Every finding on record at Salinas Valley Post Acute

Based on observation, interview and record review, the facility failed to submit the 5-day investigative report regarding an allegation of abuse within five working days to the California Department of Public Health (CDPH) for one of three residents (Resident 1).This deficient practice had the potential for delayed investigation of the residents' circumstances and could place the residents at risk for further abuse.Findings:Review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (a medical condition that causes complete or severe paralysis on one side of the body) and hemiparesis ( muscle weakness or partial loss of movement on one side of the body) following cerebral infarction (ischemic stroke, which happens when a blocked or narrowed blood vessel stops blood flow to part of the brain, causing brain cells to die from a lack of oxygen) affecting left non- dominant side; Type 2 diabetes mellitus ( a chronic condition where the body cannot use insulin properly, causing sugar to build up in the blood).Review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 4/15/26 indicated that the resident has a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15, which meant cognition is intact (mental action or process of acquiring knowledge and understanding).Review of the facility-provided SOC 341 (form used for reporting suspected dependent adult/elder abuse), dated 6/21/26, indicated the report was related to Resident1's foot getting hit with a soiled hospital gown.During an interview on 7/9/26 at 11:01 a.m., the Administrator (ADM) verified the results of the final investigation were not faxed within 5 working days to the CDPH. The Administrator stated it should be faxed on 6/26/26 but we can't find confirmation. ADM further stated I don't see anything on the list of the faxed confirmation that the 5-day investigative report was sent to CDPH and Ombudsman or police department. It should be sent to all three departments per policy, submitted by the 5th day, and the facility failed to do so.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigation, revised 4/2021, indicated All reports of resident's abuse (including injuries of unknown origin), neglect, exploitation. of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. Reporting Results of Investigation . The administrator, or his/ designee, provides the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention practices when:1. Staff did not wear appropriate personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments, e.g., gloves, mask, gown) when caring for a resident on enhanced-barrier precautions (an infection control practice used to reduce transmission of multidrug-resistant organisms); 2. Licensed Vocational Nurse (LVN) M used the same paper tissue to wipe excess liquid from both eyes during the administration of eye medications for Resident 74; 3. Staff did not perform hand hygiene between contaminated (exposed to body fluids or potentially infectious material) and clean tasks during wound treatment;4. Unlabeled resident's care items;5.Unlabeled oxygen (O2, colorless, odorless, and tasteless gas essential for life) nasal cannula (NC, a flexible plastic tube used to deliver O2 directly into the nostrils) and uncovered nebulizer treatment face mask ((a plastic covering device that fits over the nose and mouth to deliver liquid medication directly into lungs [a pair of spongy body organ, primary function to keep body cells with supply of O2]) when not in use for Resident 72;6.Failed to do hand hygiene between residents in dining room while setting lunch meal;7.Unconvered suction yankauer (a rigid medical device, with a large opening used to clear fluids/secretions from mouth and throat via suctioning [a medical procedure that uses a vacuum device to remove fluids/secretions when resident not able get rid of on his/her own]) when not in use for Resident 105;8. The facility's Water Management Plan (measures to prevent the growth of Legionella [bacteria that can cause Legionnaires' disease, a serious type of pneumonia or lung infection] or other opportunistic waterborne pathogens in the facility's water system) was not updated.9. There was no documentation of surveillance monitoring or audits that indicated staff were compliant with hand hygiene, donning PPE, and other infection control practices.These failures had the potential to result in transmission and spread of infection to all residents in the facility. 1.During a medication administration observation on 2/10/26 starting at 8:33 a.m., Registered Nurse Q (RN Q) observed administering insulin (medication to treat high sugar levels in blood) to Resident 37, Resident 37's entrance door posted a sign EBP (enhanced barrier precautions, a infection control intervention designed to reduce the spread of infections) RN Q pulled Resident 37's shirt and held Resident 37 right lower abdomen to give the insulin without using gloves, then she stopped and went back to the cart to get the gloves. During a follow up interview on 2/10/26 at 9:08 a.m., with RN Q, she confirmed she was not wearing gloves when she held resident abdomen, RN Q stated she forgot to wear gloves, and she went back to cart get gloves. During an interview on 2/12/26 at 3:14 p.m., with the Infection Preventionist (IP) she stated she expected the nurse to wear PPE (personal protective equipment, specialized clothing, equipment such as masks, gowns and gloves to protect residents and staff from spread of infections) when administering insulin or when touching residents on EBP, she further stated any contact with the resident they have to wear PPE not just gloves. A review of the facility's policy and procedures titled Enhanced Barrier Precautions, undated, indicated, 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).) 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); 2.During a medication administration observation on 2/11/26 starting at 4:15 p.m., Licensed Vocational Nurse P (LVN P), LVN P was observed preparing 2 medications for Resident 74. Included in the medications was Brimonidine 0.1% eye solution (eye medications to treat high eye pressure in the eye [glaucoma]). On 2/11/26 at 4:18 p.m., LVN P observed instilling 1 drop of the brimonidine 0.1% eye solution into each of the residents' eyes, then using same tissue to wipe Resident 74's both eyes. During an interview on 2/11/26 at 4:28p.m., LVN P confirmed she used one tissue to wipe the resident's both eyes after each eye drop administration. LVN P further stated she uses one tissue, but different corner in each resident eyes. During an interview on 2/12/26 at 3:16 p.m., with the Infection Preventionist (IP) she stated, when administering eye drops, the staff needs to use a different tissue in each eye or use a different corner of tissue. A review of the facility's policy and procedures titled Instillation of Eye Drops, undated, indicated, Gently dry the eyelid with cotton ball if dripping occurs. (Note: Use only one cotton ball per wipe). 3.During a wound treatment observation on 2/12/26 at 11:30 a.m., Treatment Nurse C (TN C) provided care to Resident 92 for sacral (lower back area) and right groin (between abdomin fold and thigh area) wounds. At the start of treatment, TN C performed hand hygiene and donned (put on) gown and gloves. TN C repositioned Resident 92, handled the Foley Catheter (FC, flexible, indwelling tube inserted through the urethra into the bladder to continuously drain urine into a collection bag) drainage bag, and removed Resident 92's old sacral wound dressing. The old dressing appeared soiled. TN C removed her gloves and donned a new pair of gloves without performing hand hygiene, then continued the wound treatment without performing hand hygiene between contaminated and clean tasks. On multiple occasions during the treatment, TN C did not perform hand hygiene, including after touching the soiled dressing and after glove removal. TN C performed hand hygiene only after completing the wound treatment and removing the gown and gloves. During a concurrent interview on 2/12/26, TN C acknowledged the old dressings were contaminated. TN C stated she performed hand hygiene at the beginning and at the end of the treatment and stated additional hand hygiene was not required between tasks. During an interview on 2/12/26 at 2:30 p.m., IP was informed of the observation. The IP stated staff should perform hand hygiene when moving from dirty to clean tasks during wound care. Review of the facility's undated policy titled Handwashing/Hand Hygiene, indicated .Hand hygiene is indicated: after touching resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal . 4.During initial room rounds on 2/9/2026 at 11:12 a.m., observed five unlabeled gray color plastic wash basins (small container, used to provide personal care for individual resident) as a stack, left on top of paper towel holder in a bathroom for room [ROOM NUMBER]. During an interview with certified nursing assistant F (CNA F) on 2/9/2026 at 11:14 a.m., CNA F confirmed above observation for unlabeled wash basins and they all were used. CNA F also confirmed this bathroom been shared by multiple residents. CNA F stated resident's personal care items should be labeled with resident's name before started using for residents. CNA also stated without resident's name label, potential for using wash basin for unassigned resident and risk of infection when bathroom been shared between more than one resident. During initial room rounds on 2/9/2026 at 11:40 a.m., observed one unlabeled plastic gray color wash basin on top of paper towel holder in a bathroom for room [ROOM NUMBER]. During an interview with CNA J on 2/9/2026 at 11:29 a.m., CNA J confirmed above observation of unlabeled wash basin and it was used. CNA J also confirmed this bathroom been shared between two rooms and more than 4 residents. CNA J stated without resident's name, risk of spreading infection if it was used for unassigned resident. During initial room rounds on 2/9/2026 at 11:47 a.m., observed six unlabeled gray color plastic wash basins stacked, left on floor next to toilet commode, one more, left on floor next to sink and one more left on paper towel holder in a bathroom for room [ROOM NUMBER]. During an interview with CNA J on 2/9/2026 at 11:52 a.m., CNA J confirmed above observation in bathroom for room [ROOM NUMBER]. CNA J confirmed this bathroom also shared between 2 room and more than 4 residents. CNA J stated all these 8 wash basins were used for residents. CNA J stated nursing staff should have labeled with resident's name before started using and should not have had left on floor in bathroom for infection control practices. CNA J also stated risk of using unassigned resident if not labeled with resident's name when this bathroom been sharing between multiple residents. During an interview with license vocational nurse L (LVN L) on 2/13/2026 at 9:09 a.m., LVN L stated nursing staff should have had labeled wash basins with resident's name to prevent used for unassigned resident and followed infection control practice. During an interview with facility's infection preventionist (IP) on 2/13/2026 at 9:24 a.m., IP stated resident's personal care items should be labeled with resident's name. IP also stated nursing staff should have labeled wash basins with resident's name before started using for individual resident for infection control. 5.During an initial observation on 2/9/2026 at 11:03 a.m., observed Resident 72 was using O2 via room air concentrator (RAC, a medical device that draws in room air, filters and provides purified O2) with a NC and this NC was not labeled with date when it was changed. Also observed nebulizer face mask left uncovered in a top drawer of night stand next to Resident 72's bed when not in use. During an interview with Resident 72 on 2/9/2026 at 11:03 a.m., Resident 72 communicated through hand gestures and written communication indicated, using O2 on and off at times for shortness of breath (SOB, difficulty breathing). Resident 72 also communicated saying that nursing staff left nebulizer mask without cover in night stand yesterday after Resident 72 completed the nebulizer treatment. Review of Resident 72's face sheet (FS, a document that gives information at a quick [NAME]) indicated Resident 72 was admitted to facility on 12/9/2020. Review of Resident 72's diagnoses included chronic respiratory failure (a progressive condition where lungs cannot adequately enough gas exchange, often requiring O2 therapy to breath). Review of Resident 72's minimum data set assessment (MDS, assessment tool) for brief interview for mental status (BIMS) dated 2/3/2026 indicated, his BIMS score of 13/15, cognitively intact. Review of Resident 72's order summary report indicated oxygen therapy 2L (liters, concentration of O2 to deliver), titratable to maintain O2 at or above 93% as needed., dated 2/8/2026. Review of Resident 72's order summary report also indicated ipratropium-albuterol (a combination medication used to treat breathing problems) solution (liquid medication) 0.5-2.5 MG/3ML (MG, milligram, a unit of mass equal to one thousandth of gram/ML, milliliter, a unit of volume, equal to one thousandth of a liter) every 4 hours as needed for SOB, dated 2/6/2026. During an interview with LVN L on 2/13/2026 at 9:09 a.m., LVN confirmed unlabeled NC and uncovered nebulizer face mask for Resident 72. LVN L stated NC tubing should be changed every week and labeled with date when changed for infection control. LVN L also stated nebulizer face mask should be stored in a plastic bag when not in use. During an interview with IP on 2/13/2026 at 9:24 a.m., IP stated nursing staff should have labeled NC tubing when changed every week for residents. IP also stated nursing staff should have stored nebulizer face mask in a plastic bag when not in use for Resident 72 to follow infection control practice. 6.During lunch meal observation in facility's dining room on 2/9/2026 at 12:19 p.m., observed CNA K took lunch meal tray from meal cart (movable cart stores and carries multiple resident's meal trays at a time), which came from facility's kitchen, CNA K went to a resident's table, set the tray for a resident. CNA K went to lunch cart, took another resident's meal tray, went to Resident's table, set the lunch meal, and went back to lunch cart, repeated same for two more residents, no hand hygiene between each resident while providing the meal trays. Observed same as above with assistant director of nursing (ADON) and CNA H when they served mealsto multiple residents, no hand hygiene between each resident. All three staff members washed hands at the end of serving meals to all residents. During an interview with CNA K on 2/9/2026 at 12:22 p.m., CNA K confirmed she did not wash hands after serving meal tray to a resident before started taking another resident's meal tray from food cart. CNA K stated should have washed hands between each resident for infection control. During an interview with ADON on 2/9/2026 at 1:14 p.m., ADON stated she did not wash hands between residents when serving meal trays. ADON stated should have wash hands between tasks for infection control practices. During an interview with CNA H on 2/9/2026 at 2:26 p.m., CNA H confirmed he did not wash hands after serving a resident before starting with another resident's tray. CNA H stated should have wash hands between each resident to follow infection control practice. During an interview with IP on 2/13/2026 at 9:24 a.m., IP stated nursing staff should have provided hand hygiene between residents and tasks while serving the meals in the dining room. 7. During room rounds on 2/10/2026 at 9:23 a.m., noted uncovered long blue color plastic suction yankauer catheter left between bed rail and bed frame when not in use in Resident 105's room. Review of Resident 105's FS indicated Resident 105 was admitted to facility on 9/10/2023. Review of Resident 105's order summary report indicated an order for, ok for bedside suction machine for oral suctioning, dated 2/1/2026. During an interview with LVN L on 2/13/2026 at 9:09 a.m., LVN L confirmed suction yankauer left on bed rail and uncovered for Resident 105. LVN L stated yankauer should be stored in a plastic bag when not in use for infection control purposes. During an interview with IP on 2/13/2026 at 9:24 a.m., IP stated suction yankauer should not be left uncovered when not in use. Nursing staff should have stored in a plastic bag for infection control. Review of facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, undated, the P&P indicated, Hand hygiene is indicated: after touching a resident; after touching the resident's environment; Review of facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised June 2011, the P&P indicated, Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge. The facility did not provide a policy and procedure for label nasal cannula, storage of nebulizer face mask, and suction yankauer catheter when not in use. 8. Review of the facility's Water Management Plan, dated 6/9/2025 indicated, This Water Management Plan expires on 10/15/25. It also indicated the plan will describe the water systems and flow diagrams within the building and develop water-system schematics. The Water Flow Diagram page was blank. The plan also indicated the facility had a decorative fountain and included a picture of the water fountain. During an interview and concurrent record review on 2/13/26 at 10:39 a.m., the Maintenance Director (MD) confirmed the facility's water management plan needed to be updated. The MD stated the facility needed to develop water flow diagram for the water system. The MD also confirmed the facility no longer had a water fountain. Review of the US Centers for Disease Control and Prevention's (CDC, a federal agency with the primary mission of protecting public health and safety through control and prevention of disease) Toolkit, Developing a Water Management Program to Reduce Legionella (a type of bacteria [living cells that can cuase infections] found in natural freshwater) Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards, dated 9/30/25 indicated, All healthcare facilities should have a Legionella water management program. The toolkit indicated the key elements of a Water Management Plan include to describe the building water systems using text and flow diagrams, identify areas where Legionella could grow and spread, and decide where control measures should be applied and how to monitor them. 9. During an interview on 2/12/26 at 12:32 p.m., the IP stated she had no documentation that indicated that she checked whether staff is following infection control practices. During an interview on 2/13/26 at 1:35 p.m., the director of nursing (DON) stated there is no surveillance log for when the IP monitors staff for appropriate hand hygiene, donning of PPE, and other infection control practices. Review of the facility's Job Description, Infection Control Nurse, dated 2/2024 indicated essential duties include to monitor infection control practices and procedures to ensure that all personnel are implementing our standard operating procedures for tasks involving exposure to blood/body fluids and monitor medications passes and treatments to ensure that appropriate handwashing/hand hygiene techniques are being followed in the handling and administering of drugs, medications, and treatments. Review of the facility's undated policy, Monitoring Compliance with Infection Control, indicated the following: Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices . Compliance surveillance includes the use of standardized assessment and observation tools . The infection preventionist and or the IPC [Infection Prevention and Control] committee provides reports to the QAPI [Quality Assurance and Performance Improvement] committee that reflect: a. staff adherence to infection prevention processes (hand hygiene, use of personal protective equipment, etc.) .

Based on observation, interview, and record review, the facility failed to ensure dietary staff covered facial hair while working over exposed food in the kitchen. This deficient practice placed 95 residents at risk for receiving contaminated food in the facility. Findings: During an observation of the meal tray line on 2/11/26 at approximately 11:35 a.m., the dietary aide N (DA N) and dietary cook M (DC M ) were observed with visible facial hair and were not wearing beard restraints while working over exposed food in kitchen. Dietary staff were plating and checking meal trays while standing over exposed food items during tray line service. During an interview on 2/11/26 at 2:30 p.m., DA N stated that during tray line he was only checking the food and not handling it. During an interview on 2/11/26 at 2:40 p.m., DC M stated that his beard was long and that he needed to wear a beard restraint. During an interview on 2/11/26 at 2:45 p.m., the Registered Dietitian (RD) stated that when working in direct food preparation or plating food, staff should wear hair and beard nets. During an interview on 2/13/26 at 10:15 a.m., the DM stated that during tray line both DA N and DC M should wear beard nets to cover facial hair because exposed food was present. Review of the facility policy titled Food Preparation and Service, revised 11/22, indicated, Food and nutrition services staff wear hair restraints (hairnet, hat, beard restraint, etc.) so that hair does not contact food.

Based on observation, interview and record review, the facility failed to provide assessments and services which meet professional standards of quality for 11 of 21 sampled residents (Residents 92, 52, 83, 1, 72, 73, 7, 8, 91, 47, and 9) when the following were observed: 1.Inaccurate bed rail (metal or rigid plastic and adjustable safety bars attached to the sides of the bed) and entrapment risk observation/assessments for Resident 72, 52, 1, and 83; 2.Inaccurate bed rail and entrapment risk observation/assessments for Resident 73, 7, 8, 91, 47, and 9; 3.Treatment nurse C (TN C) applied zinc oxide (topical skin barrier) to wound without a physician's order for Resident 92.These failures had the potential to compromise the health and safety of above sampled residents. Findings: 1.During room rounds on 2/9/2026 at 11:03 a.m., observed Resident 72 was in bed with two partial bed rails or side rails (BR, SR, metal or hard plastic adjustable devices attached to the sides of a bed frame for safety or to assist with positioning and support while in bed) up at head of the bed for Resident 72's bed. Review of Resident 72's face sheet (FS, a document that gives information about resident at a quick glance) indicated, Resident 72 was admitted to facility on 12/9/2020. Review of Resident 72 's bed rail and entrapment risk observation/assessment dated [DATE] indicated No for bed rail use. During room rounds on 2/9/2026 at 11:36 a.m., observed Resident 52 was in bed and two partial bed rails up at head of the bed for Resident 52's bed. Review of Resident 52's FS indicated, Resident 52 was admitted to facility on 8/23/2025. Review of Resident 52 's bed rail and entrapment risk observation/assessment dated [DATE] indicated No for bed rail use. During room rounds on 2/9/2026 at 1:56 p.m., observed Resident 1 was in bed and two partial bed rails up at head of the bed for Resident 1's bed. Review of Resident 1's FS indicated, Resident 1 was admitted to facility on 1/19/2026. Review of Resident 1 's bed rail and entrapment risk observation/assessment dated [DATE] indicated No for bed rail use. During room rounds on 2/10/2026 at 9:11 a.m., observed Resident 83 was in bed with two partial bed rails up at head of the bed for Resident 83's bed. Review of Resident 83's FS indicated, Resident 83 was admitted to facility on 9/21/2023. Review of Resident 83 's bed rail and entrapment risk observation/assessment dated [DATE] indicated No for bed rail use. During an interview with certified nursing assistant H (CNA H) on 2/12/2026 at 12:49 p.m., CNA H confirmed bed rails up both sides, at the head of the bed for Resident 1, 52, and 83 while residents were in bed. CNA H stated bed rails have been in use since residents were admitted to facility. CNA H also stated these three residents were able to use bed rails for positioning as needed. During an interview with CNA G on 2/12/2026 at 1:25 p.m., CNA G confirmed bed rails were up both sides at the head of the bed for Resident 72 while resident was in bed. CNA H stated bed rails been in use since resident was admitted to facility. CNA H also stated Resident 72 was able to use bed rails for positioning as needed. During a concurrent record review and interview with director of nursing (DON) on 2/13/2026 at 11:15 a.m., DON reviewed bed rail and entrapment risk observation/assessments for Resident 72, 52, 1, and 83. DON confirmed nursing staff documented No for bed rail use for above residents, answer should be yes. DON stated these three residents were using bed rails since admission to facility. DON also stated nursing staff should have observed and documented bed rail assessment accurately for Residents 72, 52, 1 and 83. 2. During a review of Resident 73's clinical record it indicated Resident 73 was admitted to the facility on [DATE] with diagnoses including cardiomegaly (an enlarged heart) and major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), recurrent, unspecified. A review of Resident 73's physician's orders indicated an order for side rail 1/4 x2 up in bed as enabler to assist with mobility - non restraint, dated 3/14/23. A review of Resident 73's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment dated 11/19/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 73's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 2/5/26 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/9/26 at 10:52 a.m., inside Resident 73's room, Resident 73's bed was observed with two side rails up. During an interview on 2/12/26 at 11:22 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 73 has side rails in use. RN I further stated Resident 73 has been using the side rails for a while. During a concurrent interview and record review on 2/12/26 at 1:24 p.m., with the Director of Nursing (DON), the DON reviewed Resident 73's Bed Rail and Entrapment Risk Observation/Assessment, dated 11/19/25 and dated 2/5/26. The DON confirmed use of bed rails documented, No for above both assessments. DON stated nursing staff should have documented yes for both assessments. During a review of Resident 7's clinical record it indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including anxiety disorder and contracture, unspecified joint. A review of Resident 7's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, dated 9/12/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 7's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 12/1/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/9/26 at 10:56 a.m., inside Resident 7's room, Resident 7's bed was observed with two side rails up. During an interview on 2/12/26 at 11:21 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 7 has side rails in use. RN I further stated Resident 7 has been using the side rails for a while. During a concurrent interview and record review on 2/12/26 at 1:26 p.m., with the Director of Nursing (DON), the DON reviewed Resident 7's Bed Rail and Entrapment Risk Observation/Assessment, dated 9/12/25 other and 12/1/25 quarterly. The DON confirmed use of bed rails documented, No for above both assessments. DON stated nursing staff should have documented yes for both assessments. During a review of Resident 8's clinical record it indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including other seizure anxiety disorder, unspecified. A review of Resident 8's physician's orders indicated an order for side rail 1/4 x2 up in bed as enabler to assist with mobility - non restraint, dated 7/30/25. A review of Resident 8's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 9/18/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 8's assessment titled, Bed Rail and Entrapment Risk Observation/assessment dated [DATE] indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/09/26 at12:08 p.m., inside Resident 8's room, Resident 8's bed was observed with two side rails up. During an interview on 2/12/26 at 11:21 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 8 has side rails in use, RN I further stated Resident 8 has been using the side rails for a while. During a concurrent interview and record review on 2/12/26 at 1:28 p.m., with the Director of Nursing (DON), the DON reviewed Resident 8's Bed Rail and Entrapment Risk Observation/Assessment, dated 9/18/25 and 2/5/26. The DON confirmed section I 1. Are Bed Rails Currently in use? documented, No for above both assessments. DON stated nursing staff should have documented yes for both assessments. During a review of Resident 91's clinical record it indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, recurrent, unspecified and type 2 diabetes mellitus diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications. A review of Resident 91's physician's orders indicated an order for side rail 1/4 x2 up in bed as enabler to assist with mobility - non restraint, dated 7/29/25. A review of Resident 91's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Annual, dated 10/31/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 91's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 1/19/26 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/09/26 at12:05 p.m., inside Resident 91's room, Resident 91's bed was observed with two side rails up. During an interview on 2/12/26 at 11:22 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 91 has side rails in use. RN I further stated Resident 91 has been using the side rails for a while. During a concurrent interview and record review on 2/12/26 at 1:30 p.m., with the Director of Nursing (DON), the DON reviewed Resident 8's Bed Rail and Entrapment Risk Observation/Assessment, dated 10/31/25 annual and 1/19/26 quarterly. The DON confirmed use of bed rails documented No for above both assessments. DON stated nursing staff should have documented yes for both assessments. During a review of Resident 47's clinical record it indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, unspecified and thrombocytopenia (low blood platelet count. Platelets, also called thrombocytes, are colorless blood cells that help blood clot), unspecified. A review of Resident 47's physician's orders indicated an order for side rail 1/4 x2 up in bed as enabler to assist with mobility - non restraint, dated 1/29/25. A review of Resident 47's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 10/31/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 47's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Annual, dated 1/16/26 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/9/26 at 12:03 p.m., inside Resident 47's room, Resident 47's bed was observed with two side rails up. During a concurrent observation and interview on 2/12/26 at 11:20 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 47 has side rails and has been using for a while. During a concurrent interview and record review on 2/12/26 at 1:22 p.m., with the Director of Nursing (DON), the DON reviewed Resident 47's quarterly Bed Rail and Entrapment Risk Observation/Assessment, dated 10/31/25 and annual assessment, dated1/16/26. The DON confirmed use of bed rails documented, No for above both assessments. DON stated nursing staff should have documented yes for both assessments. During a review of Resident 9's clinical record it indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including depression (loss of pleasure or interest in activities for long periods of time),unspecified and anxiety disorder ( a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation),unspecified. A review of Resident 9's physician's orders indicated an order for side rail 1/4 x2 up in bed as enabler to assist with mobility - non restraint, dated 7/29/25. A review of Resident 9's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Quarterly, dated 10/17/25 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. A review of Resident 9's assessment titled, Bed Rail and Entrapment Risk Observation/Assessment, Type Annual, dated 1/5/26 indicated, A. section I Bed Rails Use 1. Are Bed Rails Currently in use? documented, No. During an observation on 2/9/26 at 12:22 p.m., inside Resident 9's room, Resident 9's bed was observed with two side rails up. During a concurrent observation and interview on 2/12/26 at 11:17 a.m., with Registered Nurse I (RN I), RN I confirmed Resident 9 has side rails, RN I further stated Resident 9 has been using the side rails for a while. During a concurrent interview and record review on 2/12/26 at 1:16 p.m., with the Director of Nursing (DON), the DON reviewed Resident 9's Bed Rail and Entrapment Risk Observation/Assessment, dated 10/17/25 quarterly and 1/5/26 annual. The DON confirmed use of bed rails documented No for both assessments. the DON stated no for initial assessment and for quarterly assessment, DON believes it should be Yes, the DON further stated resident is already using the side rails. 3.Review of Resident 92's active physician's order for the right genital (private area) region, dated 2/12/26, indicated the wound treatment included cleansing with normal saline, patting dry, applying 1/4 Dakins (solution used to clean and treat wounds) or Vashe (solution used to clean and treat wounds) wet-to-dry (type of treatment to remove dead tissue to promote wound healing) dressing, packing Nugauze strip gauze (cotton gauze used to packing the deep wound) into the opening near the medial groin, covering with gauze or abdominal pad, and securing with tape every day shift. The physician's order did not include zinc oxide (used to treat and prevent skin irritations). During a wound treatment observation on 2/12/26 at 11:30 a.m., TN C applied zinc oxide to the peri-wound (skin surrounding a wound) area of Resident 92's right groin wound. During a concurrent interview on 2/12/26, TN C confirmed there was no physician's order for zinc oxide prior to applying it. Review of Resident 92's Skin/Wound progress note dated 2/12/26 at 13:20 indicated maceration (skin appears white, pale and wrinkled due to prolonged exposure to excessive moisture) was noted to the peri-wound area of the right groin wound, zinc oxide had been applied, the physician was notified, and a telephone order for zinc oxide was obtained after the treatment had been completed. During a follow-up interview on 2/13/26 at 2:00 p.m., the Director of Nursing (DON) confirmed zinc oxide was not included in the facility's standing orders and stated a physician order is required before zinc oxide can be applied to Resident 92's wound or peri-wound area. Review of facility's policy and procedure (P&P) titled, Medication and Treatment Orders, revision date 7/2016, the P&P indicated, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications . Review of facility's P&P titled, Pressure Ulcers/Skin Breakdown, the P&P indicated, The physician will order pertinent wound treatments, including .application of topical agents. Review of facility's P&P titled, Bed Safety and Bed Rails, revision date August 2022, the P&P indicated, The use of bed rails or side [NAME] (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met,

Based on interview and record review, the facility failed to ensure to updated and revised comprehensive person-centered care plans for 3 of 21 sample residents (Resident 9, 25 and 88) when;1. Care plans was not revised or updated after the fall for Resident 9;2. Care plan was not revised or updated after the fall for Resident 25;3.Care plan for smoking not revised or updated for non-compliance with smoking for Resident 88.This failure had the potential to result in not meeting sampled Residents 9, 25 and 88's plan of care needs.Findings: 1.During a review of Resident 9's clinical record indicated Resident 9 was admitted to the facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time) and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Review of Resident 9's care plan Falls: indicated Resident is at risk for falls with or without injury related to history of falls the care plan included interventions, e.g. Obtain physical therapy (PT, a healthcare profession that treats residents with medical conditions or injuries that limit their ability to move around) and occupational therapy (OT, a healthcare profession that helps, develops, and maintain the skills for daily living) consult, keep bed in low position, the interventions was not updated after 7/10/25. Review of Resident 9's IDT notes indicated Resident 9 had multiple falls, including falls on 10/18/25, 10/19/25, 11/21/25, 1/30/26, and 2/10/26. Resident 9's IDT (interdisciplinary team, a group of healthcare professionals from different disciplines work together towards resident's person-centered goals) note dated 10/20/25 indicated interventions, persist in employing redirection techniques. re-orientation, and supportive care measures while maintaining ongoing follow up appointments. Medications and care interventions will be regularly reviewed and adjusted as needed. with immediate notification to the MD (medical doctor) for any new or concerning changes. After thorough review of the contributing factors and circumstances surrounding the falls. Resident 9's IDT Note dated 11/21/25 indicated interventions included, non pharmacological approaches such as music therapy, positive reinforcement, dim lighting. social service visits, redirection, and encouraging use of a communication board. Preventative measures include low bed positioning, pain management, neuro checks (a rapid and focused assessments to evaluate mental, sensation and coordination status of the resident after fall and other medical condition change). and frequent safety checks. Nursing staff will report any new signs or symptoms to the MD. Resident 9's IDT Note dated 2/2/26 indicated, interventions assess resident, neuro checks, notify provider, notify RP, remind resident to use call light, call light within reach. Resident 9's IDT Note dated 2/12/26 indicated, interventions assess resident, nuero checks, Notify provider, notify RP, encourage resident to use call light, keep call light with in reach. There was no documentation that indicated new fall interventions were implemented after falls on 10/18/25, 10/19,25, 11/11/25, 2/2/25, and 2/12/25. During a concurrent interview and record review on 2/13/26 at 12:38 p.m., with the Director (DON), the DON stated every time the resident had a fall, they do IDT meeting and updated the care plan, if the care plan is ineffective updated the care plan with new intervention. The DON reviewed Resident 9's fall risk care plan and confirmed the fall risk care plan was last updated on 7/10/25, the DON confirmed Resident 9 has multiple history of falls. The DON was asked if the care plan needs to update, the DON stated absolutely. During a follow up interview and record review on 2/13/26 at 2:55 p.m., with DON, DON reviewed Resident 9's IDT notes and fall risk care plan, DON confirmed the fall risk care plan was last updated on 7/10/25, and IDT recommendation dated 11/21/25 are not in the care plan. 2.Review of Resident 25's clinical record indicated she was admitted to the facility with diagnoses including metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood which can result in confusion and memory issues) and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 25's fall care plan, dated 8/20/25 indicated she was at risk for injury. The care plan included interventions, e.g. Obtain PT and OT, consult, keep bed in low position, initiated 8/20/25. There were no revisions to the care plan after 8/20/25. Review of Resident 25's IDT notes indicated the resident had multiple falls, including falls on 9/11/25, 9/17/25, and 12/11/25. -Resident 25's IDT Note, dated 9/15/25 indicated interventions were pain management, notify MD of any changes or conditions, neurological checks and 72 hour charting (documentation). Resident 25's IDT Note, dated 9/18/25 indicated interventions were pain management, neurological checks, and 72 hour charting. -Resident 25's IDT Note dated 12/15/25 indicated interventions were PT and OT evaluations, neuro checks, and notifying MD. There was no documentation that indicated new fall interventions were implemented after falls on 9/11/25, 9/17/25, and 12/11/25. During an interview on 2/13/26 at 12:21 p.m., the Director of Nursing (DON) confirmed new interventions were not in Resident 25's care plan for fall. He confirmed fall interventions were repeated after Resident 25's fall. The DON stated Resident 25's fall care plan should have been updated with new interventions. 3.During observation of smoking at designated smoking area, located back of the facility on 2/10/2026 at 10:50 a.m., noted Resident 88 had a lighter in his pant pocket. Resident 88 used lighter from his pant pocket to light his cigarette, placed lighter back in his pant pocket while activity staff supervised him. Resident 88 left smoking area to inside facility with a lighter in his pant pocket. Review of Resident 88's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 88 was admitted to facility on 1/28/2026. Review of Resident 88's smoking observation/assessment dated [DATE] indicated Resident 88 was a smoker, staff should light the cigarette for smokers. Review of Resident 88's care plan for smoking dated 1/29/2026 indicated, The resident's smoking supplies are kept by the activity staff during the day and kept in the west wing med room at night. Further review of this care plan indicated there was no documented evidence of revised and updated with Resident's non-compliance with smoking materials. During an interview with activity assistant C (AA C) on 2/10/2026 at 10:55 a.m., AA C confirmed Resident 88 had cigarette lighter with him. AA C stated Resident 88 keeps lighter with him, refusing to give to staff to store since he came to facility. During interview with activity director (AD) on 2/12/2026 at 8:43 a.m., AD confirmed Resident 88 was non-compliance with smoking materials, keeping cigarette lighter with him, refusing to give to staff to store. AD also confirmed care plan for smoking not revised and updated with his non-compliance with storage of lighter. During an interview with Director of nursing (DON) on 2/12/2026 at 9:19 a.m., DON confirmed care plan for smoking not updated with non-compliance with cigarette lighter for Resident 88. DON stated care plan for smoking should have been revised and updated when Resident 88 was non-compliant with cigarette lighter. Review of facility's policy and procedure (P&P) titled, Family Notification Letter-Smoking Safety Policy Update, undated, the P&P indicated, All smoking materials (cigarettes, lighters, vapes, etc.) are secured by the facility and released only during approved smoking times. Review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, revision date March 2022, the P&P indicated, Assessments of residents are ongoing and care plan are revised as information about the residents and the resident's condition change. The interdisciplinary team (IDT, a group of healthcare professionals work together to ensure all aspect of resident's health and care been addressed) reviews and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; .

Based on observation, interview, and record review, the facility failed to ensure to follow policy and procedure for electrical and smoking safety for two of six sampled residents (Resident 52 and 88) and in room one out of eleven sampled room (room [ROOM NUMBER]) when;1.Observed long cell phone charging cord on floor while charging in room [ROOM NUMBER].Observed ungraded (not certified for safe use in healthcare setting) power strip (an electrical device to be powered from a single plug in electric socket with many electrical devices to charge at same time) in Resident 52's bed;3.Observed cigarette lighter with Resident 88.Above failures had the potential for accidental hazard for fire for above sampled residents, risk for tripping and fall with or without injury for residents and staff in room [ROOM NUMBER].Findings:1.During an initial room rounds in room [ROOM NUMBER] on 2/9/2026 at 11:10 a.m., observed long cell phone cord one end plugged in electric socket on the wall opposite to bed A and B, on the floor between both beds. This cord went all way to bed B's tray table next to bed and connected to cell phone.During an interview with certified nursing assistant F (CNA F) on 2/9/2026 at 11:14 a.m., CNA F confirmed above observation. CNA F stated cell phone cord should be off the floor for safety reasons. CNA F adjusted the cell phone cord from floor and between both resident's beds before she left the room.During an interview with facility's Maintenance Director (MD) on 2/12/2026 at 10:46 a.m., MD stated cell phone long cord should be off the floor to prevent tipping hazard and potential injury for whoever goes in to room [ROOM NUMBER].2.During an initial room rounds and interview with Resident 52 on 2/9/2026 at 1:36 p.m., noted ungraded power strip plugged in wall socket, 6 different electronic equipment charging in progress, left next to pillow at head of the bed on Resident 52s bed. During interview, Resident 52 stated power strip was his own, started using to charge all his electronic equipment since came to facility, not aware of safety concerns to use. Resident 52 also stated facility staff were aware of this.Review of Resident 52's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident was admitted to facility on 8/23/2025.Review of Resident 52's minimum data set assessment (MDS, resident assessment tool) dated 12/1/2025, section C for brief interview for mental status (BIMS) score of 12/15, moderately impaired cognition.During an interview with MD on 2/12/2026 at 10:46 a.m., MD confirmed Resident 52 was using non-hospital grade power strip to charge his electronic equipment and keeping power strip on bed withing reach for him. MD stated he replaced with hospital grade power strip on 2/9/2026 for Resident 52. MD also stated facility should have used hospital grade power strip and should not kept on resident's bed for safety and to prevent fire hazard.3.During smoking observation at designated smoking area, located back of the facility on 2/10/2026 at 10:50 a.m., noted Resident 88 had a lighter in his pant pocket. Resident 88 used lighter from his pant pocket to lighten his cigarette, placed lighter back in his pant pocket while activity staff supervised him. Resident 88 left smoking area to inside facility with a lighter in his pant pocket.Review of Resident 88's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 88 was admitted to facility on 1/28/2026.Review of Resident 88's smoking observation/assessment dated [DATE] indicated Resident 88 was a smoker, staff should light the cigarette for smokers.Review of Resident 88's care plan for smoking dated 1/29/2026 indicated, The resident's smoking supplies are kept by the activity staff during the day and kept in the west wing med room at night.During an interview with activity assistant C (AA C) on 2/10/2026 at 10:55 a.m., AA C confirmed Resident 88 had a cigarette lighter with him. AA C stated Resident 88 keeps lighter with him, refusing to give to staff for storage, since he came to facility.During interview with activity director (AD) on 2/12/2026 at 8:43 a.m., AD confirmed Resident 88 was non-compliance with smoking materials, keeping cigarette lighter with him, refusing to give to staff to store. AD stated smoking materials including lighters should be with activity staff all the times for safety and Resident 88 should not have had a lighter with him.Review of facility's policy and procedure tilted, Electrical Safety For Residents, undated, the P&P indicated, Inspect electrical outlets, extension cords, power strips, and electrical devices as part of routine fire safety and maintenance inspections. Secure extension cords and do not place overhead, under carpets, or where they can cause trips, falls or overheat. Connect extension cords to only one device.Review of facility's P&P titled, Family Notification Letter-Smoking Safety Policy Update, undated, the P&P indicated, All smoking materials (cigarettes, lighters, vapes, etc.) are secured by the facility and released only during approved smoking times.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications for one of two medication carts (a mobile, secured, and organized cart to store, transport and administer medications to residents) (Medication Cart AA), when expired bottle of brimonidine eyedrop (used primarily as eye drops to lower high pressure in the eye caused by open-angle glaucoma [group of eye diseases that can cause vision loss and blindness]) or ocular hypertension (high pressure inside your eye) and latanoprost eyedrop (used to treat glaucoma) medications were not removed from medication cart's active stock. These failures had the potential for residents to receive medications with reduced efficacy. During an inspection of Medication Cart AA on 2/9/26 at 10:23 a.m., with Registered Nurse I (RN I), RN I confirmed the following findings: a. A bottle of Brimonidine eyedrop had an open date of 1/7/26. Upon reviewing with RN I, he confirmed it expired on 2/6/26. b. A bottle of latanoprost eyedrop had an open date of 12/27/25. Upon reviewing with RN I, he confirmed it expired on 2/7/26. During an interview on 2/12/26 at 1:15 p.m., with the Director of Nursing, The DON stated any expired medications in the cart should be taken and disposed. During a review of the facility's P&P titled Medication Labeling and Storage, indicated, .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During a review of the facility's P&P titled Administering Oral Medications, indicated, .Steps in the Procedure.7. Check the expiration date on the medication. Return any expired medication to the pharmacy.

Based on interview and record review, the facility failed to offer the influenza (flu, respiratory infection) vaccine timely for one of five sampled residents (Resident 4). This failure had the potential to negatively affect the resident's health and well-being.Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). Review of Resident 4's Immunization Audit Report indicated there was no documentation that the resident received or was offered the flu vaccine in 2025. During an interview on 2/12/26 at 12:32 p.m., the infection preventionist (IP) confirmed Resident 4 was admitted to the facility in March 2025. The IP stated Resident 4 was offered and recieved the flu vaccine on 2/11/26. The IP stated she was not sure why yesterday was the only time Resident 4 was offered the flu vaccine. Review of the facility's policy, Influenza Vaccine, dated 3/2022 indicated, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees .

Based on interview and record review, the facility failed to develop and implement person centered comprehensive care plans that included target symptoms, measurable objectives, and interventions for four out of 21 sampled residents (Resident 47, Resident 6, Resident 49, and Resident 72) when: 1.Resident 47, the facility did not develop care plan for bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making);2.Resident 49, facility did not develop care plan for missing/broken teeth; and3.Resident 6, facility did not develop care plan for edentulous (no natural teeth);4.Resident 72, facility did not develop care plan for use of oxygen therapy. These failures had the potential for above sampled residents not meeting their highest practicable physical, mental, and psychosocial plan of care needs. Findings: 1. During a review of Resident 47's clinical record, it indicated Resident 47 was admitted to the facility on [DATE] with diagnosis which includes bipolar disorder (a chronic mental health condition with intense mood changes between high energy episodes and low energy depressive episodes) and thrombocytopenia (low blood platelet count.Platelets, also called thrombocytes, are colorless blood cells that help blood clot). A review of Resident 47's physician's orders indicated an order for Valproate sodium (anticonvulsant medication used to treat epilepsy [all seizure types], prevent migraines, and stabilize mood in bipolar disorder) oral solution 250 mg (milligrams unit of measure) /5ml (milliliter, unit of volume) give 5ml by mouth every morning and at bedtime for bipolar disorder, dated 1/8/26. A review of Resident 47's clinical record indicated there were no comprehensive care plans developed for the resident's bipolar disorder. During a concurrent interview and record review on 2/12/26 at 1:07 p.m., with Director of Nursing (DON), DON reviewed Resident 47's clinical record and confirmed Resident 47 taking Valproate sodium for bipolar disorder. DON stated Resident 47 should have a care plan the diagnosis of bipolar disorder. The DON reviewed Resident 47's care plans and confirmed there was no care plan developed for bipolar disorder, the DON further stated we don't have a care plan for bipolar disorder for Resident 47. 2. Review of Resident 49's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 49 was admitted to facility on 1/11/2025. Review of Resident 49's nursing admission evaluation dated 1/11/2025 indicated, Resident does not have teeth or dentures (removable or fixed device to replace missing teeth). Review of Resident 49's care plans indicated there was no documented evidence for care plan for missing own teeth. During an interview with MDSC on 2/11/2026 at 12:07 p.m., MDSC confirmed there was no care plan for edentulous (no teeth) for Resident 49. MDSC stated Resident 49 should have a care plan for no teeth and nursing staff should have documented and implemented care plan for Resident 49 for missing all teeth. During an interview with facility's director of nursing (DON) on 12/13/2026 at 10:48 a.m., DON stated nursing staff should have initiated care plan for edentulous for Resident 49. 3. Review of Resident 6's FS indicated Resident 6 was admitted to facility on 12/26/2025. Review of Resident 6's admission and readmission evaluation dated 12/26/2025 indicated Resident 6 had own and broken teeth. Review of Resident 6's readmission evaluation dated 1/9/2026 indicated broken natural teeth. Review of Resident 6's care plans indicated there was no documented evidence of care plan for broken natural teeth. During an interview with MDSC on 12/11/2026 at 12:14 p.m., MDSC confirmed there was no care plan for broken and missing teeth for Resident 6. MDSC stated Resident 6 should have a care plan for broken teeth and nursing staff should have documented care plan for broken teeth for Resident 6. During an interview with DON on 12/13/2026 at 11:03 a.m., DON stated nursing staff should have initiated a care plan for broken teeth for Resident 6. 4. During an initial observation on 2/9/2026 at 11:03 a.m., noted Resident 72 was using O2 (Oxygen) via room air concentrator (RAC, a medical device that draws in room air, filters and provides purified O2). During an interview with Resident 72 on 2/9/2026 at 11:03 a.m., Resident 72 communicated through hand gestures and written communication indicated using O2 on and off at times for shortness of breath (difficulty breathing). Review of Resident 72's FS indicated Resident 72 was admitted to facility on 12/9/2020. Review of Resident 72's diagnoses included chronic respiratory failure {a progressive condition where lungs [a pair of spongy body organ, primary function to keep body cells with supply of oxygen (O2, colorless, odorless, and tasteless gas essential for life) cannot adequately provide enough gas exchange, often requiring O2 therapy to breath}. Review of Resident 72's MDS assessment for brief interview for mental status (BIMS - an assessment to test a person's cognition level, [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] dated 2/3/2026 indicated, his BIMS score of 13/15, cognitively intact. Review of Resident 72's order summary report indicated oxygen therapy 2L (liters, concentration of O2 to deliver), titratable to maintain oxygen at or above 93% as needed., dated 2/8/2026. Review of Resident 72's care plans indicated there was no documented evidence of care plan for oxygen therapy. During an interview with MDSC on 2/11/2026 at 12:14 p.m., MDSC confirmed there was no care plan for O2 therapy for Resident 72. MDSC also confirmed Resident 72 using O2 as needed. MDSC stated this resident should have a care plan for O2 therapy when receiving O2. MDSC also stated nursing staff should have documented care plan for O2 therapy for Resident 72. During an interview with DON on 2/12/2026 at 4:31 p.m., DON stated nursing staff should have initiated and implemented care plan for oxygen for Resident 72. Review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revision date March 2022, the P&P indicated, the interdisciplinary team (IDT, a collaborative group of healthcare professionals from different disciplines who work together toward person-centered plan of care and needs), in conjunction with the resident and his/her family or legal representative (a person authorized to make medical decisions on behalf of resident when he/she become incapacitated), develops and implements comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (minimum data set, assessment tool) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR, a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs) screening form for one of eight sampled residents (Resident 84). This failure had the potential to result in the resident not receiving specialized care and services appropriate to the condition. Findings: Review of Resident 84's clinical record indicated diagnoses that included Paranoid Schizophrenia (a severe mental illness characterized by persistent false beliefs and hallucinations that affect thinking, perception, and behavior) and psychosis (loss of contact with reality, often involving hallucinations or false beliefs). Review of the PASARR Level 1 screening form dated 2015, indicated incomplete information. During concurrent interview and record review on 2/13/26 at 12:00 p.m. the Minimum Data Set Coordinator (MDSC) confirmed the PASARR level 1 screening in the record was incomplete and that no Level II evaluation had been obtained. The MDSC stated she would complete a new PASARR Level 1 screening for Resident 84. Review of the facility's policy titled admission Criteria revised 3/2019, indicated All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process .If the Level 1 screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process .

Based on interview and record review, the facility failed to ensure to code minimum data set (MDS, resident assessment tool) assessment accurately to reflect status of the residents for three of six sampled residents (Resident 6, 49, and 1) when; 1.Resident 6's dental status was coded inaccurately;2. Resident 6's weight loss status was coded inaccurately;3.Resident 49's dental status was coded inaccurately;4.Resident 1's orders for insulin (medication used to treat and regulate blood sugar) was coded inaccurately. These failures can lead to inappropriate care and interventions for sampled residents.Findings: 1.Review of Resident 6's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 6 was admitted to facility on 12/26/2025.Review of Resident 6's admission and readmission evaluation dated 12/26/2025 indicated Resident 6 had his own and broken teeth.Review of Resident 6's readmission evaluation dated 1/9/2026 indicated broken natural teeth.Review of Resident 6's MDS assessment dated [DATE], section L for oral and dental status not indicated, no natural teeth or tooth fragments.During an interview with licensed vocational nurse A (LVN A) on 2/11/2026 at 11:06 a.m., LVN A confirmed several missing upper and lower teeth for Resident 6.During concurrent record review of Resident 6's above admission, readmission evaluations, and MDS assessments and interview with minimum data set coordinator (MDSC) on 2/11/2026 at 12:14 p.m., MDSC confirmed Resident 6's admission and readmission evaluation for several missing teeth. MDSC also confirmed MDS assessment was not coded accurately for missing teeth for Resident 6. MDSC stated MDS staff should have coded dental status accurately to reflect missing teeth for Resident 6.2.Review of Resident 6's MDS assessment dated [DATE] section K for weight loss indicated, Yes, on physician-prescribed weight-loss regimen.Review of Resident 6's clinical documentation indicated there was no documented evidence for physician prescribed weight loss regimen for Resident 6.During an interview with MDSC on 2/11/2026 at 12:14 p.m., MDSC confirmed above MDS assessment for section K for weight loss documented physician prescribed weight loss regimen. MDSC stated no documented evidence for MD approved weight loss regimen and MDS assessment for weight loss coded inaccurately. MDSC also stated section K for weight loss should have coded accurately.During a telephone interview with Resident 6's primary care physician (PCP) on 2/12/2026 at 1:43 p.m., PCP confirmed he did not approve planned weight loss regimen for Resident 6. PCP also stated Resident 6 was treated for fluid retention last month, not for weight loss. PCP further stated will not recommend or approve prescribed weight loss regimen based on current medical condition for Resident 6.3. Review of Resident 49's FS indicated Resident 49 was admitted to facility on 1/11/2025.Review of Resident 49's nursing admission evaluation dated 1/11/2025 indicated, Resident does not have teeth or dentures (removable or fixed device to replace missing teeth).Review of Resident 49's MDS assessment dated [DATE], section L for dental status not indicated No natural teeth or tooth fragment(s) (edentulous) (no natural teeth).During a concurrent record review of Resident 49's above nursing admission evaluation, MDS assessment and interview with MDSC on 2/11/2026 at 12:07 p.m., MDSC confirmed Resident 49 edentulous and MDS assessment coded inaccurately for dental assessment. MDSC stated it should be coded accurately to reflect no natural teeth for Resident 49. 4. Review of Resident 1's FS indicated Resident 1 was admitted to facility on 1/19/2026. Review of Resident 1's diagnoses included diabetes type 2 (DM 2, a chronic disorder when body becomes resistant to insulin, causes high blood sugar levels).Review of Resident 1's order summary indicated insulin glargine (long acting insulin to treat diabetes type 2) 100 units (concentration of insulin) /ML (milliliter, a metric unit of volume equal to one thousandth of a liter) 6 units inject subcutaneous (SQ, inject under the skin, using thin needle to deliver medication) one time a day for DM 2, dated 1/19/2026. Humalog SQ 100 unit/ML, SQ inject SQ per sliding scale (a customized scheduled insulin regimen that adjusts does based on blood sugar levels) before meals and bedtime for DM 2, dated 1/19/2026.Review of Resident 1's electronic medication administration record (EMAR, a digital healthcare document to track and manage the administration of medications) for January/2026 and February/2026 indicated Resident 1 received glargine insulin 6 units everyday at 9:00 a.m., and Humalog insulin per sliding scale everyday before meals and at bed time for January/2026 and February/2026.Review of Resident 1's MDS assessment dated [DATE], section N for medications hypoglycemic (medications used to treat high blood sugar) (including insulin) documented No.During an interview with MDSC on 2/12/2026 at 1:03 p.m., MDSC confirmed above MDS assessment for medications for insulin. MDSC stated MDS assessment dated [DATE] coded wrong, it should have coded Yes for hypoglycemic including insulin for Resident 1. MDSC also stated MDS staff should have coded to reflect Resident 1's insulin as ordered and received.Review of facility's policy and procedure (P&P) titled, Resident Assessments, undated, P&P indicated, Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observation/interviews.

Based on interview and record review, the facility failed to ensure one out of four residents (Resident 9) is free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when: Resident 9's Seroquel (an antipsychotic medication that helps treat several kinds of mental health conditions) ordered as needed with no stop date. This failure had the potential for increased risks associated with use of psychotropic medication that could negatively affect the resident's physical, mental, and psychosocial well-being.During a review of Resident 9's clinical record indicated Resident 9 was admitted to the facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time),unspecified and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation),unspecified.During a review of Resident 9's physician's order indicated an order for Seroquel Oral Tablet 25 MG (milligram, unit of measure) Give 1 tablet by mouth every 6 hours as needed for Paranoid Schizophrenia (a chronic mental health condition [now clinically classified under the broader diagnosis of schizophrenia] characterized primarily by intense delusions and auditory hallucinations. Individuals often experience extreme fear, mistrust, and false beliefs that others are plotting against them) Breakthrough agitation, dated 11/27/25. During a concurrent interview and record review on 2/12/26 at 1:00 p.m., with director of nursing (DON), DON reviewed Resident 9's physician's order and confirmed there was no stop date for Seroquel, and it was ordered more than 14 days. The DON stated it should be discontinued. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revised date February 2025, the P&P indicated, .PRN medication 3. PRN order for psychotropic medications are limited to 14 days. a. For psychotropic medications that are not antipsychotic: If the prescriber or the attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. b. For psychotropic medications the ARE antipsychotics: PRN orders cannot be renewed unless the attending physicians or prescriber evaluates the resident and documents the appropriateness of the medications. Monitoring and Adverse Consequences.4. In addition, residents are monitored for adverse consequences associated with psychotropic medication.

Based on interview, and record review, the facility failed to ensure free from loss of personal property for one (Resident 6) of three sampled residents. This failure had the potential to affect the health and emotional well-being of sampled Resident 6.Findings:During room rounds for Resident 6 on 2/10/2026 at 8:38 a.m., Resident 6 informed facility lost his clothes and shoes and he informed facility staff. Resident 6 also stated no staff responded back to him for his missing items.Review of Resident 6's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 6 was admitted to facility on 12/26/2025.Review of document for Resident 6's inventory of personal effects (record of personal belongings, clothing and valuables brought into the facility) undated, indicated several items including clothes, shoes and slippers. Review of facility's list of grievance and theft/ lost logs for December 2025, January 2026 and February 2026 indicated no documented evidence of lost personal clothes and shoes for Resident 6.During an interview with certified nursing assistant E (CNA E) on 2/10/2026 at 1:06 p.m., CNA E stated Resident 6 informed he lost clothes and shoes while in facility last week. During an interview with social service assistant (SSA) on 2/11/2026 at 11:30 a.m., SSA confirmed there were no grievance or report of theft, and lost process initiated for missing clothes and shoes for Resident 6. SSD stated not aware of Resident 6 lost clothes and shoes in facility.During on interview with director of nursing (DON) on 2/12/2026 a 4:22 p.m., DON searched for clothes and shoes in Resident 6's personal belongings in facility and confirmed one grey pant, one gray shirt and one gray slippers missing from documented Resident 6's inventory of personal effects. DON stated facility should not have lost clothes and slippers for Resident 6. DON also stated facility will reimburse or replace missing 3 items for Resident 6.Review of Facility's policy and procedure (P&P) titled, Investigation Incidents of Theft and /or Misappropriation of Resident property, revised April 2017, the P&P indicated, Resident have the right to be free from theft and/or misappropriation of personal property. When an incident of theft and/or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident.

Based on interview and record review, the facility failed to ensure fall management was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was not monitored after 5 falls;2. No interdisciplinary team meeting was conducted after 3 falls;3. No care plan was developed after one fall; and4. Resident 1's Responsible Party was not notified after 2 falls. These failures had the potential for Resident 1 to develop ill effects from a fall, to result in future falls and injury, and for Resident 1's responsible party being uninformed and unaware of his condition.A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including unspecified fall, muscle weakness, abnormalities of gait and mobility, and cellulitis (bacterial infection of the skin) of the left lower limb. A review of Resident 1's admission Fall Risk Observation/Assessment, dated 3/12/25, indicated his fall risk score was 16 which indicated a high risk for falls. Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] and was discharged on 6/2/25. Resident 1 had 5 unwitnessed falls during his stay in the facility. Review of Resident 1's clinical record indicated he had unwitnessed falls on 4/1/25, 5/2/25, 5/19/25, 5/24/25, and 5/29/25. There was no documentation in the progress notes that licensed nurses were monitoring Resident 1 every shift after these falls for any ill effects from the falls for a 72 period. During an interview and concurrent record review with the director of nursing (DON) on 7/2/25 at 2:00 p.m., he stated licensed nurses should monitor a resident for 72 hours after a fall and record the resident's post-fall status in the progress notes every shift. The DON confirmed documentation by licensed nurses every shift for 72 hours was not done after Resident 1's 5 falls on the above dates. Review of Resident 1's clinical record indicated three of Resident 1's 5 falls, on 5/19/25, 5/24/25, 5/29/25, had no documented evidence that the facility's interdisciplinary team (IDT, team members from different departments involved in a resident's care) met to discuss Resident 1's falls. During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he stated the IDT should meet after every fall to discuss the cause of the fall and to develop a plan to prevent further falls, and revise and/or update the care plan based on the IDT's decision. The DON confirmed there was no evidence the IDT met after Resident 1's 3 falls on 5/19/25, 5/24/25. and 5/29/25. Review of Resident 1's clinical record indicated Resident 1 had an unwitnessed fall on 4/1/25. This was the first fall in the facility since Resident 1's admission on [DATE]. There was no care plan developed for Resident 1's actual fall on 4/1/25. During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he confirmed there was no care plan developed for Resident 1's fall on 4/1/25. The DON stated there should be a care plan created after a fall with interventions identified to prevent further falls. A review of Resident 1's Change of Condition Evaluation, dated 5/2/25, indicated Resident 1 had an unwitnessed fall. The section titled Resident Representative Notification indicated notification was done on 5/2/25 at 2:00 p.m., and Resident 1 was self-responsible party. Another Change of Condition Evaluation, dated 5/19/25, indicated Resident 1 had an unwitnessed fall. The section titled Resident Representative Notification indicated notification was done on 5/19/25 at 4:00 p.m., and Resident 1 was self-responsible. A review of Resident 1's face sheet (a document summarizing key information about a resident) indicated Resident 1's son was the responsible party (RP, a person designated to make health care decisions for a resident). During an interview and concurrent record review with the DON on 7/2/25 at 2:00 p.m., he stated Resident 1 was not identified as being self-responsible and confirmed the son was listed as the RP. The DON confirmed the son was not notified of Resident 1's falls on 5/2/25 and 5/19/25, and stated the son should have been informed of the falls. Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Review of the facility's policy titled Care Plans - comprehensive Person Centered, dated 2001, indicated the interdisciplinary team develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to develop care plans and implement interventions to meet the resident's needs. Findings: 1. Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses including hemiplegia/hemiparesis (one side of the body is paralyzed or weak), difficulty in walking, and muscle weakness. Review of Resident 1's Change in Condition Evaluation, dated 8/22/24, indicated Resident 1 had an unwitnessed fall. Resident 1's MDS, dated [DATE], was reviewed. Section J1800 of the MDS was designated to indicate if the resident had any falls during the specified time frame. The individual who completed the MDS coded 0, which indicated the resident did not have any falls during the specified time frame. During an interview and concurrent record review with the MDS nurse (MDSN) on 1/29/25 at 10:37 a.m., the MDSN reviewed Resident 1's medical record and confirmed the resident had a fall on 8/22/24. The MDSN stated this fall should have been coded on the MDS dated [DATE], but confirmed it was not. The MDSN confirmed the individual who completed the MDS should have coded 1 in section J1800 to indicate that Resident 1 did have a fall during the specified time frame. The Centers for Medicare & Medicaid Services 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame. 2. Review of Resident 1's Change in Condition Evaluation, dated 11/26/24, indicated Resident 1 had an open wound on her left arm due to pressure from a splint (a strip of rigid material used to immobilize a body part). Review of Resident 1's treatment administration record (TAR) indicated the resident received treatment for the above left arm pressure injury (injury to the skin and underlying tissue as a result of prolonged pressure) from 11/28/24 to 12/17/24. Resident 1's MDS, dated [DATE], was reviewed. Section M0210 of the MDS was designated to indicate if the resident had any unhealed pressure injuries. The individual who completed the MDS coded 0, which indicated Resident 1 did not have any unhealed pressure injuries. During an interview and concurrent record review with the MDSN on 1/29/25 at 10:37 a.m., the MDSN reviewed Resident 1's medical record and confirmed the resident had a pressure injury that should have been coded on the MDS, dated [DATE], but was not. The MDSN confirmed the individual who completed the MDS should have coded 1 in section M0210 to indicated that Resident 1 did have an unhealed pressure injury. The 2023 RAI Manual indicated for section M0210, Code 1, yes if the resident had any pressure injuries during the 7-day look back period.

Based on interview, and record review, the facility failed to ensure the consultant pharmacist (CP) identified irregularities and make recommendations to the facility during the monthly medication regimen review (MRR) for 4 of 23 sampled residents (Residents 72, 40, 44 and 2). This failure had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings: 1. A review of Resident 72's medical record indicated he was an elderly resident admitted to the facility with diagnoses including Parkinson's disease with dyskinesia (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), unspecified dementia (a condition characterized by memory loss) unspecified severity, without behavioral disturbance, mood disturbance, and anxiety, unspecified psychosis (condition that affect the mind, where there has been some loss of contact with reality), depression unspecified and anxiety disorder, unspecified. A review of Resident 72's physician's orders indicated the following: a. Pimavanserin (medication for hallucinations and delusion) 34 milligrams (mg, unit of measure) by mouth at bedtime for Parkinson's, dated 1/11/24. b. Seroquel (medication for mental disorder) 25 mg, give 1 tablet by mouth at bedtime for psychosis (hallucinations and delusions) for seeing things that doesn't exist, dated 1/11/2024. A review of Lexi-comp online (www.[NAME].com), a nationally recognized drug information resource, indicates pimavanserin is used for treatment of Parkinson disease psychosis. For Seroquel, Lexi-comp indicated it can cause increase in the blood lipids and to monitor lipid panel 4 months after initiation and annually. A review of Resident 72's clinical record indicated there had been no identification of and monitoring for specific targeted behaviors; no side effect monitoring; no developed care plan with specific behavioral symptoms, goals, and interventions; no quarterly review by the interdisciplinary team; and no evidence of informed consent for pimavanserin. Also, there was no lipid panel monitoring for the use of Seroquel. During an interview and record review on 09/18/24 at 3:25 p.m. with the Director of Nursing (DON), the DON stated residents receiving psychotropic medications are monitored for behavior(s) and side effects. The DON verified pimavanserin's use for hallucinations and thoughts that happen with Parkinson's disease. He verified there were no documentation of any specific hallucinations and delusions associated with Parkinson's disease psychosis and no care planning specific to Resident 72's symptom of hallucinations. The DON also confirmed there was no informed consent, no quarterly review for this medication, and no documentation of a cholesterol panel for the use of Seroquel. A review of the medication regimen review (MRR) dated January to September 2024 for Resident 72 did not indicate recommendations for pimavanserin from the Consultant Pharmacist (CP). During a phone interview on 9/19/24 at 11:00 a. m. with the CP, the CP stated he should have made the recommendations for target behaviors, side effect monitoring, psychotropic review, and informed consent for Resident 72's pimavanserin use. Regarding the lipid panel monitoring, the CP confirmed Resident 72 was receiving Seroquel there should have been a recommendation for a lipid panel monitoring, but he did not make the recommendation. Review of the facility's policy, titled, Medication Regimen Reviews, dated May 2019, indicated the CP performs a medication regimen review, at least monthly, to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. It also indicated, The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems medication errors and other irregularities . A review of the facility's policy titled, Pharmacy Services- Role of the Consultant Pharmacist, dated 4/2019, indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including . Providing the facility with written and electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. 38087 2. Review of Resident 44's medical record indicated Resident 44 had a physician's order dated 7/11/24, for pantoprazole sodium (medication used to treat too much acid in the stomach) 40 milligrams (mg, unit of dose measurement) one time a day for GERD (a chronic digestive disorder in which stomach acid irritates the food pipe lining). Review of Resident 44's document titled Nursing Recommendations, written by the CP and dated 6/9/24, indicated: Pantoprazole is recommended to be administered 30 minutes before the morning meal. The document had initials written in the column marked Follow-Through. Review of Resident 44's medication administration record (MAR) for July, August, and September of 2024 indicated pantoprazole sodium was administered at 9 a.m. beginning on 7/12/24 through 9/19/24. During an interview and concurrent record review with the director of nursing (DON) on 9/19/24 at 2:05 p.m., he stated the initials on the document were his own. The DON further stated that he followed through with the pharmacist's recommendations and adjusted the administration time of the pantoprazole sodium to be one half hour before breakfast. The DON reviewed Resident 44's medication administration record for July, August, and September of 2024. The DON confirmed the licensed nurses were documenting an administration time of 9 a.m. for the pantoprazole sodium. The DON stated I don't know how the administration time got switched back to 9 a.m., I followed the pharmacist's recommendation and changed it to be 6:30 a.m. The DON confirmed the pantoprazole should be administered one half hour before breakfast. 46552 3. Review of Resident 40's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 40 was admitted to facility on 12/11/2020. Review of Resident 40's current physician medication orders indicated, Acidophilus Capsule (used to help maintain the number of healthy bacteria in stomach (body organ part of digestive system) (Lactobacillus [also called acidophilus]) give 2 capsules two times a day, dated 12/15/2020. Another order dated 4/1/2022 indicated diphenhydramine (used to relieve symptoms of allergy and common cold) 50 mg (milligram: unit of mass equals a thousandth of a gram) at bedtime, dated 4/1/2022. Other order indicated, Ondansetron (used to prevent nausea and vomiting) 8 mg three times a day, dated 11/26/2023. Review of medication administration record for September/2024 indicated, Resident 40 receiving all three medications as ordered above. Review of Resident 40's CP recommendations dated 6/4/2024 indicated, In order to prevent polypharmacy (multiple medications) and unnecessary medication use, may we consider discontinuing the following medications? Ondansetron Acidophilus Diphenhydramine. During a telephone interview with CP on 9/20/2024 at 12:30 p.m., CP confirmed he provided recommendations to the facility to discontinue above three medications for Resident 40. CP stated facility was responsible to follow up with MD (medical doctor) for CP's recommendations for residents as needed. During a concurrent record review of CP recommendations for Resident 40 dated 6/4/2024 and interview with director of nursing (DON) on 9/20/2024 at 1:01 p.m., DON confirmed received CP recommendations for Resident 40, and not been followed up with MD to discontinue above three medications for Resident 40. DON also confirmed Resident 40 currently receiving above three medications as ordered. DON stated nursing staff should have been followed up with MD regarding CP's recommendations to discontinue to prevent use of unnecessary medications for Resident 40. Review of facility's policy titled, CONSULTANT PHARMACIST REPORTS, undated, the P&P indicated, Recommendations are acted upon and documented by the facility staff and/or the prescriber. 48935 4. Review of Resident 2's face sheet indicated he was admitted to the facility on [DATE] with a diagnosis of paraplegia, neuromuscular dysfuction of bladder (a disorder of control of the urinary bladder) and history of COVID-19 (a respiratory illness). Review of Resident 2's physician orders indicated an order for Keflex (antibiotic medications)250 mg one tablet by mouth in the morning for presence of indwelling catheter & chronic UTI prophylaxis x indefinite, with a start date of 1/31/23. Review of the medication regimen review (MRR) binder, which contains the CP's recommendations from January to September 2024, reflected no recommendations from the current CP or previous CP for reviewing the Keflex order with the physician. During a telephone interview with the CP on 9/19/24 at 10:57 AM, the CP stated antibiotics was a part of the MRR review. When asked about Resident 20's physician order for Keflex, the CP stated I do not recall prior review of this resident's Keflex order and Typically we don't recommend keeping someone on Keflex indefinitely.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) form for 9 of 9 sampled residents (Residents 39, 37, 92, 43, 11, 85, 58, 91, and 78). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes. Findings: Review of Resident 39's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 39 was admitted to facility on 7/3/2018. Review of Resident 39's POLST form dated 7/3/2018 indicated, section D for AD documented No Advance Directive. Further review of Resident 39's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 39. Review of Resident 37's FS indicated Resident 37 was admitted to facility on 7/29/2024. Review of Resident 37's POLST form dated 7/29/2024 indicated section D for AD documented No Advance Directive. Further review of Resident 37's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 37. Review of Resident 92's FS indicated Resident 92 was admitted to facility on 5/14/2024. Review of Resident 92's POLST form dated 5/14/2024 indicated section D for AD documented No Advance Directive. Further review of Resident 92's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 92. Review of Resident 43's FS indicated Resident 43 was admitted to facility on 8/14/2024. Review of Resident 43's POLST form dated 6/10/2024 indicated clinical section D for AD documented Advance Directive not available. Further review of Resident 43's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 43. Review of Resident 11's face sheet indicated Resident 11 was admitted to facility on 8/25/2024. Review of Resident 11's POLST form dated 8/25/2024 indicated, section D for AD documented No Advance Directive. Further review of Resident 11's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 11. Review of Resident 85's FS indicated Resident 85 was admitted to facility on 5/13/2024. Review of Resident 85's POLST form prepared on 5/13/2024 indicated, section D for AD documented No Advance Directive. Further review of Resident 85's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 85. Review of Resident 58's FS indicated Resident 58 was admitted to facility on 8/17/2024. Review of Resident 58's POLST form dated 8/15/2024 indicated section D for AD documented No Advance Directive. Further review of Resident 58's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 58. Review of Resident 91's FS indicated Resident 91 was admitted to facility on 6/4/2024. Review of Resident 91's POLST form prepared on 7/15/2024 indicated section D for AD documented No Advance Directive. Further review of Resident 91's clinical record indicated there was no documented evidence for facility discussed for AD or offered or assisted to execute AD for Resident 91. Review of Resident 78's FS indicated Resident 78 was admitted to facility on 3/10/2023. Review of Resident 78's POLST form dated 3/25/2023 indicated section D for AD blank, uncompleted. Further review of Resident 78's clinical record indicated there was no documented evidence for facility discussed for AD or verified for executed AD or offered or assisted to execute AD for Resident 78. During an interview with facility's social service director (SSD) on 9/19/2024 at 9:56 a.m., SSD verified and confirmed there was no documented evidence for social service staff discussed or verified or offered or assisted to execute AD for above all 9 residents (Residents 39, 37, 92, 43, 11, 85, 58, 91, and 78). SSD stated social service staff should have verified, discussed, offered, and assisted to execute AD and documented as needed for these residents. During an interview with facility's director of nursing (DON) on 9/19/2024 at 10:30 a.m., DON stated social service staff should have discussed or verified or offered or assisted to execute AD for above residents. DON also said nursing staff should have completed all sections for POLST form for Resident 78. Review of facility's P&P titled, Advance Directive, last revised December 2016, the P&P indicated, Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's discussion to accept or decline assistance. Review of State of California law for POLST form indicated California law requires that a POLST form be followed by healthcare providers and provides immunity to those who comply in good faith. POLST must be completed by healthcare provider based on patient preferences and medical indications. Refer to WWW.caPOLST.org.

Based on interviews and record review, the facility failed to ensure two of 23 sampled residents (Residents 72 and 91) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 72 received pimavanserin (an antipsychotic medication to treat hallucinations and delusions associated with Parkinson's disease psychosis) without specific target behaviors, side effect monitoring, quarterly psychotropic review, care plan, and evidence of informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for over 8 months. Also, Resident 72 did not receive periodic monitoring of the blood lipids while being on Seroquel (antipsychotic medication) that would affect the blood lipids). 2. Resident 91 received Remeron (anti-depressant medication) without monitoring for potential side effects of the medication. The failures resulted in unnecessary medications for the residents and had the potential for medication interactions, adverse reactions, and increased risks associated with the use of psychotropic medications that included, but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, and memory loss. Findings: 1. A review of Resident 72's medical record indicated he was an elderly resident admitted to the facility with diagnoses including Parkinson's disease with dyskinesia (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), unspecified dementia (a condition characterized by memory loss) unspecified severity, without behavioral disturbance, mood disturbance, and anxiety, unspecified psychosis (condition that affect the mind, where there has been some loss of contact with reality), depression unspecified and anxiety disorder, unspecified. A record review of Resident 72's physician's orders indicated the following: a. Pimavanserin 34 milligrams (mg, unit of measure) by mouth at bedtime for Parkinson's, dated 1/11/24. b. Seroquel 25 mg, give 1 tablet by mouth at bedtime for psychosis for seeing things that doesn't exist, dated 1/11/2024. A review of Lexi-comp online (www.[NAME].com), a nationally recognized drug information resource, indicates pimavanserin is used for treatment of Parkinson disease psychosis. For Seroquel, Lexi-comp indicated it can cause increase in the blood lipids and to monitor lipid panel 4 months after initiation and annually. During an interview and observation on 9/18/24 at 9:00 a.m., Resident 72 was observed in his room speaking and answering questions in a hard-to-understand manner of speech. Resident 72 was observed to be a bit confused but had a pleasant demeanor. No behaviors were noted. A telephone interview was conducted on 9/18/24 at 2:07 p.m. with Resident 72's responsible party (RP1). RP1 stated the pimavinserin was prescribed by Resident 72's neurologist (doctor who diagnoses, treats, and manages disorders of the brain and nervous system) for Parkinson's symptoms such as seeing cats in the house, seeing someone sitting on the chair, or children playing outside when they were not there. A review of Resident 72's clinical record indicated there had been no identification of and monitoring for specific targeted behaviors; no side effect monitoring; no developed care plan with specific behavioral symptoms, goals, and interventions; no quarterly review by the interdisciplinary team; and no evidence of informed consent for pimavanserin. Also, there was no lipid panel monitoring for the use of Seroquel. During an interview and record review on 09/18/24 at 3:25 p.m. with the Director of Nursing (DON), the DON stated residents receiving psychotropic medications are monitored for behavior(s) and side effects. The DON verified pimavanserin's use for hallucinations and thoughts that happen with Parkinson's disease. He verified there were no documentation of any specific hallucinations and delusions associated with Parkinson's disease psychosis and no care planning specific to Resident 72's symptom of hallucinations. The DON also confirmed there was no informed consent, no quarterly review for this medication, and no documentation of a cholesterol panel for the use of Seroquel. 2. A review of Resident 91's medical record indicated he was an elderly resident admitted to the facility with diagnoses including unspecified depression. A review of Resident 91's order summary report indicated a physician's order for Remeron 7.5 mg, 1 tablet by mouth at bedtime for depression for poor meal intake, dated 8/14/2024. A review of Resident 91's medical record indicated there was no monitoring for adverse effects of Remeron. Lexi-comp, a nationally recognized drug information resource, indicated Remeron can produce marked sedation in the elderly and Older patients with depression being treated with an antidepressant should have been closely monitored for response and adverse effects. An interview and record review on 9/19/24 at 10:03 a.m. with the DON, the DON stated when a resident is on psychotropic medication, the staff monitors the target behaviors and side effects on the medication administration record (MAR). He stated there should have been an order for it. After looking on the electronic health record, he stated When Resident 91 was sent to the hospital the order was discontinued, and when he returned on 8/14/24, we did not renew the order but, the order should have been renewed at that time. The DON verified the side effects for Remeron had not been monitored for over one month. Review of the facility's undated policy and procedures titled Psychoactive/Psychotropic Medication Use, indicated, Residents will only receive psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. The attending physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. Prior to administration of a psychotropic, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative, and document the consent in the medical record. Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences and Staff will monitor for potential adverse consequences such as iii. Metabolic: increase in total cholesterol and triglycerides .

Based on observation, interview, and record review, the facility failed to ensure safe use and disposition of medications, and accurate accountability of controlled drugs (those with high potential for abuse and addiction), when: 1. There were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 2 out of 4 residents (Residents 34 and 83). The failure had the potential for abuse or misuse of controlled drugs; 2. The pharmacy failed to label 3 insulin pens in accordance with the current standards of practice to prevent mix-ups or administration errors; and 3. There was no process in place for the disposition of hazardous drugs (HDs, medications capable of toxic effects on humans) in accordance with the current standards of practice (See United States Pharmacopeia 800 or USP 800, a scientific non-profit organization that sets standards for safe handling of HDs to minimize the risk of exposure to healthcare personnel, patients, and the environment). This deficiency had the potential for exposing healthcare workers, residents, and the environment to dangerous hazardous medications. Findings: 1. During the survey, the CDR (or count sheet) for four residents receiving PRN (as-needed) controlled medications was requested for review. During an interview with the Director of Nursing (DON) on 9/18/24 at 9:15 a.m., he stated any time a resident requests for a PRN (as-needed) controlled medication, the nurse assesses the resident; reviews the physician's order, and if it's time to give the medication, removes the medication from the medication cart; signs it out of the count sheet; administers the medication to the resident; and documents the administration on the resident's MAR. a. A review of Resident 83's clinical record indicated a physician's order, dated 8/12/24, for oxycodone (a potent narcotic for pain) 5 milligrams (mg, unit of measure) every 4 hours as needed for severe pain. During a concurrent interview and record with the DON on 9/18/24 at 9:20 a.m., a review of Resident 83's CDR for oxycodone and the August and September 2024 MARs indicated, on 4 occasions, the nursing staff signed out of the count sheet but did not document on the MAR to show it was administered to the resident, as follows: - 8/14/24 at 1700 (5 p.m.) - 8/21/24 at 6:50 a.m. - 9/7/24 at 10:20 a.m. - 9/14/24 at 1800 (6 p.m.) During this interview and record review, the DON confirmed the above finding. He also reviewed Resident 83's progress notes and stated he could not find documented evidence to show the medication was administered to the resident. b. A review of Resident 34's clinical record indicated a physician's order for hydrocodone/acetaminophen (brand name Norco, a potent narcotic for pain) 5/325 mg 1 tablet every 4 hours PRN pain, dated 7/31/2024. During a concurrent interview and record review with the DON on 09/18/24 at 9:31 a.m., a review of Resident 34's CDR for hydrocodone/acetaminophen 5/325 mg and the September 2023 indicated Resident 34 had 9 instances where Norco 1 tablet was signed out of the count sheet but not documented on the MAR. They were as follows: - 9/12/24 at 1600 (4 p.m.), 2000 (8 p.m.), 2359 (11:59 p.m.) - 9/13/24 at 1600, 2000, and 2359 - 9/14/24 at 1545, 2000, and 2359 The DON confirmed the above finding and stated the same nurse (RN M) removed the medication each of those 9 times. During a concurrent interview and record review with RN M on 9/18/24 at 3:51 p.m., he verified he had removed the Norco for Resident 34 each of the above 9 occasions but failed to document the administration on the MAR. He stated he was supposed to document each time but sometimes I forget. A review of the facility's policy and procedures (P&P) titled Administering Medications, dated 4/2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. A review of the facility's P&P titled Controlled Substances, dated 11/2022, indicated in part, The system of reconciling the . dispensing .of controlled substances includes the following . a. Records of personnel access and usage; b. Medication administration records . 2. During the inspection of the Station 4 Medication Cart with Licensed Vocational Nurse (LVN) L on 9/17/24 at 11:17 a.m., an insulin pen (a pre-filled pen containing insulin - to lower blood sugar) was identified with the pharmacy label on the cap (not the body) of the pen. LVN L confirmed this finding. On 9/17/24 at 11:30 a.m., an inspection of the Station 2 Medication Cart with RN A identified an insulin pen with the pharmacy label on the cap, not on its body. The cap of the pen was found loosely re-capped and could become loose during movement/shuffling. RN A confirmed this finding and acknowledged that the pen cap labeling had the potential for mix-ups when multiple pen caps become loose when not tightly capped. On 9/17/24 at 12:11 p.m., an inspection of the Station 3 Medication Cart with LVN J identified an insulin pen with the pharmacy label on the pen cap. LVN J confirmed this finding. A review of the Institute for Safe Medication Practices' (ISMP, a non-profit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, 2017, indicated A patient-specific label is affixed on the body of the insulin pen (not on the removable cap), without obscuring important information on manufacturer labeling or the dose counter/dose window. It further indicated, Insulin pen mix-ups between patients have been reported to ISMP when patient-specific labels were stuck to (or placed on) the pen caps rather than to the barrel of the pen and the caps of two different pens were inadvertently switched. Thus, patients were at high risk for receiving insulin from another patient's pen device as well as exposure to bloodborne pathogens or even the wrong insulin. All patient-specific labels should be applied to the barrel of the pen in a manner as not to obstruct manufacturer drug information. 3. During a medication pass observation on 9/16/24 at 9:36 a.m., RN A was observed preparing 10 medications for Resident 40. One of the medications called Junel 1/20 (a birth control pill) was observed inside a plastic bag with large yellow imprint on the outside: CAUTION HAZARDOUS DRUG. During a visit to the Station 3 Medication Room (main medication room) with the DON on 9/17/24 at 10:46 a.m., five blue-lidded pharmaceutical bins were identified inside the room. The DON stated the discharged and unused medications were discarded in these bins. When asked if there was a separate bin for hazardous drugs (HD), he stated he will get back to the surveyor. During a follow-up interview on 9/18/24 at 9:12 a.m., the DON stated, We are using the blue lidded container for wasting of all the meds. We don't have a separate one [for hazardous drugs]. He confirmed the facility is supposed to have one for HD disposition. On 9/19/24 at 12:15 p.m., the DON provided a copy of the National Institute for Occupational Safety and Health (NIOSH) List of Antineoplastic (cancer treating)] and Other Hazardous Drugs in Healthcare Settings, 2016. A review of 2016 NIOSH List revealed it included commonly used medications in skilled nursing facilities such as colchicine (medication for gout), finasteride (for enlarged prostate), topiramate (an anticonvulsant), fluconazole (an antifungal), warfarin (an anticlotting medication), etc. A review of the current USP 800, effective 11/1/2023, indicated the following under LIST OF HAZARDOUS DRUGS, The National Institute for Occupational Safety and Health (NIOSH) maintains a list of antineoplastic and other HDs used in healthcare. Further review of the USP 800 indicated: This chapter describes practice and quality standards for handling hazardous drugs (HDs) to promote patient safety, worker safety and environmental protection. Handling HDs includes .receipt, storage . administration, and disposal of sterile and nonsterile products and preparations. This chapter applies to all healthcare personnel who handle HD preparations and all entities that store, prepare, transport, or administer HDs (e.g., pharmacies .healthcare institutions .). Personnel who may potentially be exposed to HDs include . nurses . Entities that handle HDs must incorporate the standards in this chapter into their occupational safety plan. The entity's health and safety management system must, at a minimum, include: A list of HDs . Safe work practices . Policies for HD waste segregation and disposal.

Based on observation, interview and record review, the facility failed to ensure the proper use of side rails for six (Residents 303, 304, 91, 44, 75, and 12) of 30 residents when: 1. For Residents 303 and 304, there were no signed informed consents for the use of side rails by the resident or the responsible party for either resident. 2. For Resident 91, the informed consent on file was missing a signature from the resident or responsible party. 3. For Residents 44, 75 and 12, there were no care plans for the use of side rails for any of the three residents These failures had the potential to compromise the resident's rights to fully make informed decisions on the use of side rails, and had the potential to put residents at risk for entrapment or serious injury. Findings: 1. During an observation on 9/16/24 at 10:11 AM, Resident 303 was observed lying in bed, with two siderails up in the upright position. Review of Resident 303's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis (partial paralysis and blindness) following cerebral infarction (a brain attack, also known as a stroke) affecting right dominant side, systemic lupus erythematosus (a disease of the immune system that attacks the body), and right humerus fracture. Review of Resident 303's record indicated there was no signed informed consent for the use of side rails signed by either the Resident or the Responsible Party (RP) During an observation on 9/17/24 at 9:08 AM, Resident 304 was observed lying in bed, with two side rails up in the upright position. Review of Resident 304's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease, type 2 diabetes mellitus (a disorder that affects regulation of blood sugar levels), and cardiomyopathy (enlarged heart). Review of Resident 304's record indicated there was no signed informed consent for the use of side rails signed by either the Resident or the responsible party. During a concurrent interview and record review on 9/18/24 at 3:50 PM with the director of nursing (DON), the DON confirmed there were no signed informed consents for the use of side rails for both resident 303 and Resident 304. The DON also stated he expects they should have an informed consent for the use of side rails, for residents that use side rails. Review of facility policy titled Bed Safety and Bed Rails, last revision date unknown, indicated Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. 46552 2. During an observation on 9/17/2024 at 10:38 a.m., Resident 91's bed had 1/4 bed rails up both sides at the head of the bed. Review of Resident 91's FS indicated Resident 91 was admitted to facility on 6/4/2024. Resident 91's FS also indicated resident 91 was self-responsible for decision making. Review of resident 91's minimum data set (MDS: clinical assessment tool) dated 9/4/2024 indicated Resident 91's brief interview for mental status (BIMS) score of 13/15 (score of 00-07: severely impaired cognition, 08-12: moderately impaired cognition, 13-15: intact cognition). During an interview with Resident 91 on 9/17/2024 at 10:38 a.m., Resident 91 stated did not recall given consent or not to facility for use bed side [NAME]. Review of Resident 91's physician orders dated 8/14/2024 indicated, Bilateral upper side rails for bed mobility/positioning and /or transfer. Review of Resident 91's clinical document for bed rail and entrapment risk observation/assessment dated [DATE] indicated no signature by Resident 91 for informed consent given for bed side rails use. During record review and interview with facility's director of nursing (DON) on 9/19/2024 at 10:54 a.m., DON reviewed 91's no signature for informed consent for Resident 91. DON stated nursing staff should have completed and taken signature for informed consent from Resident 91 before started using bed side [NAME] for Resident 91. 38087 3. During an observation on 9/17/24 at 8:48 a.m., in Resident 12's room, Resident 12 had 1/4 bed rails up, bilaterally. Review of Resident 12's physician order, dated 6/7/24 indicated he had an order for Bilateral upper side rails for bed mobility/positioning and/or transfer. During a review of Resident 12's Bed Rail Observation/Assessment, dated 6/7/24, indicated bed rails are recommended at all times when resident is in bed to enhance mobility. During an observation on 9/16/24 at 11:08 a.m., in Resident 44's room, Resident 44 had 1/4 bed rails up, bilaterally. Review of Resident 44's physician order, dated 11/2/23 indicated he had an order for Bilateral upper side rails for bed mobility/positioning and/or transfer. During a review of Resident 44's Bed Rail Observation/Assessment, dated 1/10/24, indicated bed rails are recommended at all times when resident was in bed to enhance mobility. During an observation on 9/16/24 at 9:28 a.m., in Resident 75's room, Resident 75 had 1/4 bed rails up, bilaterally. Review of Resident 75's physician order, dated 11/17/23 indicated he had an order for Bilateral upper side rails for bed mobility/positioning and/or transfer. During a review of Resident 75's Bed Rail Observation/Assessment, dated 11/17/23, indicated bed rails are recommended at all times when resident was in bed to enhance mobility. Review of residents 12, 44, and 75, care plan documents indicated the residents did not have bed or side rails care plans. During an interview and concurrent record review with the director of nursing (DON) on 9/17/24 at 3:15 p.m., he confirmed Residents 12, 44, and 75 were using side rails on their beds, and did not have care plans addressing the use of the side rails. The DON further stated residents who had bed rails in use should have a care plan in place. Review of the facility's policy titled Care Planning - Interdisciplinary Team, revised March 2022, indicated The interdisciplinary team is responsible for the development of resident care plans . Comprehensive person-centered care plans are based on resident assessments and developed by an interdisciplinary team.

Based on interview and record review, the facility failed to ensure the laboratory company urgently reported Resident 1's stat (immediate or urgent) test results. Resident 1 had a symptom of a urinary tract infection (UTI, an infection of the urinary system such as the kidneys and bladder, with symptoms including shakiness, confusion, and burning sensation or pain during urination) and the physician ordered stat laboratory tests. The laboratory reported one stat laboratory result a day later and the other test five days later. The failure of the late reporting resulted in a delay in notifying the physician, initiating treatment and had the potential of causing health complications to Resident 1. Findings: Review of Resident 1's Change in Condition (CIC) report, dated 1/25/2020 at 10:25 a.m., indicated Resident 1 was having pain when she went to the restroom, her pain started four days ago and the physician ordered urinalysis (UA, a urine test) with culture and sensitivity (CS, test to identify bacteria and which antibiotics the bacteria is sensitive to treatment) laboratory tests. Review of Resident 1's record indicated she had a physician's orders [REDACTED]. Review of Resident 1's UA and CS and CBC tests were all obtained on 1/25/2020 at 11:49 a.m. The CBC test was reported by the laboratory company on 1/26/2020 at 1:41 p.m. and there was an undated documentation indicating the physician was informed of the test result. Review of the UA form indicated the results was reported on 1/30/2020 at 9:15 p.m. and the form indicated a registered nurse on 2/5/2020 noted a physician's orders [REDACTED]. Review of Resident 1's record lacked documentation indicating licensed nurses were following up in obtaining and reporting laboratory results to the physician prior to 2/5/2020. During an interview on 2/12/2020 at 10:15 a.m., the director of nurse (DON) stated the facility changed laboratory company a few months ago and they were having challenges, such as laboratory test results being reported late. During an interview on 2/12/2020 at 1:10 p.m., the licensed nurse (LN) stated, when a physician ordered a stat laboratory test the results should be in by the same day. Since changing to a new laboratory company we have been having problems such as in obtaining stat and routine test results, having them timely pick up laboratory specimens and in phlebotomists being unable to obtain blood tests. The LN also stated, we often had to call and remind the laboratory company to pick up and report laboratory tests. During a follow-up interview on 2/12/2020 at 4:50 p.m., the DON who reviewed the record stated Resident 1's 1/25/2020 laboratory tests were not reported by the laboratory company as stat. The DON stated she did not find any policy specifying the timeframe in obtaining stat laboratory results. Review of Resident 1's hospital History and Physical, dated 2/6/2020, indicated the resident was doing well until two weeks prior, when she was noted to have some weakness and a little confusion. A UA was ordered and the resident was found to have a UTI. However, it was not treated until yesterday and she was diagnosed with [REDACTED]. Review of the CLINICAL LABORATORY AND RADIOLOGY SERVICES AGREEMENT contract, dated 10/28/19, indicated for all stats ordered by the physician the providers was to dispatch services immediately and return results to the facility promptly, as required by law. Review of the LAB WORK, ORDERING & REPORTING policy, dated 11/2012, indicated if critical or stat labs were not received in a timely manner, the nurse was to call for them.

Based on interview and record review, the facility failed to provide quality of care for one of 18 sampled residents (47) when the licensed nurses did not follow-up with the physician after he was notified of the laboratory results of a positive urine culture (a test to find germs in the urine and indicates a urinary tract infection [MEDICAL CONDITION]). This failure resulted in Resident 47's admission to the acute care hospital for due to UTI. Findings: 1. The clinical record for Resident 47 was reviewed on 9/21/18. Resident 47 had a [DIAGNOSES REDACTED]. Resident 47 had a history of [REDACTED]. Review of the nurse's notes dated 9/8/18 at 7:20 p.m., indicated Resident 47 presented with chills and a temperature of 104.5 degrees Fahrenheit. The notes indicated licensed vocational nurse I (LVN I) notified the primary care physician (PCP), obtained an order for [REDACTED]. Review of the Physician order [REDACTED]. Review of Resident 47's Lab Results Report dated 9/12/18 at 11:15 a.m., indicated a urine culture specimen was obtained on 9/9/18 at 4:30 a.m. The report further indicated Resident 47's culture was positive for extended spectrum beta-lactamase (ESBL, an enzyme which causes antibiotics not to work to kill bacteria). The lab report further indicated the ESBL found in the urine was resistant (the medication is unable to kill the germs) to all cephalosporins and [MEDICATION NAME] (types of antibiotic medication). Resident 47 received [MEDICATION NAME] sodium on 9/8/18 which was a cephalosporine antibiotic. Review of the nurse's notes dated 9/12/18 at 12:53 p.m., indicated the laboratory results of the urinalysis from 9/9/18 were sent to the PCP via facsimile (fax, transmission of printed material over the telephone wires) and the licensed nurse was waiting for the PCP to reply with new orders. Review of the nurse's notes dated 9/13/18 at 10:43 p.m., indicated urine culture results were sent a second time via fax and the licensed nurse telephoned the physician's office and was waiting for the PCP to reply. The note further indicated Resident 47 continued to have cloudy urine. Review of the nurse's notes dated from 9/13/18 to 9/18/18 indicated there was no further evidence the licensed nurses followed up with Resident 47's PCP regarding the 9/12/18 urine culture results. Review of the nurses's notes dated 9/19/19 at 3:33 a.m., indicated Resident 47 presented with stomach discomfort, nausea, stomach distention (swollen due to pressure from inside) and there was there was no urine draining from the catheter (indicates a blocked urine tube). The note further indicated a new catheter was placed and 600 milliliters (ml, a unit of measurement) of urine drained from the new catheter. Review of the nurse's notes dated 9/19/18 at 11:13 a.m., indicated Resident 47 presented with chills, nausea, abdominal pain, abdominal distention and no urine had drained from the catheter into the drainage bag since 3:33 a.m. The note indicated another new catheter was placed and 900 ml of urine with a blood clot drained from the new catheter. The note further indicated Resident 47 was transfered to the acute care hospital on [DATE] at 11:30 a.m. During an interview with licensed vocational nurse B (LVN B) on 9/21/18 at 10:48 a.m., she stated she was not aware Resident 47 had a urine culture during the past three weeks when she cared for him. LVN B stated the licensed nurses should have communicated and carried over the information about the urine culture results and they should have made her aware the PCP did not respond to the two facsimiles. During an interview and concurrent record review with the director of nursing (DON) on 9/21/18 at 10:59 a.m., he reviewed Resident 47's electronic clinical record and he stated there should have been a communication on the electronic communication board about waiting for the PCP's response and about the results of the urine culture; but he acknowledged no evidence was there that any nursing staff followed up on the urine culture results issue. The DON stated the licensed nurses should have contacted the facility's medical director about the results of Resident 47's urine culture if the PCP did not get back to them. Review of Resident 47's acute care facility history and physical (H&P) dated 9/19/18 at 12:18 p.m., indicated he presented to the emergency room with abdominal pain and general malaise (general feeling of discomfort) and his urine was quite dirty (cloudy). The H&P further indicated he was admitted to the acute care facility [MEDICAL CONDITION] due to UTI due to urinary catheter. Review of Resident 47's acute care Summary Discharge Report dated 9/25/18 at 12:05 a.m., indicated the urine culture collected on 9/19/18 in the acute care hospital's emergency department was positive for EBSL and was resistant to [MEDICATION NAME] sodium. Review of the facility's (YEAR) policy, Change of Condition, indicated facility staff should identify, inform the physician, and intervene to provide medical or nursing care for a resident experiencing a medical change of condition.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent Resident 9 from falling consistent with the resident's assessed needs and plan of care. These failures resulted in Resident 9 sustaining a fracture of her right hand, a head injury, and laceration of the scalp on 11/20/15 after a fall incident. Findings: Resident 9's medical record was reviewed and indicated she was admitted with [DIAGNOSES REDACTED]. Her minimum data set (MDS, an assessment tool) dated 11/13/15, indicated she had severely impaired decision making skills and required assistance from the nursing staff with activities of daily living (ADLs; bed mobility, transfer, ambulation, dressing, toileting, personal hygiene and bathing). During an interview and record review with the registered physical therapist on 10/4/16 at 4:15 p.m., she stated Resident 9 had physical therapy on 6/3/15 and Resident 9 was discharged on [DATE] to ambulate with supervision on an even surface, and distant supervision with all functional transfers. Review of Resident 9's progress notes, dated 10/3/15 at 2 a.m. indicated Resident 9 had an unwitnessed fall in the hallway, was transferred to an acute hospital and returned to the facility with the [DIAGNOSES REDACTED]. Resident 9's fall care plan and intervention, dated 10/3/15, indicated continue at risk plan intervention, e.g., to provide a safe environment with floors free from spills or clutter and encourage resident to participate in activities, and a bed alarm to alert staff if the resident tried to get out of bed without assistance. Review of Resident 9's fall risk assessment, dated 10/3/15, indicated she had a score of 21 (represents a high risk for falls). It also indicated under gait analysis, Resident 9 exhibited loss of balance while standing, used short discontinuous steps or shuffling steps, changed gait pattern when walking through doorways, exhibited jerking or instability when making turns, and decrease in muscle coordination. Review of Resident 9's progress notes indicated another unwitnessed fall in her room on 11/20/15 at 3 p.m. She was transferred to the acute hospital and returned to the facility with a [DIAGNOSES REDACTED]. Resident 9's fall care plan and intervention, dated 11/20/15, indicated a landing floor pad was not indicated due to an increased risk of the resident tripping on it, one-on-one with the resident, and assist with all ADLs. Review of Resident 9's fall risk assessment, dated 11/13/15, indicated she had a score of 22 (represents a high risk for falls). It also indicated under gait analysis, Resident 9 exhibited loss of balance while standing, used short discontinuous steps or shuffling steps, the resident required hands-on assistance to move from place to place, changed gait pattern when walking through doorways, exhibited jerking or instability when making turns, and decrease in muscle coordination. During an interview and record review with the registered physical therapist on 10/4/15 at 4:20 p.m., she stated Resident 9 had a decline related to fall. She started physical therapy on 10/19/15 and was discharged on [DATE] with supervision or standby assistance for safe ambulation and transfer. She also stated due to her shuffling gait and impaired cognition, Resident 9 was at risk for falling which required assistance from the facility staff with her ADLs. Review of Resident 9's fall scene investigation report on 12/28/15 at 11:20 a.m. indicated Resident 9 had another witnessed fall in the activity room when she transferred herself from her wheelchair and slid onto the floor. Resident 9's fall care plan and intervention, dated 12/28/15, indicated continue with one-on-one supervision with the resident, and ambulation with facility staff in the hallway. Review of Resident 9's fall scene investigation report on 2/17/16 at 1:15 p.m., documented Resident 9 had a witnessed fall at the facility's front lobby when Resident 9 transferred herself from the wheelchair to the chair and slid to the floor. Resident 9's fall care plan and intervention, dated 2/17/16, indicated to assist the resident to ambulate on her own, and offer a chair when the resident appears to be tired or have an unsteady gait. Review of Resident 9's fall scene investigation report on 7/30/16 at 12:41 p.m., documented Resident 9 had a witnessed fall when Resident 9 ambulated in the dining area, stepped backward and lost her balance. Resident 9's fall care plan or intervention, dated 7/30/16, indicated staff will ambulate Resident 9 with standby supervision and provide the resident with a seat to rest. Review of Resident 9 on 9/23/16 at 9:45 a.m. in the dining area, Resident 9 had a witnessed fall when she got up from her chair, slipped on wet floor and fell . Resident 9's care plan or intervention, dated 9/23/16, indicated staff will ambulate the resident with standby supervision, and if noted to be tired provide her with a seat to rest. During an observation on 10/3/16 at 5:15 p.m. Resident 9 was laying on her bed by herself with a landing floor pad on the floor by the left side of her bed. On 10/4/16 at 4:45 p.m., during activities observation in the dining area, Resident 9 walked around while the activity assistant (AA) did some activities with other residents and was not paying attention to Resident 9. There was no other staff in the activity room to supervise Resident 9. During an observation and interview with the clinical consultant (CC) at 10/4/16 at 10:30 a.m., Resident 9 sat alone, inside the office of the director of nursing. The CC confirmed Resident 9 was alone and with no supervision by the facility staff. She also verified Resident 9 had a landing floor pad on the left side of her bed which was a tripping hazard for Resident 9. The CC stated Resident 9 should have interdisciplinary team (IDT, team members from different departments involved in a resident's care) notes regarding her landing floor pad at her bedside. During an interview with registered nurse B (RN B) on 10/5/16 at 2:55 p.m., she stated she was the assigned charge nurse for Resident 9 and Resident 9 required assistance with her ADLs. Resident 9 was not steady with her gait and Resident 9 was observed ambulating by herself without staff assistance. She confirmed Resident 9 was a fall risk due to her cognition and unsteady gait. Review of the facility's 11/2012, Falls Management, indicated it was the policy of this facility that the physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risks, and interventions will be implemented to reduce the risk of falls. Residents scoring as a high risk will have interventions implemented to reduce the potential for falls to outline in their plan of care.