Patient to wear eye patch to left eye during lunch time or as tolerated.During a dining observation on 2/17/26 at 12:37 p.m., Resident 61's lunch was served, his hands had tremors, spilled a lot of his food, and no eye patch was applied to his Left eye.During a concurrent observation and interview on 2/17/26 at 12:37 p.m., with the RNA/Certified Nurse Assistant 2 (RNA/CNA 2), RNA/CNA 2 confirmed Resident 61 did not wear the eye patch to his left eye.During an interview on 2/17/26 at 2:36 p.m., Resident 61 stated the eye patch was not applied when he ate his lunch. Resident 61 stated he did not know where the eye patch was.During a concurrent observation and interview on 2/18/26 at 1:31 p.m. with CNA 1, CNA 1 confirmed Resident 61 ate his lunch without the eye patch.During a concurrent interview and record review on 2/18/26 at 1:40 p.m. with the Assistant Director of Nursing (ADON), Resident 61's clinical record was reviewed. The ADON confirmed Resident 61 had an order to use the eye patch when in dining as tolerated. The ADON stated the eye patch should be applied to manage Resident 61's double vision and to strengthen his weaker eye. The ADON confirmed that by not using the eye patch as ordered, Resident 61's functional eyesight could deteriorate more.During a concurrent interview and record review on 2/19/26 at 1:28 p.m., with the Occupational Therapist (OT), Resident 61's clinical record was reviewed. The OT confirmed the eye patch was used to help Resident 61's double vision. The OT stated the use of the eye patch would strengthen Resident 61's focus during mealtime and less food spillage. During an interview on 1/20/26 at 11:30 a.m. with the Director of Nursing (DON), the DON stated, she expected the staff to follow the PO.During a review of the facility's Policy and Procedure (P&P), titled, ASSISTIVE DEVICES AND EQUIPMENT, dated 2/21, the P&P indicated, Facility maintains and supervises the use of assistive devices and equipment for residents. 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided .During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/18, the P&P indicated, Residents will be provided with care, treatment services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Based on observation, interview, and record review, the facility failed to provide quality care and dignity to maintain good grooming for one of 23 sampled Residents (Resident 65), when Resident 65 had sweaty smell and scattered white flakes on his scalp, strands of his hair, ears, face and neck. This failure resulted to Resident 65's with unkempt appearance and not attaining his highest practicable physical, mental and psychological well-being.Findings:During a review of Resident 65's admission Record (AR) dated 3/5/21, the AR indicated, Resident 65 was admitted with diagnoses which included traumatic brain injury (TBI, a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) and abnormal posture.During a review of Resident 65's Physician's Order (PO) dated 10/8/24, the PO indicated, Resident 65 cannot understand rights and responsibilities and/or able to participate in treatment plan.During a review of Resident 65's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/6/25, the MDS indicated, Resident 65 required moderate assistance with personal hygiene.During an observation on 2/17/26 at 10:02 a.m. and on 2/19/26 at 8:03 a.m., Resident 65 laid in bed, appeared stiff, his scalp, hair strands, ear, neck and face smelled sweaty and white flakes were scattered over his scalp, hair strands, ear, neck and face.During a concurrent observation, interview, and record review on 2/19/26 at 9:37 a.m., with Licensed Nurse 1 (LN 1), LN 1 inspected the head, face, ear, neck, hair stands and scalp of Resident 65. LN 1 confirmed the sweaty smell and the scattered flakes around Resident 65's face, scalp, hair strands, ear and neck. LN 1 confirmed there was no documented evidence Resident 65's sweaty and flaky condition was reported to the physician. LN 1 stated Resident 65 should be clean, smell free and flake free.During an interview on 2/20/26 at 11:45 a.m. with the Director of Nursing (DON), the DON stated, Residents should be clean, smell and flake free. The DON stated that the sweaty smell and flaky condition should have been reported to the MD for proper treatment.During a review of the facility's policy and procedure (P&P), titled, ACTIVITIES OF DAILY LIVING (ADL), SUPPORTING, dated 3/18, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure safe and quality care services were provided for two of twenty-three sampled residents (Resident 67 and Resident 1) when:Resident 67 indwelling urinary catheter (IUC, a flexible tube inserted into the bladder to continuously drain urine, typically used when a patient cannot urinate on their own) smelled foul odor of urine and the tubing had creamy-white-brownish encrustation (forms when minerals and other debris accumulate inside the catheter or drainage bag) The physician was not notified of creamy-white encrustation in Resident 1's IUC. These failures had the potential for Resident 67 and Resident 1 to develop complications including blockage of urine flow, urine leakage, bladder pain, and recurrent urinary tract infections (UTIs). Findings: During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was admitted with diagnoses which included urine retention, neuropathic bladder (nerve damage causing loss of bladder control) and benign prostatic hyperplasia (BPH, enlargement of the prostate). During a review of Resident 67's Physicians' Order (PO), dated 9/3/24, the PO indicated, Indwelling Urinary Catheter Irrigate with 100 milliliters (ml, unit of measurement) of normal saline as needed (clogging) and notify MD [physician] as needed. During a review of Resident 67's Care Plan (CP), dated 7/11/25, the CP indicated, [Resident 67] has IUC related to Diagnoses of Flaccid (hanging loosely) neuropathic bladder, BPH and retention of Urine. The CP interventions indicated, .provide catheter care every shift, and monitor and report to MD for signs and symptoms of urinary tract infection: including pain, burning, blood-tinged urine, cloudiness, no output, foul smelling of urine . During a concurrent observation and interview on 2/17/26 at 1:46 p.m., Resident 67 had a foul-smelling urine, and the IUC tubing had creamy-white-brownish encrustation. Resident 67 stated, It hurts when I pee [urinate]. During a concurrent observation, interview, and record review on 2/19/26 at 9:49 a.m. with Licensed Nurse 1 (LN 1), Resident 67's clinical record was reviewed. LN 1 confirmed the findings that Resident 67's had foul smelling urine and the IUC tubing had creamy-white-brownish encrustation. LN 1 also confirmed the IUC tubing was last flushed on 6/7/25 and had not been flushed since then. LN 1 confirmed there was no documented evidence that indicated the IUC tubing was regularly flushed. LN 1 stated it was important to regularly flush and care for the IUC tubing to prevent infection and also of patients' rights. LN 1 stated she did not like to see that kind of IUC tubing encrustation and the foul-smelling urine connected to her or to her loved ones. During an interview on 1/20/26 at 11:30 a.m. with the Director of Nursing (DON), the DON confirmed the IUC tubing with creamy-white-brownish encrustation should be changed to prevent infection. During a review of the facility's policy and procedures (P&P) titled, CATHETER CARE, URINARY, dated 8/22, the P&P indicated, The purpose of the procedure is to prevent urinary- catheter associated complications, including urinary tract infection . Changing catheters #3: Residents who form encrustations that can quickly lead to obstruction need more frequent catheter changes (i.e. weekly or twice weekly) at intervals specific to the individual resident. The catheter should be changed before blockage is likely to occur. 2. During a review of Resident 1's AR, the AR indicated Resident 1 was admitted in late 2025 with diagnoses which included bladder dysfunction, and infection due to indwelling urethral catheter. During a review of Resident 1's PO, dated 2/20/26, the PO indicated Indwelling Urinary Catheter: Irrigate with 100 ml of normal saline PRN [as needed] (Clogging) and notify MD as needed. During a review of Resident 1's CP, the CP indicated, Notify physician of signs and symptoms of UTI such as. sedimentation [encrustation]. During a concurrent observation and interview on 2/20/26 at 8:44 a.m. in Resident 1's room, LN 2 confirmed the findings that Resident 1's IUC drainage bag contained urine with visible creamy-white sediment present within the tubing and collection chamber and stated Resident 1's IUC was expected to have yellowish urine with no sediments. and that the physician should be notified to rule out an infection. During a concurrent interview and record review on 2/20/26 at 8:45 a.m. with LN 2, LN 2 Resident 1's clinical record was reviewed. LN 2 confirmed there was no documented evidence that Resident 1's IUC contained encrustation and that the MD was notified. During an interview on 2/20/26 at 8:59 a.m. with LN 3, LN 3 stated, it was expected that staff should check the IUC for color and sediment and if found to notify the physician to avoid pain and sepsis (a widespread infection of the blood). During an interview on 2/20/26 at 9:38 a.m. with the IPN, the IPN stated she expected the staff to identify cloudy, sediment, and foul smelly urine as a possible UTI and report the findings to the charge nurse, IPN, and the physician to rule out a possible infection. During an interview on 2/20/26 at 10:52 a.m., with the DON, the DON stated she expected staff to carry out orders and follow care plans to meet the needs of the patients. During a review of the facility's P&P titled, CATHETER CARE, URINARY, dated 8/22, the P&P indicated, Complication: 1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately: .b. if urine has an unusual appearance . Documentation: The following information should be recorded in the resident's medical record.4. Character of urine such as color. clarity (.solid particles).

Based on observation, interview and record review, the facility failed to ensure the Mince and Moist level 5 (MM5) texture (the food texture is designed for residents who experience biting, chewing, or swallowing limitations. All food must be soft, moist and minced to size [no larger than 4 millimeters (mm) x 15 mm]. The food item size and texture must pass testing requirements, fork test and spoon tilt test) food items prepared properly for one of 23 sampled residents (Resident 9). This deficient practice had the potential to increase risk for Resident 9 with swallowing and chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway).Findings:According to Academy of Nutrition and Dietetics (AND, the organization of food and nutrition professionals, and is a leading source for credible, science-based information on nutrition and health), IDDSI (International Dysphagia Diet Standardization Initiative) diets was recognized to be the only texture-modified diet beginning in October 2021.According to IDDSI, MM5 texture food should be soft and moist. Minced and Moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important the food should not be too sticky which can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. MM5 food much pass the fork test and spoon tilt test. Fork test is to test the size, the food lump size is 4 mm, which is about the gap between the prongs of a standard dinner fork. Spoon tilt test is to test the texture; the food should hold its shape on the spoon and fall off easily if the spoon is tilted or lightly flicked. In addition, the food should not be firm or sticky. (IDDSI source: www.iddsi.org/images/Publications-Resources/PatientHandouts/English/Adults/5_minced_moist_adults_consumer_handout_30jan2019.pdf)Review of Resident 9's medical record, Resident 9 had pertinent diagnosis to nutrition and chewing/swallowing ability which included: hydrocephalus (a condition with abnormal accumulation fluid on the brain that affect the surrounding tissues of the brain), brain tumor, oropharyngeal dysphagia (a condition with difficulty initiating a swallow, causing food to stick in the throat, coughing, choking, or nasal regurgitation due to impaired mouth/throat muscle control), and moderate protein-calorie malnutrition (a nutritional deficiency characterized by weight loss, reduced body fat/muscle mass and decrease of body mass index [BMI]). Resident 9 was on CCHO (consistent carbohydrate) diet (diet to control blood sugar and/or manage diabetes), Minced and Moist level 5, Mildly Thick Liquid (MT2) as ordered on 1/19/26. On the initial nutritional assessment on 7/20/24, indicated Resident 9 required assistance with eating and had chewing/swallowing problems. On the follow-up nutrition notes on 1/19/26, indicated Resident 9 admitted to hospice care.During a dining observation of lunch meal on 2/17/26 at 12:38 p.m., noted Resident 9 was eating her meal with assistance from a Certified Nursing Assistant (CNA). On the meal ticket (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes), indicated Resident 9 was on CCHO, MM5, MT2 diet and dislike pork, chicken thigh, and beef). Noted Resident 9 received MM5 texture breaded fish and MM5 texture fried rice were dry and without any sauce. Observed the texture of the MM5 breaded fish was sticky when the CNA scooped up with the spoon from the plate, and the fish stuck on the spoon and would not slide down easily and smoothly.A concurrent interview with Registered Dietitian (RD), RD confirmed and stated the MM5 breaded fish and MM5 fried rice were dry and without any sauce on them and agreed the MM5 breaded fish was sticky. RD stated the MM5 texture food items should be moist and should not be sticky.During the follow-up interviews with Dietary Manager (DM) on 2/18/26 at 8:52 a.m. and on 2/29/25 at 11:16 a.m., DM stated they used the fork test to test the size of the MM5 texture food items. She stated if the MM5 texture food item stuck on the spoon would not pass the spoon tilt test. She further stated the MM5 food item should be able to slide from the spoon easily. DM stated if the MM5 food item was dry and they needed to add sauce to moisten the food, and the [NAME] needed to follow the recipe and performed the fork test and spoon tilt test to ensure the texture prepared properly.Review of a facility document titled, Recipe: Breaded Fish Fillet, dated 2025, indicated, IDDSI #5/Minced & Moist.Mince until food is in pieces = 4mm by 15mm. Moisten with gravy/sauce.utilize the critical tests and IDDSI audit to confirm texture meets level #5 specifications.Review of a facility document titled, Recipe: Fried Rice, dated 2025, indicated, IDDSI #5/Minced & Moist.Mince until food is in pieces = 4mm by 15mm. Moisten with gravy/sauce.utilize the critical tests and IDDSI audit to confirm texture meets level #5 specifications.Review of a departmental diet manual section titled, IDDSI Level #5: Minced & Moist, dated 2025, indicated MM5 diet has both size and texture specifications that must pass IDDSI level #5 testing requirements.fork pressure, and spoon tilt tests. In addition, it indicated, .moist fish (plain or breaded), without bones, moistened with gravy or sauce.breading on fish, must meet size requirements and be moistened throughout.avoid serving without a sauce or gravy.Rice.that meet size specification, cooked, soft.not sticky, served with a thick sauce.Review of a facility document titled, Job Description - Cook, revised 9/1/16, indicated [NAME] should, follow recipes and prepares foods that correspond to menu cycles.

Based on observation, interview and record review the facility failed to provide appropriate, sufficient supervision to each resident to prevent an avoidable accident for one of two sampled residents (Resident 1) and failed to investigate an accident thoroughly when:Resident 1 fell to the floor while being transferred from her bed to a shower chair, and the facility failed to provide documentation of a fall investigation for Resident 1.These failures had the potential for Resident 1 to sustain a major injury, be exposed to physical pain, increased anxiety from her history of falls, and placed Resident 1 at risk for an unidentified injury from the failure to investigate.During a review of Resident 1's Hospital Discharge Summary dated 1/5/26, summary indicated, Resident 1 had hospital problems including but not limited to Closed pelvic ring fracture (serious injury, often from high-energy trauma like car accidents, causing severe pelvic/groin pain, bruising, and inability to bear weight) and a pubic ramus fracture(a common break in the pelvic ring, typically affecting elderly individuals after a fall. Symptoms include severe groin/hip pain and inability to walk.) Summary indicated, [Resident 1] admitted on [DATE] after a witnessed fall when patient's leg reportedly gave out and fell backward.During a record review of Resident 1's Minimum Data Set (MDS: assessment used in Skilled Nursing Facilities, a mandatory federal tool for evaluating the health, functional, and cognitive status of residents in Medicare/Medicaid-certified nursing homes to guide care planning, and monitor quality) Section C, dated 1/9/26, MDS-C indicated Resident 1 had a brief interview for mental status (BIMS: assessment tool used in skilled nursing facilities (SNFs) to screen resident cognition) was a 15 out of 15, indicating Resident 1 was cognitively intact.During a review of Resident 1's MDS GG, dated 1/9/26, MDS GG indicated, Resident 1 required Substantial/maximal assistance for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair.During an interview on 1/30/25, at 10:02 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 1/9/26 during the morning shift, Resident 1 was being cared for by CNA students and their CNA instructor. CNA 1 stated he told the CNA instructor that Resident 1 preferred a bed bath due to her hip pain from a recent fall and injury. CNA 1 stated, he told the CNA instructor to come get him to help before they attempted to transfer Resident 1 out of bed for the first time so he can help. CNA 1 stated, CNA instructor disregarded his instruction and stated the CNA students and herself got Resident 1 out of bed and into the shower room via the shower chair. CNA 1 stated, he left his gait belt (a wide strap secured around a patient's waist with a metal or plastic buckle. It is used by caregivers to provide a secure, safe grip to assist with balancing, walking, lifting, or transferring individuals with limited mobility.) for the CNA Instructor to use and left the room to care for another Resident. CNA 1 stated he heard a commotion in Resident 1's room and when he arrived back into the room, he heard Resident 1 yelling they dropped me several times. CNA 1 stated, he saw Resident 1 had some redness to her lower legs and Resident 1 complained that her lower legs and back hurt. CNA 1 stated, he saw the gait belt across the room on the table and suspected the CNA instructor did not use the gait belt.During an interview on 1/30/26 at 10:32 a.m., with Resident 1, Resident 1 stated, she was being helped by 3 female students and their teacher to get out of bed for a shower in the shower room. Resident 1 stated, they were trying to get me from my bed to the shower chair, and I told them I was going to fall, when the instructor stated something along the lines of no you're not going to fall we've got you. Resident 1 stated, her legs buckled, and she fell onto her knees on the floor of the ground in her room. Resident 1 stated, the students and teacher could not lift her up from the floor so one of the students yelled for their male student to assist who was outside the room. Resident 1 stated, the male student picked her up off the ground onto the shower chair, and then her CNA (CNA 1) came running in from the noise. Resident 1 stated, CNA 1 was mad at them for not getting him to help with the transfer. Resident 1 stated, CNA 1 told her there was redness to her lower legs and she looked herself and saw the redness. Resident 1 stated, she had anxiety about falling again at the facility because that is the cause of her injury which sent her to the facility in first place.During an interview on 1/30/26, at 3:44 p.m., with anonymous witness (AW) AW stated, she was present in Resident 1's room on 1/6/26 in the morning. AW stated, there were 4 CNA students in the room with the CNA Instructor. AW stated, the group was assisting with Resident 1's shower for the morning and were preparing to transfer her from the bed to a shower chair. AW Stated, Resident 1 told the group she was in pain when they assisted her, so the CNA instructor advised the group to hurry with the transfer. AW stated, three CNA students and the instructor attempted to transfer Resident 1 when she started to slip towards the ground and Resident 1 yelled to the group that they were dropping her. AW stated, Resident 1 fell onto the floor on her legs, with one bent backward on her knee. AW stated, a male nursing student came into the room and picked Resident 1 off the ground and placed her into the shower chair. AW stated, at the time there were no staff present and no one notified the nurse about the fall before picking up Resident 1.During a review of Resident 1's shower sheet dated 1/9/26, shower sheet indicated, Slow bruising slight red'. Shower sheet indicated a circle was drawn around the resident's lower legs at the knee level. Sheet indicated, Skin Codes D for discoloration was circled. Shower sheet was signed by the CNA 1 and signed by Licensed Vocational Nurse (LVN) 1.During an interview on 1/30/26, at 10:55 a.m., with Director of Staff Development (DSD), DSD stated she was notified by CNA 1 on 1/9/26, that CNA instructor told him Resident 1 was lower to the ground. DSD stated, one of the CNA students said Resident 1 fell on the floor, and Resident 1 told us she was dropped. DSD stated, there was no documented assessment after the allegation of a fall on 1/9/25. DSD stated the only assessment I see was a daily skilled charting. DSD stated, we didn't do anything because the CNA [CNA 1] stated there was redness, but the nurse said there were no skin issues.During an interview on 1/30/25, at 12:04 p.m., with the Director of Nursing (DON) DON stated, I have 2 conflicting incidents about whether she [Resident 1] fell or not. DON stated, one of the CNA students told her Resident 1 fell, the instructor stated she did not fall. DON stated, Resident 1 told the nurse LVN 1 she had a fall, I don't know if she charted an assessment for it. DON stated, the fall protocol is to make sure that if patient has a fall we do an investigation. DON stated, she interviewed Resident 1 who told her she hit the floor during the transfer. DON stated, she did not document any of the investigation. DON stated, when we have a fall we meet with the interdisciplinary team (IDT: group of healthcare professionals with a purpose: To address patient needs, coordinate care, and facilitate discharge planning). DON stated, there was no documentation for an IDT meeting for Resident 1's investigation. DON stated, if a resident has a fall it is the facility policy to leave the resident on the floor and call for help to assess the resident before picking them up. DON stated, during her investigation she had assumed the fall took place in the shower room. DON stated, the patient did not fall in her room, and she thought the patient fell in the shower room. During a review of Resident 1's Progress notes dated 1/5/26-1/27/26, indicated, no IDT meeting or investigation notes regarding Resident 1's fall on 1/9/26 were documented.During an interview on 1/30/26, at 12:30 p.m., with Administrator (Admin), Admin stated, the facility protocol if someone alleges a fall, we investigate it. During a review of Resident 1's Physician Progress Note dated 1/6/26, at 10:46 p.m., note indicated, she [Resident 1] expressed that she is very anxious about being in the facility because when they transferred her this morning she was dropped from the bed. She states that she is scared of falling again.During a record request on 1/30/26, the facility was unable to provide documentation they investigated Resident 1's fall on 1/9/26.During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents-Investigating and Reporting dated, 2017, the P&P indicated, All accidents or incidents involving residents.occurring on our premises shall be investigated and reported to the administrator. 1. The nurse supervisor/charge nurse and/or the department director shall promptly initiate an investigation of the accident or incident. 2. The following data, if applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 62 residents who received food prepared from the kitchen, when: 1. Expired food items were found on the kitchen shelf; 2. An unclean appliance attachment cap was on the steam table and an unclean oven top and mesh rack for storage of water pitchers were found in the kitchen; 3. Pans with hard black residue were available for use in the kitchen; 4. The dry storage room had no documented evidence of temperature monitoring; 5. The freezer section of the refrigerator used for storage of resident foods had no thermometer and no documented temperature monitoring evidence; and, 6. the ice dispensing mechanism of the ice maker had dark residue. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings: 1. During a concurrent observation and interview on [DATE] commencing at 8:31 a.m. with the Registered Dietitian (RD) the initial tour of the kitchen was conducted and five bread crumb containers measuring 680 grams (g- metric unit for mass) were found labeled with by 30SEP2024 . [expiration of [DATE]]. The RD confirmed the bread crumb label information and stated she had to check the supplier guidelines to confirm it was expired. In an interview on [DATE] at 2:11 p.m., the RD confirmed the bread crumb containers found in the kitchen on [DATE] were expired. A review of facility's policy and procedure (P&P) titled Storage of Food and Supplies, dated 2023, indicated, Food and supplies will be stored properly and in a safe manner .No food will be kept longer than the expiration date on the product . 2. During a concurrent observation and interview in the kitchen on [DATE] at 2:21 p.m. with the Dietary Supervisor (DS), a steam table was observed with a metal appliance cap with particles and discolored dark residue. The DS confirmed the cap was not clean and had residue which was crusty and old. During a concurrent observation and interview on [DATE] at 9:24 a.m. with DS in the kitchen, a large pan of wheat rolls was observed resting on top of the main oven. The surface of the oven top was observed covered in dark, dust-like particles. The DS confirmed the oven top was dusty. During a concurrent observation and interview on [DATE] at 9:58 a.m. with the RD in the kitchen, a metal wire rack was observed with dark residue on its shelving and clear plastic water pitchers were placed on the bottom of the shelf. The RD confirmed the rack was not clean and it was used to store clean pitchers. 3. During a concurrent observation and interview on [DATE] commencing at 10:16 a.m. with the DS and the RD in the kitchen, pans with hard dark residue were observed hanging above the table. The DS confirmed the pans had a dark hard residue and one of the pans had the same residue on the inside of it. The RD stated the pans were to be replaced on an as needed basis. In an interview on [DATE] commencing at 9:47 a.m. RD agreed the black carbon buildup on the pans could leach into the food during cooking and affect food quality and safety. A review of facility's P&P titled, Sanitation, undated, indicated, .There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order . Each employee shall know how to operate and clean all equipment in his specific work area .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas . 4. During a concurrent observation and interview on [DATE] commencing at 8:31 a.m. with the RD, the dry storage area was observed with a thermometer but there was no temperature log for monitoring of the room temperature on a periodic basis. The RD confirmed the facility did not have documented evidence the dry storage temperatures were being monitored on a regular basis. In an interview on [DATE] at 10:43 a.m. the RD agreed dry storage foods needed to be kept in a dry, cool place and temperatures of the dry storage needed to be monitored to ensure food temperatures did not go outside recommended ranges so foods did not spoil. A review of facility's P&P titled, Storage of Food and Supplies, dated 2023, indicated, .The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 [Degrees Fahrenheit- Deg. F. standard temperature units]-85 [deg. F.]- if dry food storage goes over 85 [deg. F.] take corrective action . 5. During a concurrent observation of the resident foods refrigerator (located in the utility room near the nurse's station) and interview on [DATE] at 12:48 p.m. with the RD, the RD was unable to locate the thermometer for the freezer section of the refrigerator. The RD confirmed the freezer section did not contain a thermometer. In an interview on [DATE] at 12:55 p.m., the RD confirmed the facility did not have documented evidence of the freezer section of the refrigerator was being monitored for the storage of resident foods. A review of facility's P&P titled, Procedure for Freezer Storage, dated 2023, indicated, .Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0 [Deg. F.] or lower .Each freezer must have two thermometers that are easily visible .Freezer temperature should be recorded twice daily by a designated employee and logged in the Cold Storage Temperature Log . 6. During a concurrent observation and interview on [DATE] at 2:24 p.m. with the Maintenance Supervisor (MS) in the breakroom, the ice maker was inspected and the plastic mechanism above the ice bin was observed with dark residue. After wiping the area with a white napkin, a dark smear on the napkin. The MS confirmed the ice maker was the only available ice maker in the building and he did not expect it to produce a dark residue on the dispenser mechanism. A review of facility's P&P titled, Sanitation, undated, indicated, .There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order . Each employee shall know how to operate and clean all equipment in his specific work area .All utensils, counters, shelves, and equipment shall be kept clean .

Based on observation and interview, the facility failed to maintain the reach-in meat freezer in safe operating condition when door seals were observed with tears/cracks, and the top of the freezer had ice buildup on the inside. This failure decreased the facility's potential to ensure food safety and quality for 62 residents who ate facility prepared meals. Findings: During a concurrent observation and interview on 10/18/24 at 10:37 a.m. with the Registered Dietitian (RD) in the kitchen, the reach-in meat freezer was observed with two cracks on door seals (under 1/2 inch in length) and ice build-up hung near the fan at the top of the freezer. The RD confirmed observations. A review of the facility provided freezer installation and operations manual, undated, indicated, The door gaskets should be cleaned in place with a mild soap solution to extend their life. A review of the United States Food and Drug (FDA) Food Code 2022 indicated, EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. The FDA Food Code 2022 further indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.

Based on observation, interview, and record review the facility failed to ensure nursing care provided met professional standards for three residents (Resident 63, Resident 36, and Resident 53) of 23 sampled residents when licensed nursing staff did not: 1. Perform Resident 63's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen, just above the pubic bone) care and coccyx (also known as the tailbone which is the triangular bony structure found at the bottom of the spine) skin care as ordered; 2. Ensure Resident 36's medical record indicated the physician was notified as ordered; and, 3. Ensure Restorative Nurse Assistant (RNA, a program which provides exercise and a range of motion activities to the residents) services were provided to Resident 53 without active prescriber orders. These failures decreased the facility's potential to provide adequate and accurate care to residents. Findings: 47563 1. A review of an admission record indicated Resident 63 was admitted to the facility in Winter of 2023 with diagnoses which included benign prostatic hyperplasia (BPH: causes prostate to grow and can cause difficulty urinating) with a history of a urinary tract infection (UTI: an infection in the bladder/urinary tract), diabetes mellitus type II (DM2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and moderate malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets which can lead to reduced ability to fight off infection and impair wound healing). A review of Resident 63's care plans, initiated 3/7/24, indicated, Focus: bladder: At risk for complications with urinary system related to BPH .suprapubic catheter .interventions/tasks .suprapubic catheter care per facility policy and physician order . and Focus: Skin: Resident is at risk for skin breakdown related to .diabetes, nutritional risk .interventions/tasks .administer treatments as ordered .apply barrier cream as indicated . In an interview on 10/18/24 at 9:42 a.m., the Licensed Nurse 2 (LN 2) stated nurses should follow physician orders to check suprapubic urinary catheters every shift for placement, drainage, signs of infection, and ensure it is clean to prevent infection. The LN 2 further stated staff were expected to follow orders to clean and apply protective ointments to skin areas with redness, such as a coccyx, to prevent it from worsening to a pressure ulcer. The LN 2 acknowledged staff were expected to document all care provided and added, If it is not documented it didn't happen. In an interview on 10/18/24 at 10:46 a.m., the Director of Staff Development (DSD) stated she expected care to be provided as ordered by the physician. The DSD acknowledged residents with suprapubic urinary catheters were at risk for acquiring infections and residents with skin redness on the coccyx would be at risk of acquiring pressure ulcers if orders for care are not followed. During a concurrent interview and record review on 10/18/24 at 10:57 a.m., with the Assistant Director of Nursing (DON), Resident 63's medical records were reviewed. The ADON confirmed Resident 63's Treatment Administration Record (TAR : a daily documentation record to document treatments given to a resident), dated September 2024, indicated Resident 63 had a suprapubic urinary catheter with orders to provide routine catheter care including cleaning and monitoring catheter site for redness and irritation every shift. The ADON acknowledged Resident 63's TAR indicated catheter care was not documented as completed for at least one shift on the following dates: 9/2/24, 9/3/24,9/6/24, 9/7/24, 9/12/24, 9/18/24, 9/21/24, 9/27/24, 9/29/24, and 9/30/24. The ADON acknowledged there were no nursing notes in Resident 63's medical record which indicated why the care had not been documented or provided as ordered. The ADON also confirmed Resident 63's TAR dated September 2024 indicated Resident 63 had skin redness to the coccyx with an order to clean and apply barrier cream (a product that can help prevent pressure ulcers, by protecting the skin from moisture, friction, and pressure) to area of skin redness on Resident 63's coccyx. The ADON acknowledged Resident 63's TAR indicated there was no documented evidence the coccyx was cleaned and barrier cream was applied on the following dates: 9/2/24, 9/3/24, 9/6/24, 9/7/24, 9/12/24, 9/18/24, 9/27/24, 9/28/24,9/29/24, and 9/30/24. The ADON acknowledged there were no nursing notes in Resident 63's medical record which indicated why the care had not been documented or provided as ordered. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised August 2022, indicated, .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .the following information should be recorded in the resident's medical record .the date and time that catheter care was given . A review of the facility's P&P titled, Prevention of Pressure Injuries, revised April 2020, indicated, . The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Review the residents care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .during the skin assessment, inspect .presence of erythema [abnormal redness of the skin] .inspect pressure points .coccyx .skin care .use a barrier product to protect skin from moisture .evaluate, report, and document potential changes in the skin . 2. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility in the winter of 2022 with diagnoses including a history of having a stroke (a life-threatening condition that happens when part of your brain does not have enough blood flow) and depended on feeding through a gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A review of Resident 36's care plan, dated 12/22/22, indicated, Focus: enteral [route of feeding] care plan .interventions/tasks .check residual [the amount of fluid that remains in the stomach after being fed through a gastrostomy tube] prior to each feeding .hold [temporary stop order] enteral tube feeding if residual more that 100 ml [milliliter: metric unit of measure] or as ordered .Notify MD [medical doctor] if unable to tolerate tube feeding . In an interview on 10/18/24 at 9:42 a.m., the LN 2 stated staff are expected to check GT residual prior to the start of a new tube feed and if the residual is over 250 milliliters (ml), staff are expected to hold the tube feed and notify the physician. The LN 2 confirmed staff were expected to document the physician was notified in the resident's medical record. The LN 2 clarified if a staff member were to speak with the physician directly, the conversation would would be expected to be documented in the resident's medical record. The LN 2 added, If it is not documented, it did not happen. During a concurrent interview and record review on 10/18/24 at 10:57 a.m., with the ADON, Resident 36's medical records were reviewed. The ADON confirmed Resident 36 had an order which indicated the MD was to be notified if a resident's GT residual amount was over 250 ml. The ADON stated he expected the physician to have been notified each instance a resident's residual was over 250 ml and the notification to be documented in the resident's medical record. The ADON confirmed Resident 36's Medication Administration Record (MAR: a daily documentation record used by a licensed nurse to document medications given to a resident) indicated on 9/10/24, 9/11/24, and 9/14/24 Resident 63 had instances of residual amounts over 250 ml. The ADON acknowledged there was no documented evidence in Resident 36's medical record which indicated the physician had been notified of the instances residual amounts over 250 ml. A review of the facility's P&P titled, Charting and Documentation, dated July 2017, indicated, .All services provided to the resident .shall be documented in the resident's medical records 46242 3. A review of Resident 53's admission record indicated admission in August 2022 with diagnoses which included muscle weakness, hemiplegia and hemiparesis (weakness or total paralysis of the arm, leg, and trunk on the same side of the body). A Minimum Data Set (MDS: a federally mandated resident assessment tool), dated 9/18/24, indicated Resident 53 received restorative nursing services. The following documents in Resident 53's medical record indicated: -An order summary report dated 10/18/24 indicated no current orders for Resident 53 to receive RNA services. -An order listing report (a history of physician orders) indicated the latest order for RNA services was discontinued on 9/9/23. -A care plan for Resident 53's contractures (a stiffening /shortening at any joint that reduces the joint's range of motion) initiated on 9/9/23 and revised on 10/6/24 indicated, .Restorative nursing program: As Ordered .Notify MD if pain noted with ROM [Range of Motion] as indicated . -A nursing-RNA weekly summary report, dated 10/13/24, indicated Resident 53 received RNA services three times. In an interview on 10/17/24 at 4:23 p.m. the Director of Rehabilitation department (DOR) stated if the RNA program is recommended for a resident, the therapy department provides training to RNAs. The resident is then transferred to the RNA program which is managed by the nursing department. The DOR added the therapy department conducts monthly reviews of residents on the RNA program. During a concurrent interview and record review on 10/17/24 at 14:33 p.m. with the DOR and the Director of Nursing (DON), Resident 53's current orders and the RNA charting was reviewed. The DON confirmed Resident 53 was receiving RNA services without orders since the latest RNA order had been discontinued on 9/9/23. The DON stated Resident 53 was likely moved to comfort care and orders were discontinued but the RNAs were not notified. The DON and DOR agreed services must be provided in accordance with the physician's orders. A review of the facility's P&P titled, Restorative Nursing Services, revised July 2017, indicated, .Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care . Restorative goals may include, but are not limited to . implementation of his/her plan of care.

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Resident 37's nephrostomy bag (a bag that collects urine from a nephrostomy tube, which is a thin, flexible tube placed into the kidney) was observed touching the floor and the antimicrobial bag used as a privacy bag was not labeled with a placement date; and, 2. The Continuous Air Mist (CAM) respiratory equipment was not labeled with placement dates for Resident 14 and Resident 59. These failures had the potential to result in infection among a facility census of 85 residents. Findings: 1. A review of Resident 37's admission record indicated admission to the facility in August 2024 with diagnoses which included pyelonephritis (a bacterial or viral infection that causes inflammation of the kidneys) and urinary tract infection (UTI- an infection in the bladder/urinary tract). A review of Resident 37's medical records indicated the following: -An Order Summary Report (OSR) dated 10/18/24 indicated orders for the provision of nephrostomy care. -A care plan initiated on 10/16/24 indicated, The resident has a nephrostomy . nephrostomy bag will hang on bed as safe as able and be placed below kidneys .Ensure privacy cover is placed on foley bag [referring to nephrostomy bag] . During concurrent observation and interview on 10/15/24 at 11:54 a.m. with the Infection Preventionist (IP) by Resident 37's bedside, Resident 37's antimicrobial cover bag (used for privacy) was observed hanging on the left side of the bedframe and touching the floor. The antimicrobial bag did not have a date to indicate when it was placed. The IP stated the antimicrobial bag should be kept off the floor. The IP confirmed the antimicrobial bag needed to be dated with the date it was placed in order for it to be properly replaced. A review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated August 2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . 2. A review of Resident 14's admission record indicated admission to the facility in 2013 with diagnoses which included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs can't exchange gases properly) and tracheostomy (an opening in the neck to provide an airway and remove secretions from the lungs) use. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/25/24 indicated Resident 14 was receiving tracheostomy care. A review of Resident 14's medical records indicated the following: -An OSR indicated orders for tracheostomy care which included weekly respiratory equipment (Tracheostomy mask, corrugated tubing, oxygen line, HHN [handheld nebulizer], NEB [Nebulizer] T Adapter and oxygen adapter) to be changed every Friday. -A respiratory care plan initiated 4/1/24 indicated, Resident is at risk for complications with respiratory system .Administer medications as ordered .Trach [tracheostomy] management. A review of Resident 59's admission record indicated admission tot he facility in June 2023 with diagnoses which included chronic respiratory failure and tracheostomy use. A review of an MDS dated [DATE] indicated Resident 59 was receiving tracheostomy care. A review of Resident 59's respiratory care plan initiated on 3/29/24 indicated, Resident is at risk for complications with the respiratory system .[intervention] Trach management . During a concurrent observation and interview on 10/17/24 at 4:09 p.m. with the Respiratory Therapist (RT) at Resident 14's bedside, Resident 14's CAM equipment was observed. The RT confirmed Resident 14's tracheostomy mask and corrugated tubing were not labeled with the date they were replaced. During a concurrent observation and interview on 10/17/24 at 4:15 p.m. with the RT at Resident 59's bedside, Resident 59's CAM equipment was observed. The RT confirmed Resident 59's humidifier bottle was not labeled with the date it was replaced. The RT stated he expected individually removable parts of the CAM system (including tracheostomy mask, corrugated tubing, and humidifier bottle) to be labeled with the date they were replaced. During a concurrent observation and interview on 10/17/24 commencing at 5:09 p.m., the Director Of Nursing (DON) walked over to the subacute nursing station and pointed to the posted note with the CAM equipment weekly change schedule. The DON stated she expected all listed parts to be labeled with a replacement date which included the CAM tubing [corrugated tubing], pressure line, tee adapter, drain bag, and trach mask. The DON also added humidifiers should also be dated and changed at least weekly. A review of facility's P&P V.A.P. Ventilator Associated Pneumonia [PNA, an infection/inflammation in the lungs], undated, indicated, [NAME] prevention strategies . Remove condensate from ventilator circuits or aerosols .Change ventilator circuits only when malfunctioning, visibly soiled, or per equipment change schedule .

Based on interviews and record reviews, the facility failed to follow their policy and procedure (P&P) to investigate an allegation of abuse for one of three sampled residents (Resident 1), when on [DATE] Resident 1 was noted to have a degloving (avulsion-a traumatic injury that occurs when the top layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone) injury to right forearm and finger point areas to posterior right forearm and right wrist', and claimed it was from rough treatment from the Certified Nursing Assistant. This failure had the potential to place the resident at risk for further harm. Findings: Review of an anonymous staff report received by the department on [DATE] indicated, During Afternoon shift, Resident acquired an avulsion (degloving) [avulsion-a traumatic injury that occurs when the layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone] injury to RUE [right upper extremity] while brief change. Per resident CNA [certified nursing assistant] grabbed him by his arm and stated, she pulled me, and was so strong .she tore the last piece of skin I had DON [director of nursing]/ administrator do not want to report and is insisting to Nursing staff to reword documentation, due to I can misinterpret to physical abuse. CNA was not written up. During a review of Resident 1's face sheet, Resident 1, [AGE] years old, was admitted to the facility on [DATE], on hospice care (focuses on care, comfort, and quality of life of a person with serious illness who is approaching the end of life) and with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in body tissue), malignant (cancer) neoplasm (tumor) of skin, and heart failure. Resident 1 was his own responsible party. During a review of Resident 1's Significant Change in Status Minimum Data Set (MDS-an assessment tool), dated [DATE], the MDS described Resident 1 as able to make himself understood and able to understand others. Resident 1's Brief Interview for Mental Status (BIMS-a screening that aids in detecting cognitive impairment) score was 5 which indicated he had severe cognitive impairment. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. The MDS also described Resident 1 as needing setup or clean up assistance with eating, oral hygiene and personal hygiene, as needing substantial/maximal assistance with toileting hygiene and lower body dressing and as needing partial/moderate assistance with shower/bathe self and upper body dressing. Review of Resident 1's physician orders contained an order, dated [DATE], indicating Resident 1 had the capacity to make his medical decisions and a physician's order, dated [DATE], indicating Resident 1 was capable of understanding rights and responsibilities, and/or able to participate in treatment plan. A review of Resident 1's care plan, dated [DATE] **Hospice Skin Care Plan** At risk for altered skin integrity R/T (related to): Clinical Risk Factors: Altered ADL (Activities of Daily Living-activities related to personal care) Ability, Bowel & Or Bladder Incontinence. During a review of Resident 1's Progress Notes, dated [DATE] at 5:23 p.m., Wound Nurse 1 documented she was alerted by a CNA that patient had a 'skin tear' and moments later by charge nurse that patient had a tear to arm. Upon entering room, patient alone, lying in bed to left side with arm resting on side rail. Degloving noted to right forearm and finger point areas to posterior right forearm and right wrist. Patient tearful and in pain asking repeatedly, 'why did she do this to me' and 'they treat me like a rag doll' when I asked if he was having difficulty turning when CNA grabbed his arm to reposition? Patient also remarked 'she took the last of my skin I had.' Writer able to gently unroll flap of skin approximately halfway up forearm and at wrist securing edges with steri-strips (thin adhesive strips) .MD (Medical Doctor)/NP (Nurse Practitioner) sent message for notification . During a review of Resident 1's Progress Note, dated [DATE] at 11:23 p.m., Charge Nurse (CN) 1 documented notified by CNA at 1610 (4:10 p.m.) about resident's skin tear that occurred while CNA is changing resident. Upon entering room, resident is lying in bed with a major skin tear while being changed and wound nurse notified immediately. Resident stated, 'watch out with this one, s/he's tough.' While talking about the CNA. Resident alert and oriented x4. Hospice notified about incident. Resident also stated that the CNA 'skinned' him today. During an interview, on [DATE] at 10:47 a.m., with the Wound Nurse 1, she stated she was in her office when a CNA came by and told her about Resident 1's skin tear. Wound Nurse 1 stated she went to the treatment cart to get supplies and then proceeded to Resident 1's room. Resident 1 stated to her, Why did she do this to me. Wound Nurse 1 stated Resident 1's skin was pulled back from wrist area up forearm to elbow area. Wound Nurse 1 stated Resident 1 stated out loud, Treated me like a rag doll. Wound Nurse 1 verified she had documented her findings in Resident 1's Progress Notes on [DATE]. She verified she had not documented, any other information regarding Res 1's skin tear, anywhere else in Resident 1's clinical record. Wound Nurse 1 stated she had taken pictures of Resident 1's wounds and sent a notification, along with the wound pictures, to the physician. During a follow up interview on [DATE] at 10:18 a.m., with Wound Nurse 1, she confirmed she reported Resident 1's skin tear to Charge Nurse (CN) 1 and Desk Nurse (DN) 1, and to the Director of Nursing (DON), on [DATE]. Resident 1 was not able to be interviewed because he expired [DATE]. During an interview on [DATE] at 10:52 a.m., with the DON, the DON confirmed she had become aware of Resident 1's skin tear on [DATE] from Wound Nurse 1. The DON confirmed she reviewed Resident 1's clinical record on [DATE] and was aware of the statements made by Resident 1 documented in the Progress Notes on [DATE]. During a review of Resident 1's Progress Notes, an Interdisciplinary team (IDT) Note dated [DATE] at 12:17 p.m., indicated, Resident hospice since admission to the facility with cachectic (sic) (physical wasting with loss of weight and muscle mass due to disease) appearance d/t (due to) severe loss of body weight and muscle most likely d/t to progression of chronic disease. admitted with terminal dx [diagnoses] of hypertensive disease and heart failure. Alert and oriented x2 with baseline confusion, verbally responsive to care, at times able to verbalize needs, one person assist with ADLs, has very thin, fragile skin. Sustained a skin tear to right forearm, and right wrist during pericare [cleaning of a person's genital area] and repositioning. Per report resident became severely agitated during care possibly due to generalized pain pulling his right forearm out from CNA's hold scraping his right forearm on the hard surface of right side rail. Resident at high risk for sudden onset of skin breakdown r/t (related to) end of life status (hospice status), very thin fragile skin, and poor safety awareness. During an interview on [DATE] at 9:18 a.m., with the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) Nurse, the ADON reviewed Resident 1's clinical record and indicated there was no documentation and no care plan that Resident 1 had a history of being resistive to care or combative. The Department requested a copy of the facility's investigation report regarding Resident 1's skin tear and allegation of alleged abuse. The ADON stated he called the Director of Nursing who was currently out of the facility at the time, the DON informed the ADON, via the telephone call, the facility's investigation report was documented in the IDT Note dated [DATE] at 12:17 p.m. The Department requested the name and information of the CNA, involved in the alleged abuse, the Department was given CNA 2's name. The IP Nurse then stated CNA 2 was not the CNA after all and it was CNA 1 instead. During a review of the facility's investigation report, which according to the DON, was the IDT Note dated [DATE] at12:17 p.m., the investigation report did not include the following elements per the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised [DATE]: Observations of the alleged victim, including his or her interactions with staff and other residents, did not include interviews of the person(s) reporting the incident, did not include interviews with any witnesses to the incident, did not include interviews with Resident 1, did not include interviews with staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, did not include interviews with the resident's roommate, did not include interviews with other residents to whom the accused employee provided care or services to, did not include review of all events leading up to the alleged incident, did not include complete and thorough documentation of the investigation, and did not include upon conclusion of the investigation, the findings of the investigation on approved documentation forms. The facility's investigation report also did not provide a five day follow up investigation report that described the result of the investigation, any corrective actions taken if the allegation was verified. Review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised [DATE], the P&P indicated, All allegations are thoroughly investigated. The administrator initiates investigations .The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility .The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. interviews the resident's roommate; I. interviews other residents to whom the accused employee provides care or services; j. review all events leading up to the alleged incident; and k. documents the investigation completely and thoroughly .Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator . The P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised [DATE], also indicated, With five (5) business days of the incident, the Administrator will provide a follow-up investigation report. The follow- up investigation report will provide sufficient information, to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow- up investigation report will provide as much information as possible at the time of the submission of the report. The resident and/or representative are notified at the outcome immediately upon conclusion of the investigation. Any allegation of abuse are filed in the accused employee's personal record along with any statement by the employee disputing the allegation, if the employee chooses to make one.

Based on interviews and record review, the facility failed to report an incident of alleged abuse for one of three sampled residents (Resident 1), when Resident 1 verbalized he was treated roughly and handled like a rag doll. This failure had the potential to place the resident at risk for further harm. Findings: Review of an anonymous staff report received by the department on [DATE] indicated, During Afternoon shift, Resident [Resident 1] acquired an avulsion (degloving) [avulsion-a traumatic injury that occurs when the layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone] injury to RUE [right upper extremity] while brief change. Per resident CNA [certified nursing assistant] grabbed him by his arm and stated, she pulled me, and was so strong .she tore the last piece of skin I had. DON [director of nursing]/ administrator do not want to report and is insisting to Nursing staff to reword documentation, due to I can misinterpret to physical abuse. CNA was not written up. During a review of Resident 1's face sheet, Resident 1, [AGE] years old, was admitted to the facility on [DATE], on hospice care (focuses on care, comfort, and quality of life of a person with serious illness who is approaching the end of life) and with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in body tissue), malignant (cancer) neoplasm (tumor) of skin, and heart failure. Resident 1 was his own responsible party. During a review of Resident 1's Significant Change in Status Minimum Data Set (MDS-an assessment tool), dated [DATE], the MDS described Resident 1 as able to make himself understood and able to understand others. Resident 1's Brief Interview for Mental Status (BIMS-a screening that aids in detecting cognitive impairment) score was 5 which indicated he had severe cognitive impairment. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. The MDS also described Resident 1 as needing setup or clean up assistance with eating, oral hygiene and personal hygiene, as needing substantial/maximal assistance with toileting hygiene and lower body dressing and as needing partial/moderate assistance with shower/bathe self and upper body dressing. Review of Resident 1's physician orders contained an order, dated [DATE], indicating Resident 1 had the capacity to make his medical decisions and a physician's order, dated [DATE], indicating Resident 1 was capable of understanding rights and responsibilities, and/or able to participate in treatment plan. During a review of Resident 1's Progress Notes, dated [DATE] at 5:23 p.m. Wound Nurse 1 documented she was alerted by a CNA that patient had a 'skin tear' and moment later by charge nurse that patient had a tear to arm. Upon entering room, patient alone, lying in bed to left side with arm resting on side rail. Degloving noted to right forearm and finger point areas to posterior right forearm and right wrist. Patient tearful and in pain asking repeatedly ' why did she do this to me' and ' they treat me like a rag doll' when I asked if he was having difficulty turning when CNA grabbed his arm to reposition? Patient also remarked 'she took the last of my skin I had.' Writer able to gently unroll flap of skin approximately halfway up forearm and at wrist securing edges with steri-strips (thin adhesive strips) .MD (Medical Doctor)/NP (Nurse Practitioner) sent message for notification . During a review of Resident 1's Progress Note, dated [DATE] at 11:23 p.m., Charge Nurse (CN) 1 documented Notified by CNA at 1610 [4:10 p.m.] about resident's skin tear that occurred while CNA is changing resident. Upon entering room, resident is lying in bed with a major skin tear while being changed and wound nurse notified immediately. Resident stated, 'watch out with this one, s/he's tough.' While talking about the CNA. Resident alert and oriented x4. Hospice notified about incident. Resident also stated that the CNA ' skinned' him today. During an interview, on [DATE] at 10:47 a.m., with the Wound Nurse 1, she stated she was in her office when a CNA came by and told her about Resident 1's skin tear. Wound Nurse 1 stated she went to the treatment cart to get supplies and then proceeded to Resident 1's room. Resident 1 stated to her, Why did she do this to me. Wound Nurse 1 stated Resident 1's skin was pulled back from wrist area up forearm to elbow area. Wound Nurse 1 stated Resident 1 stated out loud, Treated me like a rag doll. Wound Nurse 1 verified she had documented her findings in Resident 1's Progress Notes on [DATE]. She verified she had not documented, any other information regarding Resident 1's skin tear, anywhere else in Resident 1's clinical record. Wound Nurse 1 stated she had taken pictures of Resident 1's wounds and sent a notification, along with the wound pictures, to the physician. During a follow up interview on [DATE] at 10:18 a.m., with Wound Nurse 1, she confirmed she reported Resident 1's skin tear to Charge Nurse (CN) 1 and Desk Nurse (DN) 1, and to the DON on [DATE]. Resident 1 was not able to be interviewed because he expired [DATE]. During an interview on [DATE] at 10:52 a.m., with the Director of Nursing (DON), the DON confirmed she became aware of Resident 1's skin tear on [DATE] from Wound Nurse 1. The DON confirmed she reviewed Resident 1's clinical record on [DATE] and was aware of the statements made by Resident 1 and documented in the Progress Notes on [DATE]. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised [DATE], indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator / designee or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Law enforcement officials; . Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .Upon receiving any allegations of abuse. neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on interview and record review, the facility failed to ensure person centered care plans were developed which included specific goals and interventions for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure had the potential for Resident 2 to experience unmet care needs. Findings: Resident 2 admitted early 2023 with diagnoses which included Multiple Sclerosis (a disease of the brain and spinal cord), stage four pressure ulcer (wound caused by pressure that extends to the muscle and bone), and paraplegia (paralysis that affect the legs). Resident 2 is listed as his own responsible party (RP). During a review of Resident 2's face sheet (a document that gives patient information at a quick glance), admitted ,d+[DATE], the face sheet indicated, .Allergies: HYDROcodone (sic) . During a review of Resident 2's Order Summary Report (OSR), Active Orders As Of 6/12/24, the OSR indicated, Allergies: HYDROcodone (sic) . Resident 2's OSR further indicated, Percocet Oral Tab .[Oxycodone w/ Acetaminophen] [narcotic medication that contained Oxycodone] .Give 1 tablet my mouth as needed for Pain Severe . During a review of Resident 2's ' Progress Notes (PN) Type: Physician Progress Note, dated 6/2/24 at 7:30 a.m. the PN indicated, .He [Resident 2] says he was given norco (sic) by mistake yesterday and got some itching and shortness of breath, which is better .Allergies .Hydrocodone . During a review of the facility provided document titled, ONE ON ONE IN-SERVICE SIGN IN SHEET, dated 6/3/24, the document indicated, LN [licensed nurse] ADMINISTERED NARCOTIC TO RESIDENT ON ACCIDENT AND STATES THAT SHE GOT CONFUSED AS HE WAS TALKING TO HER WHILE SHE PREPARING (sic) ANOTHER RESIDENT'S MEDICATIONS . During a review of the facility provided document titled, MEDICATION ERROR REPORT, dated 6/2/24, the document indicated, On 6/1/24 @1231 [12:31 p.m.], patient received Norco 5/325 [Hydrocodone-Acetaminophen] instead of Percocet 5/325 [Oxycodone-Acetaminophen]. Resident has Hydrocodone Allergy-unknown reaction . During a concurrent interview and record review on 6/12/24 at 12:03 p.m. with the Infection Preventionist (IP- nurse responsible for managing healthcare associated infections), Resident 2's care plans (CP) were reviewed. A CP for the medication error was not found. The IP confirmed there was not a care plan. When asked the expectation of care plans, the IP stated, They are implemented immediately .They are important because it tells our interventions . During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated 3/23, the P&P indicated, .Care plan goals and objectives are defined as the desired outcome for a specific resident problem .Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information .

Based on interview and record review, the facility failed to notify the physician promptly or implement monitoring timely for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure resulted in Resident 2 not being monitored for an allergic reaction for approximately 20 hours, which increased the risk for unmet health care needs. Findings: Resident 2 admitted early 2023 with diagnoses which included Multiple Sclerosis (a disease of the brain and spinal cord), stage four pressure ulcer (wound caused by pressure that extends to the muscle and bone), and paraplegia (paralysis that affect the legs). Resident 2 was listed as his own responsible party (RP). During a review of Resident 2's face sheet (a document that gives patient information at a quick glance), admitted ,d+[DATE], the face sheet indicated, .Allergies: HYDROcodone (sic) . During a review of Resident 2's Order Summary Report (OSR), Active Orders As Of 6/12/24, the OSR indicated, Allergies: HYDROcodone (sic) . Resident 2's OSR further indicated, Percocet Oral Tab .[Oxycodone w/ Acetaminophen] [narcotic medication that contained Oxycodone] .Give 1 tablet my mouth as needed for Pain Severe . During a review of Resident 2's Progress Notes (PN) Type: Physician Progress Note, dated 6/2/24 at 7:30 a.m. the PN indicated, .He [Resident 2] says he was given norco (sic) by mistake yesterday and got some itching and shortness of breath, which is better .Allergies .Hydrocodone . During a review of the facility provided document titled, ONE ON ONE IN-SERVICE SIGN IN SHEET, dated 6/3/24, the document indicated, LN [licensed nurse] ADMINISTERED NARCOTIC TO RESIDENT ON ACCIDENT AND STATES THAT SHE GOT CONFUSED AS HE WAS TALKING TO HER WHILE SHE PREPARING (sic) ANOTHER RESIDENT'S MEDICATIONS . During a review of the facility provided document titled, MEDICATION ERROR REPORT, dated 6/2/24, the document indicated, On 6/1/24 @1231 [12:31 p.m.], patient received Norco 5/325 [Hydrocodone-Acetaminophen] instead of Percocet 5/325 [Oxycodone-Acetaminophen]. Resident has Hydrocodone Allergy-unknown reaction . During a concurrent interview and record review on 6/12/24 at 11:32 a.m. with the Infection Preventionist (IP- nurse responsible for managing healthcare associated infections), Resident 2's change of condition (COC) for medication error was reviewed. The IP confirmed the COC was completed on 6/2/24, and stated, The incident [medication error] happened on 6/1 and it was reported late to staff. The IP stated the expectation was for the error to be reported immediately. When asked the reason for reporting immediately the IP stated, For any adverse effects, it needs to be reported immediately. During a concurrent interview and record review on 6/12/24 at 11:40 a.m. with the IP, Resident 2's PN were reviewed. The IP confirmed there was no documentation on 6/1 that a medication was given in error or any monitoring of potential allergic reactions. The IP stated she would expect to see a progress note when it happened, It happened a.m. shift, it went 24 hours, there was no documented monitoring. During an interview on 6/12/24 at 12:38 p.m. with LN 1, LN 1 was asked about Resident 2's medication error. LN 1 stated, I was in the middle of passing medications, [Resident 2] knows my name, he said he wanted pain medications. The narcotic drawer was open. I picked up the card that started with [first letter of Resident 2's last name]. I gave Norco, he was asking for oxycodone. I realized it during the count that I gave the wrong medication . When asked if she reported the error to anyone, LN 1 stated, I totally forgot. The next day I told the charge nurse. When asked if any note was entered in Resident 2's chart about receiving a medication error that was listed as an allergy, LN 1 stated, No, I totally forgot . During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, dated 2/23, the P&P indicated, .a 'medication error' is defined as the preparation or administration of drugs .which is not in accordance with the physician's order, manufacturer specification, or accepted professional standards .Examples of medication errors include .wrong drug .Monitor the resident for medication-related adverse consequences when there is a .medication error .promptly notify the provider of any significant error or adverse consequence .communicate the event to the oncoming shift as needed to alert staff of the need for continued monitoring .

Based on staff interviews, policy and document review, the facility failed to prevent the formation of pressure ulcers for 1 of 4 residents (Resident 1) when a care plan was not developed with defined approaches for a resident at risk and preventative interventions were not provided consistently to address all identified needs based on Resident 1's comprehensive assessment. Findings: Review of Resident 1's medical record, included a form titled Resident Admission Record, which revealed Resident 1 was admitted to the facility on [DATE] with a tracheotomy (surgical opening on the neck to facilitate breathing) and [DIAGNOSES REDACTED]. Documentation on both, Skin Observation assessment and the Resident Progress Notes completed on admission by Licensed Nurse (LN1), dated 1/2/14, revealed Resident 1's skin as being intact with no pressure ulcers (open wounds or skin breakdown), No hx (history) of pressure ulcers with no redness or soreness noted during skin assessment. On 1/22/16, during an interview with the Director of Medical Records (DMR) at 3:45 p.m., she reviewed the medical record and confirmed that, during the first seven days of the resident's stay (January 2nd through 9th, 2014), documentation failed to show evidence the resident's skin condition was assessed or monitored for pressure ulcers by licensed nursing staff. There was no evidence any interventions were consistently provided in the Progress Notes from (MONTH) 2nd through 8th, 2014, and the DMR concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided to prevent skin breakdown. On 8/3/2016, at 3 p.m., in an interview with LN2, she reviewed Resident 1's Care Plans, Observation Reports and Resident Progress Notes from (MONTH) 2nd through 8th, 2014, and concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided. LN2 further stated that, after knowing that the resident was a quadriplegic and could not turn on his own, It should have been automatic (Resident 1 was paralyzed and therefore was at risk for pressure ulcers) for the nurses to routinely change the resident's position every 2 hours and conduct periodic skin assessments. Review of the clinical record of Resident 1 revealed the following 3 pressure ulcers were documented in the resident's Progress Notes within seven days of admission to the facility: 1. RIGHT BUTT[NAME]KS - An entry, dated 1/8/14 at 3:11 a.m., indicated Resident 1 was observed by LN1 to have, .an open area on bilateral (both right and left) buttocks, measuring 8 cm x (by) 4 cm by 2 cm (cm=centimeter-Units of measure). 2. POSTERIOR (back side of) LEFT HEEL - On 1/9/14, an observation, documented at 5:28 p.m., indicated the development of a pressure ulcer on the resident's posterior left heel. The document titled, Pressure Ulcer Report, identified the wound as a Stage II pressure ulcer (partial thickness loss of the skin with a red moist wound base), measuring 4 x 4 cm, depth UTD (unable to determine), with light exudate (cells and fluid that have leaked out of blood vessels) of serrosanguinous (yellowish fluid leaking from the body or a wound) drainage. 3. LEFT BUTT[NAME]K - On 1/9/14 at 4:54 p.m., an entry was made into the facility's Skin--Pressure Ulcer Report describing a Stage II pressure ulcer to the left buttock. This wound measured 4 x 2 cm x UTD. Facility's Policy and Procedure titled, Pressure Ulcers/Skin Breakdown, last revised date, (MONTH) 2010, indicated that, The nursing staff and Attending Physician will assess and document an indiviual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition the nurse shall assess and document/report the following: .Resident's mobility status. Facility's Policy and Procedure titled, Prevention of Pressure Ulcers, last revised date, (MONTH) 2010, indicated: The facility should have a system/procedure to assure assessments are timely .Identify risk factors for pressure ulcer development . for a person in bed .Change position at least every two hours or more frequently if needed Determine if resident needs a special matress .Risk Factor - Bed Fast .change position at least every two hours and more frequently if needed .Risk Factor - Immobility . When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended .For residents with risk factors, implement preventative measures as indicated . There was no documented evidence that the facility followed the policy and procedure on intervening and preventing the formation of pressure ulcers in Resident 1's care plans. Subsequent documentation review of Resident 1's clinical record revealed the following documented additional assessments of his wounds on the form titled Skin-Pressure Ulcer Report: 1. RIGHT BUTT[NAME]KS- An entry dated 1/9/14 at 13:12 (1:12 p.m.) indicated a Stage II Pressure Ulcer and the wound size was noted to be 8cm x 4 cm and the depth of the wound was UTD. The document noted the wound was dark purple in color with some skin peeling off, irregular shaped edges, [DIAGNOSES REDACTED] (redness of the surrounding skin surface), no exudate, no drainage, and no odor. An entry dated 1/16/14 at 13:07 (1:07 p.m.) indicated a Stage II Pressure Ulcer that now measured 10 cm x 3 cm and the depth was again noted as UTD. The note indicated that the wound now had light serosanguinous exudate on the edges, no signs and symptoms of infection, dark purple in color with some skin peeling off, irregularly shaped edges, wound area with redness, and no odor. An entry dated 1/21/14 at 15:59 (3:59 p.m.) noted a Stage II Pressure Ulcer measuring .09cm (sic) x2.08cm with the depth again noted to be UTD. 2. POSTERIOR LEFT HEEL An entry dated 1/16/14 at 12:58 (12:58 p.m.) indicated a Stage II Pressure Ulcer measuring 4 cm x 3 cm, with a light serosanguinous exudate described as an open area. All documentated assessements were provided by the facility to the Department per request by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided. 3. LEFT BUTT[NAME]K All documentated assessements were provided by the facility to the Department per request by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided. On 1/23/14 Resident 1 was transferred to the General Acute CAre Hospital (GACH). Review of Resident 1's clinical record from the GACH indicated staff there assessed the wounds on admission with the following notations in the document titled Wounds: 1. C[NAME]CYX (small bone at the base of the spine)- An entry dated 1/23/14 at 0900 (9a.m.) indicated an unstageable full thickness pressure ulcer, tunneled deep tissue wound, unable to get exact measurements. 2. HEEL LEFT - An entry dated 1/23/14 at 0832 (8:32 a.m.) indicated an unstageable necrotic (dead tissue) wound 3 cm in diameter. 3. RIGHT HIP- An entry dated 1/23/14 at 0900 (9 a.m.) indicated a Stage II pressure ulcer with a dressing in place. 4. LEFT FOOT - An entry dated 1/23/14 at 08:35 (8:35 a.m.) indicated an unstageable wound described as a 2 cm round blood blister to the sole of the foot.