Every finding on record at San Jacinto Valley Post Acute

Based on interview and record review, the facility failed to immediately notify the attending physician timely of a low potassium level for one of three residents (Resident 1). This failure resulted in Resident 1's transfer to the acute hospital for treatment had the potential for the resident to sustain a cardiac arrest (an electrical malfunction that causes the heart to suddenly stop beating effectively, halting blood flow to the brain and vital organs) or death.Findings: On July 9, 2026, at 12:15 p.m., an unannounced visit was made to the facility to investigate a complaint. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses that included muscle wasting and atherosclerotic heart disease (heart vessels become narrowed or hardened). Resident 1 was discharged to an acute hospital on December 6, 2025. On July 9, 2026, at 1:40 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated on December 4, 2025, at 3:00 p.m., a Comprehensive Metabolic Panel (CMP) lab test was collected from the resident. On December 4, 2025, at 4:40 p.m., the lab reported to the facility that the resident had a low potassium level of 2.9. The normal range is 3.5 to 5.1. RN 1 stated he called the attending physician on December 5 , 2025, at 10:00 p.m. (approximately 29 hours after the lab result was received.) He received orders to administer Potassium 40 meq (milliequivalent-unit of measure). The medication was administered at 10:55 p.m. RN 1 notified the physician on December 5, 2025, at 11:33 p.m., that the facility did not have enough potassium for the morning dose. The physician gave orders to transfer the resident to the acute hospital for further treatment. On July 20, 2026, at 3:13 p.m., Registered Nurse 2 was interviewed. RN 2 stated he worked on December 4, 2025, 2:30 p.m., to 10:30 p.m. and December 5, 2025, 6:30 a.m. to 3:00 p.m. RN 2 stated, I did not review lab results because I have my routine duties of admissions and room changes. On July 20, 2025, at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated it was the responsibility of RN 2 to review lab results. A review of facility policy and procedure titled, Acute Condition Changes-Clinical Protocol, dated, 2001, indicated, . The nursing staff will contact the physician based on the urgency of the situation .

Based on observation, interview and record review, the facility failed to ensure an exit door (EXD 1), located along (name of street), was readily accessible and unobstructed for 24 of 24 residents when the door handles were secured with a zip tie.This failure resulted in an obstructed exit door and had the potential to result in a delay or prevent the residents from exiting the facility during an emergency, such as a fire.Findings:On April 14, 2026, at 10:07 a.m., during a concurrent observation and interview, Resident 1 was awake and alert, sitting in his wheelchair near EXD 1. Resident 1 stated EXD 1 used to be the main entrance. Resident 1 stated he observed EXD 1 door handles were zip tied on two separate occasions. Resident 1 stated on the first occurrence, the door handles were secured with three zip ties; he could not remember when. The second occurrence was two days ago, when a black zip tie was on the door handles, which was later removed by a maintenance staff. Resident 1 stated they are not supposed to zip tie EXD 1 because if there is an emergency they cannot get out.On April 14, 2026, at 1:30 p.m., during a concurrent observation and interview, Resident 2 was awake and alert, sitting in his wheelchair near EXD 1. Resident 2 stated EXD 1 was zip tied on two occasions; approximately one or two weeks ago and again on April 12, 2026, at 7:15 p.m. Resident 2 stated he took a photograph of EXD 1 on April 12, 2026. Resident 2 stated when EXD 1 was zip tied, it made him feel like it was not a safe situation if there was a fire; the only way to remove the zip tie is to cut it.On April 14, 2026, at 1:54 p.m., during a concurrent interview and observation of the facility's exit doors (EXDs), the Maintenance Director (MTD) stated they check the EXDs weekly to make sure they are working properly and are unobstructed, so that egress (exit) is easy and there are no delays if an emergency occurs.On April 14, 2026, at 2:33 p.m., during a concurrent interview and review of the photograph of EXD 1, received by the California Department of Public Health, with the MTD and Maintenance Assistant (MA) 1, the MTD stated the photograph is the facility's lobby area showing EXD 1, and the door was zip tied and it should not be zip tied. During the same interview, the Administrator (ADM) joined and he was shown the same photo. The ADM stated a night shift (11 p.m. to 7 a.m.) staff member decided to zip tie EXD 1 because they were concerned that residents may exit through that door, but that is not their policy. The ADM stated EXD 1 was zip tied one week ago and was identified again on Monday, (April 13, 2026). The ADM further stated a zip tie is not a lock and can be removed easily. The MTD and MA 1 both stated that the zip tie can be undone by forcing the doors to open. The MTD stated when EXD 1 was zip tied, it could lead to a delayed egress.On April 14, 2026, at 4:15 p.m., during an interview, the Director of Nursing stated that the MTD notified her on April 13, 2026, at 8:53 a.m. that EXD 1 was zip tied and it was removed right away. On April 15, 2026, at 1:05 p.m., during a telephone interview, the Registered Nurse (RN) stated EXD 1 used to be the main entrance, and it always had an alarm. The RN stated all the EXDs are closed and have two alarms each and anyone can exit those doors anytime but cannot come back inside. The RN stated on April 12, 2026, he was the RN for the PM (3 p.m. to 11 p.m.) shift, and during dinner time, he noticed a food delivery driver was already inside the facility near EXD 1. The RN stated he then noticed that the gate outside EXD 1 was wide open and they did not hear the alarm go off. The RN stated he and a Certified Nurse Assistant (CNA) checked on EXD 1 and the alarm was deactivated. The RN stated he tried to set the alarm, but he did not know how, as the alarm was new. The RN stated as an immediate solution for safety, he placed a black zip tie on the door handles of EXD 1. The RN stated he usually calls MA 2, who is the on-call maintenance staff, when there is something in the facility that needs to be fixed, but he forgot because he was doing two admissions that night. The RN stated exit doors should be accessible in case of an emergency.A review of Resident 1's admission Record (AR) dated April 14, 2026, indicated he was admitted to the facility on [DATE], with diagnoses which included transient ischemic attack (a temporary blockage of blood flow to the brain).A review of Resident 1's History and Physical (H&P) dated August 22, 2025, indicated he has the capacity to understand and make decisions.A review of Resident 2's AR dated April 14, 2025, indicated he was admitted to the facility March 14, 2025, with diagnoses which included paraplegia (the partial or complete paralysis of the lower half of the body, typically affecting both legs and sometimes part of the trunk).A review of Resident 2's H&P dated November 12, 2025, indicated he has the capacity to understand and make decisions.A review of the facility's policy and procedure titled Exits or Means of Egress dated July 2024 indicated, .The facility has emergency exits for rapid evacuation .exit doors remain unlocked at all times .

Based on observation, interview, and record review, the facility failed to implement, review, and re-evaluate care plan interventions to prevent falls two of 19 residents reviewed (Resident 20 and Resident 86).This failure resulted in Resident 20 and Resident 86 experiencing multiple falls and had the potential for Resident 20 and Resident 86 to sustain avoidable injuries. Findings:On January 26, 2026, at 3:59 p.m., a concurrent observation and interview was conducted with Resident 20. Resident 20 was observed alert and oriented, in a low bed with floor mat, receiving gastrostomy (medical device inserted into the stomach for administering formula, fluids, and medication) feeding. Resident 20 stated he fell out of bed attempting to go to the restroom.Resident 20's medical record was reviewed.Resident 20 was admitted into the facility on July 21, 2025, with diagnoses which included muscle weakness, gastrotomy, and encephalopathy (brain dysfunction).The history and physical dated July 22, 2025, indicated Resident 20 did not have the capacity to understand and make decisions.The BIMS (Brief Interview for Mental Status- an assessment tool) dated October 28, 2025, indicated a score of 9 (meaning moderate thinking impairment).The change of condition note for the following dates December 28, 2025; January 5, 2026; and January 20, 2026, indicated Resident 20 experienced three falls within 23 days.The care plan dated December 30, 2025, indicated .Falls: Resident had an unwitnessed fall and is at risk for fear of falls, injury, recurring falls .Intervention .Anticipate and meet needs .Keep bed in low position with brakes locked .Keep call light within reach .Keep personal items frequently used within reach .Medication regimen review as indicated . There was no documented evidence in Resident 20's medical record that the medication regimen review was conducted as indicated in the care plan intervention dated December 30, 2025.The care plan dated January 20, 2026, indicated .Falls: resident had an unwitnessed fall on 1/20/2026 .interventions .Anticipate and meet needs .Educate/remind resident to call for assistance .Evaluation of medications for side effects that may increase fall risk .Keep bed in low position with brakes locked .Keep call light within reach .Keep personal items frequently used within reach .Medication regimen review as indicated .There was no documented evidence in Resident 20's medical records that a medication regimen review was conducted as indicated in the care plan intervention dated January 20, 2026.There was no documented evidence in Resident 20's medical record that the care plan interventions had been reviewed and updated by the Intradisciplinary Team (a group of professionals from diverse fields who work together collaboratively and independently to achieve a common goal) for effectiveness since Resident 20 experienced three falls within 23 days.On January 28, 2026, at 9:40 a.m., Resident 86 was observed sitting in a wheelchair next to his bed. The bed was observed in a low position with floor mats next to it. Resident 86 was able to respond to introductions but was not interviewable.On January 28, 2026, at 9:44 a.m., an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated she was Resident 86's assigned CNA. CNA 1 stated Resident 86 was a fall risk resident.Resident 86's medical record was reviewed.Resident 86 was admitted to the facility on [DATE], with diagnoses which included left femur fracture healing (healing thigh bone fracture), history of falls, cerebral infarction (brain injury) and dementia (loss of intellectual function).The history and physical dated December 4, 2025, indicated Resident 86 had intermittent (occasional) capacity to make decisions.The BIMS dated December 9, 2025, indicated score of 0 (resident is rarely/never understood).The change of condition notes for the following dates December 12, 2025; December 28, 2025; December 29, 2025; December 31, 2025; and January 25, 2026, indicated Resident 86 experienced five falls within 44 days.Resident 86's care plan was reviewed. There was no documented evidence of a care plan update for the falls dated December 12, 2025, and December 31, 2025.Resident 86's Intradisciplinary Team (IDT) notes were reviewed. There was no documented evidence that an IDT meeting was conducted for the falls dated December 12, 2025; December 31, 2025; and January 25, 2026.On January 29, 2026, at 9:48 a.m., an interview was conducted with CNA 2. CNA 2 stated Resident 20 was a fall risk resident. CNA 2 stated Resident 20 had several falls attempting to get out of bed.On January 29, 2026, at 9:56 a.m., a concurrent interview and record was conducted with the Registered Nurse (RN). The RN stated the facility's process for falls was to assess the resident, notify the physician and the family, execute physician orders, develop a care plan and conduct an IDT meeting. The RN stated Resident 20 was at risk falls. The RN stated the change of condition notes indicated Resident 20 had three falls on the following dates December 28, 2025, January 5, 2026, and January 20, 2026. The RN stated there was no documented evidence of a medication regimen review as indicated in the care plan intervention dated December 30, 2025, and January 20, 2026. The RN stated there was no documented evidence that an IDT meeting was held for the fall on January 20, 2026, and there should have been an IDT meeting for that fall.The RN stated Resident 86 was at risk for falls. The RN stated the change of condition notes indicated Resident 86 had five falls on the following dates December 12, 2025; December 28, 2025; December 29, 2025; December 31, 2025; and January 25, 2026. The RN stated there was no documented evidence of an updated care plan for the falls dated December 12, 2025, and December 31, 2025, and there should have been an updated care plan for those falls. The RN stated there was no documented evidence that an IDT meeting was conducted for the falls dated December 12, 2025; December 31, 2025; and January 25, 2026. The RN stated there should have been an IDT meeting for each fall.On January 29, 2026, at 11:01 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 20 is at risk for falls. The DON stated Resident 20 had 3 falls on the following dates December 28, 2025; January 5, 2026; and January 20, 2026. The DON stated there was no documented evidence of a medication regimen review as indicated in the care plan interventions dated December 30, 2025, and January 20, 2026. The DON stated there should have been a medication regimen review conducted for Resident 20. The DON stated there was no documented evidence that an IDT meeting was conducted for the fall dated January 20, 2026, and there should have been an IDT meeting for the fall on January 20,2026.The DON stated Resident 86 was at risk for falls. The DON stated Resident 86 change of condition notes indicated five falls on the following dates December 12, 2025; December 28, 2025; December 29, 2025; December 31, 2025; and January 25, 2026. The DON stated there was no documented evidence of an updated care plan for the falls dated December 12, 2025, and December 31, 2025, and there should have been an updated care plan for those falls. The DON stated there was no documented evidence that an IDT meeting was conducted for the falls dated December 12, 2025; December 31, 2025; and January 25, 2026. The DON stated there should have been an IDT meeting for each fall.A review of the facility policy titled Safety and Supervision of Residents, revised July 2017, indicated .Implementing interventions to reduce accidents and hazards shall include the following: ensuring that interventions are implemented.monitoring the effectiveness of interventions shall include the following: evaluating the effectiveness of interventions; evaluating the effectiveness of new or revised interventions.A review of the facility policy titled Care Plans, Comprehensive Person Centered, dated December 2016, indicated .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements.person -centered care plan for each resident.The interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure provision of safe and effective pharmaceutical services to meet the needs of the residents when: Medications with holding parameters were not administered according to the physician's orders for three of four reviewed residents (Resident 2, 3, and 109) on blood pressure (BP) medications. This failure had the potential to significantly lower blood pressure to cause dizziness, confusion, fainting and a fall.Findings: 1. On January 28, 2026, a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Care Plan Report, dated October 24, 2025, indicated, Resident has a diagnosis of hypertension (HTN, high blood pressure) and is at risk for chest pain, decreased blood pressure, dizziness, edema (swelling in parts of body).Administer medication as ordered.Monitor blood pressure as ordered and PRN (as needed).Observe for signs and symptoms of abnormal blood pressure.and notify physician as needed. A review of Resident 2's physician orders indicated Metoprolol Tartrate (medication for high blood pressure) 50 mg (milligram - unit of measurement) was ordered on December 25, 2025, to be given one tablet by mouth two times a day for hypertension, Hold med (medication) if SBP (systolic blood pressure - top number in a blood pressure reading) is less than 110 or PR (pulse rate) less than 60. Take with food. A review of Resident 2's Medication Administration Record (MAR) for January 2026 indicated metoprolol 50 mg was administered to Resident 2 when the SBP was below 110 on the following date and time:- January 6, 2026, at 0900 (9 a.m.), SBP 108. 2. On January 29, 2026, a review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hypertension, hyperlipidemia (high cholesterol) and coronary artery disease (heart disease). A review of Resident 3's Care Plan Report, dated January 8, 2026, indicated, .Hypertension.Administer medications as ordered.Notify physician of signs of.irregular heart rate.obtain vital signs as indicated. A review of Resident 3's physician orders indicated Lisinopril (medication for high blood pressure) 10 mg was ordered on December 29, 2025, to be given one tablet by mouth one time a day for Hypertension, Hold med if SBP is less than 110 or PRE (PR - pulse rate) less than 65. A review of Resident 3's MAR, dated January 2026, indicated lisinopril 10 mg was administered to Resident 3 when the pulse rate was below 65 on the following dates and times:- January 12, 2026, at 0900 (9 a.m.), pulse 60; and- January 28, 2026, at 0900 (9 a.m.), pulse 63. 3. On January 29, 2026, a review of Resident 109's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hypertension, atrial fibrillation (irregular heartbeat), and hyperlipidemia. The record also indicated Resident 109 had a previous admission to the facility on August 21, 2023. A review of Resident 109's Care Plan Report, dated August 21, 2024, indicated, .Hypertension.obtain vital signs as indicated.Administer medications as ordered. A review of Resident 109's physician orders, dated January 27, 2026, indicated the following medications:- Losartan potassium (medication for high blood pressure) 50 mg, Give 1 tablet by mouth one time a day for HTN. Hold if SBP <110 or pulse < 65.; and- Metoprolol tartrate 25 mg, Give 1 tablet by mouth one time a day for HTN. Hold if SBP <110 or Pulse < 60. A review of Resident 109's MAR, dated December 2025 and January 2026, indicated Losartan and Metoprolol were administered to Resident 109 when the SBP was below 110 on the following dates and times: For Losartan potassium 50 mg:- December 14, 2025, at 0900 (9 a.m.), SBP 106;- January 17, 2026, at 2100 (9 p.m.), SBP 101;- January 19, 2026, at 0900 (9 a.m.), SBP 98; For Metoprolol tartrate 25 mg:- January 19, 2026, at 0900 (9 a.m.), SBP 98. On January 30, 2026, at 10 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON verified the findings for Resident 2, 3 and 109 and confirmed the blood pressure medications were documented as administered on the MARs despite the physician's orders requiring medications to be held when SBP or pulse rate fell below specified parameters. The DON acknowledged the physician orders were not followed and stated the medications should have been held when the residents' SBP or pulse rate were outside of the prescribed holding parameters. A review of the facility's policy and procedures titled Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in accordance with the facility policy and procedures (P&P) and manufacturer's specifications when: 1. One expired house supply medication (medications kept for general use for residents, rather than dispensed or labeled for a specific resident) was stored in one of two reviewed medication rooms (North Medication Room); and2. An expired medication was kept in stock in one of five reviewed medication carts (Middle Medication Cart) along with other active medications. These failures had the potential for the residents to receive expired or ineffective medications, which could lead to medication errors and compromised treatment outcomes.Findings: 1. On January 26, 2026, at 2:43 p.m., during an inspection of North Medication Room with Licensed Vocational Nurse (LVN) 1, an expired unopened bottle of glucosamine sulfate (dietary supplement) 750 mg (milligram - unit of measurement) was observed stored in the medication cabinet with other house supply medications. The bottle indicated the manufacturer's expiration date of October 2025. On January 26, 2026, at 2:43 p.m., during a concurrent interview with LVN 1, LVN 1 verified the manufacture's expiration date on the bottle was October 2025. LVN 1 stated expired medications should be stored separately from medications maintained as house supply for potential resident use. LVN 1 stated the facility assigns a nurse each shift to conduct a medication room check as part of daily assigned duties, and the assigned nurse is responsible for completing a quality check of the medication room, including checking expiration dates of house supply medications stored, and signing the assignment log sheet upon completion. LVN 1 further stated any expired medication identified during the medication room check should be placed in a designated medication cabinet in the medication room for proper disposition or discarded into the pharmaceutical waste bin by documenting the medication information in the Medication Disposition Log for Non-controlled Medications logbook located in the medication room. 2. On January 26, 2026, at 3:22 p.m., during an inspection of Middle Medication Cart with LVN 1, an expired, opened, and used vial of acetylcysteine solution (medication used to help thin and loosen mucus in the airway) 20 % (percent - unit of measurement) 30 mL (milliliter - unit of measurement) for inhalation or oral administration was observed stored in the medication cart with other active medications. The vial was observed to contain remaining solutions. The opened date was handwritten on the vial as December 28, 2025, and the manufacture's label on the vial indicated Discard opened container after 96 hours. A review of the pharmacy-affixed label on the vial indicated the medication was dispensed for Resident 97 with directions to inhale 1 mL orally every 4 hours for wheezing, cough; give while awake. A review of Resident 97's Medication Administration Record (MAR), dated December 2025 and January 2026, indicated the acetylcysteine solution was administered to Resident 97 from December 27, 2025, to January 26, 2026. On January 26, 2026, at 3:22 p.m., during a concurrent interview with LVN 1, LVN 1 verified the vial of acetylcysteine solution was opened on December 28, 2025, and confirmed the solution was used and expired, but remained stored in medication cart with other active medications. LVN 1 further confirmed there were no additional acetylcysteine vials available in the medication cart for Resident 97. LVN 1 stated expired medication should have been disposed of in the pharmaceutical waste bin located in the medication room. On January 27, 2026, at 3:38 p.m. during a concurrent interview and record review with Director of Nursing (DON), the DON confirmed the findings and stated expired medications should have been removed from the medication storage area for active medications and disposed of properly. A review of the manufacturer's package inserts (information on how to safely use a drug) for acetylcysteine, dated November 2024, indicated, .Acetylcysteine solution does not contain an antimicrobial agent, and care must be taken to minimize contamination of the sterile solution.store the remaining undiluted portion in a refrigerator and use within 96 hours. A review of the facility's policies and procedures (P&P) titled, Storage of Medications, dated November 2020, indicated, .outdated, or deteriorated drugs .are returned to the dispensing pharmacy or destroyed . A review of the facility's P&P titled Administering Medications, dated April 2019, indicated, .The expiration/beyond use date (the date after which a medication that has been opened, mixed, or prepared should no longer be used, as its safety and effectiveness may no longer be guaranteed) on the medication label is checked prior to administering.

Based on observation, interview, and record review, the facility failed to ensure food items readily available for use were stored in the freezer with a label of open date or expiration date. This failure had the potential to result in foodborne illness to a vulnerable facility population.Findings:On January 26, 2026, at 1:46 p.m., during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Supervisor (DS). One whole piece of roast beef (approx. 7 lbs.) was observed in the freezer, readily available for use. The roast beef was observed with no open date, no use-by date, and no expiration date. The DS stated all items stored in the refrigerator or the freezer should have a label of open date, a use-by date, or an expiration date. The DS stated the roast beef should not have been stored in the freezer without a label and it should have been discarded. The facility policy and procedure titled, Labeling and Dating of Foods, dated 2023, was reviewed. The policy and procedure indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated .

Based on interview and record review, the facility failed to ensure two of five sampled residents (Residents 3 and 105) reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications were free from unnecessary psychotropic medications when: 1. For Resident 3, Mirtazapine (Antidepressant medication used to treat depression) was prescribed with an indication of Depression without physician-documented clinical evidence supporting a diagnosis of depression; and 2. For Resident 105, the physician did not document the clinical rationale for continued use of the as-needed temazepam (a psychotropic medication used for inability to fall asleep) beyond 14 days. This failure had the potential to result in unnecessary use of psychotropic medications, and increased risk for adverse effects, including falls or sedation.Findings: 1. On January 29, 2026, a review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (memory loss), anxiety, history of falling, and fracture of right femur (thigh bone). A review of Resident 3's Care Plan Report, dated January 10, 2026, indicated, .Antidepressant (Mirtazapine): Resident requires antidepressant medication related to depression as evidenced by poor oral intake, meal intake of 50 % (percent - unit of measurement) or less.At risk for ASE (adverse side effects - undesired effect of a drug) . A review of Resident 3's physician orders indicated Mirtazapine 15 mg (milligram - unit of measurement) was ordered on January 10, 2026, to be given one tablet by mouth at bedtime for depression m/b (manifested by) meal intake of 50 % or less. A review of Resident 3's Medication Administration Record (MAR), dated January 2026, indicated the mirtazapine was administered to Resident 3 from January 10, 2026, through January 29, 2026, except when refused on January 20 and January 27, 2026. A review of Resident 3's hospital discharge record titled Discharge Medication Reconciliation Order Report, dated December 18, 2025, indicated diagnoses including dementia with agitation and anxiety; depression was not documented. A review of Resident 3's Physician History and Physical, dated December 31, 2025, indicated Resident 3's diagnoses including dementia with agitation and anxiety; depression was not documented. A review of Resident 3's medical record titled SBAR Summary for Provider (Situation, Background, Assessment, and Recommendation - a standardized communication framework nurses use to provide concise, critical resident information to other healthcare professionals), dated January 3, 2026, indicated Resident 3's diagnoses of dementia and anxiety; depression was not documented. A review of Resident 3's medical record titled, Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated January 5, 2026, indicated a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3, consistent with severe cognitive impairment. A review of the MDS Section D - Mood, dated January 5, 2026, indicated Resident 3 endorsed symptoms of depressed mood during the resident interview. A review of MDS Section I - Active Diagnoses, dated January 5, 2026, did not indicate an active diagnosis of depression within the previous seven days. A review of Resident 3's Physician Monthly Progress Note dated January 26, 2026, indicated, .Assessment: .Depression on Mirtazapine. which was the first physician progress note documenting depression as a diagnosis in the medical record, following the initiation of mirtazapine. A review of Resident 3's Nurse Practitioner (NP) Notes, dated January 27, 2026, indicated the initial psychiatric evaluation was conducted on by the psychiatric NP on January 13, 2026. The NP's note indicated, .Assessment/Dx (diagnosis): .Dementia.Anxiety.Continue Mirtazapine as ordered by PCP (primary care physician) . On January 30, 2026, at 2:10 p.m., during a phone interview with the psychiatric Nurse Practitioner (NP), the NP stated the resident was receiving mirtazapine at the time of the evaluation. When asked whether signs or symptoms of depression were observed during evaluation session, the NP stated, based on his assessment, anxiety-related symptoms stood out. The NP stated mirtazapine was continued because it had already been ordered by the primary care physician and can be used for the treatment of depression or anxiety. On January 30, 2026, at 10 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed no physician documentation supporting a diagnosis of depression was identified prior to the initiation of mirtazapine. On January 30, 2026, at 2:36 p.m., during a phone interview with the Medical Doctor (MD), the MD stated the resident's poor oral intake was due to multiple contributing factors, including dementia, recent GI (gastrointestinal - stomach and intestines) bleeding issue, and sundowning behaviors (increased confusion, anxiety, agitation in individual with dementia), and agreed that sundowning was associated with dementia rather than depression. The MD stated mirtazapine was prescribed in response to poor oral intake and was later determined to be ineffective, prompting the order for megestrol acetate as appetite stimulant. When asked whether nursing documentation, including MDS documentation indicating the resident had a depressed mood, may have contributed to the entry of a depression diagnosis when he prescribed the mirtazapine, the MD acknowledged this may have contributed and stated the diagnosis of depression did not accurately reflect the clinical indication, which should have reflected poor oral intake or appetite stimulation rather than depression. 2. On January 29, 2026, a review of Resident 105's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including insomnia, anxiety, and depression. A review of Resident 105''s Care Plan Report, dated January 1, 2026, indicated, .Resident requires hypnotic (sedative) medication related to insomnia m/b (manifested by) inability to sleep. At risk for ASE (adverse side effect) for the use of Temazepam. A review of Resident 105's physician orders indicated temazepam 30mg was ordered on October 30, 2025, to be given one capsule by mouth every 24 hours as needed for insomnia manifested by inability to sleep. This order was renewed on November 27, 2025, and December 12, 2025, each with a duration of 14 days. The temazepam dose was later decreased to 15 mg, with an order to give one capsule by mouth at bedtime as needed for insomnia manifested by inability to sleep for 14 days. This order was renewed on January 1, 2026, and January 15, 2026. A review of Resident 105's Medication Administration Records (MAR), dated November, December 2025 and January 2026, indicated the as-needed temazepam was administered 13 times in November 2025, 25 times in December 2025, and 27 times in January 2026. A review of Resident 105's medical record titled IDT (interdisciplinary) Psychotherapeutic Review, dated November 10, 2025, December 1, 2025, and January 5, 2026, did not indicate documented clinical rationale for continued use of the as-needed temazepam beyond 14 days. On January 30, 2026, at 2 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed there was no documented rationale for supporting the extended use of the as-needed temazepam beyond 14 days. The DON stated the medication was continued because the resident continued to request temazepam. A review of the facility's policies and procedures (P&P) titled, Psychoactive/Psychotropic Medication Use, undated, indicated: .A Psychotropic medication.include. Antidepressant.Sedative-Hypnotic.Resident 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.The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of Psychotropic medications.Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following: indication and clinical need for medication.duration.A clinical [review] in conjunction with the interdisciplinary team must evaluate and document the situation, to identify and address any contributing and underlying causes of the acute condition and verify the need for Psychotropic medication.PRN Psychotropic drug orders.are limited to 14 days. If it is appropriate to extend the order beyond 14 days, the Attending Physician or prescribing practitioner shall document the rationale in the medical record and indicate a duration for the PRN order.

Based on observation, interview and record review, the facility failed to accurately assess one of 19 residents (Resident 14) reviewed for Minimum Data Set (MDS - an assessment tool) to reflect the resident's status when Resident 14's MDS assessment had a diagnosis of schizophrenia (a mental illness characterized by disturbances in thought process) without a psychiatric evaluation.This failure had the potential for Resident 14 to receive inappropriate care and services.Findings:On January 26, 2026, at 2:52 p.m., Resident 14 was observed lying in bed, awake and alert. Resident 14 stated she was ok and did not want to be bothered.A review of Resident 14's PASRR (Preadmission Screening and Resident Review (PASRR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care), conducted at the General Acute Care Hospital (GACH) on November 3, 2025, prior to facility admission was reviewed. The screening indicated Resident 14 was negative for serious mental illness, intellectual disability, developmental disability, or related conditions.A review of Resident 14's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included schizophrenia.A review of the History and Physical, dated November 18, 2025, indicated Resident 14 did not have the capacity to make decisions.A review of the MDS, Section C: Cognitive Patterns, dated November 12, 2025, indicated a Brief Interview of Mental Status (BIMS - a cognitive assessment tool) score of 12 (moderately impaired cognition).A review of the MDS, Section I: Active Diagnosis, dated November 12, 2025, indicated a diagnosis of schizophrenia.A review of the Care Plan, dated November 18, 2025, indicated, .Focus.Cognitive Impairment.Schizophrenia.A review of the Resident 14's Order Summary, did not indicate the resident was referred to a psychiatrist for evaluation. There was no documented evidence Resident 14 was seen and evaluated by a psychiatrist to support, validate and verify the diagnosis of schizophrenia.On January 30, 2026, at 10:53 a.m., the MDS Coordinator (a licensed nurse in long-term care facilities who assesses, monitors, and documents patient health using a standardized federal tool) was interviewed. She stated the MDS information was based on data collection and assessment or direct observation of the resident. During a concurrent record review of the MDS dated [DATE], with the MDS Coordinator, she stated that based on the MDS data, Resident 14 was awake, alert, and oriented x 3 (a medical phrase meaning a person is aware of their surroundings, and knows their Person [name], Place [location], and Time [date/day/year]. She stated Resident 14 did not have mental illness behavior or signs of schizophrenia. She stated MDS, Section I, indicated Resident 14 had a diagnosis of schizophrenia. She stated she got the information from Resident 14's diagnosis information on the admission Record. She stated there was no psychiatric consult ordered and/or evaluation conducted either from the GACH or from the facility. She stated there should have been a psychiatric evaluation done either from the hospital or the facility to confirm the diagnosis of schizophrenia. She stated the MDS conducted on November 18, 2025, did not accurately reflect Resident 14's mental status.On January 30, 2026, at 12:03 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). She stated there was no psychiatric evaluation conducted for Resident 14 when she was admitted to the facility. She stated the diagnosis for mental illness should have been validated and should have not been coded as schizophrenia unless there was a psychiatric evaluation conducted to confirm the diagnosis.The facility policy and procedure, titled, Comprehensive Assessments, revised October 2023, indicated, .Comprehensive MDS assessments are conducted to assist in developing person-centered care plans.The facility conducts comprehensive, accurate, standardize, reproducible assessments of each resident's functional capacity.The comprehensive assessment process includes direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members.Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals on the interdisciplinary team (a group of professional from diverse fields who work together collaboratively and independently to achieve a common goal.

Based on interview and record review, the facility failed to ensure one of five residents reviewed (Resident 2) was free of unnecessary medications, when pain assessments were not consistently implemented and documented in conjunction with the administration of scheduled narcotic pain medication. This failure resulted in unmonitored medical condition and had the potential for ineffective pain management, unnecessary excessive dosing, and adverse effects for Resident 2. Findings: On January 28, 2026, a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic pain syndrome, polyneuropathy (nerve damage causing pain or numbness), multiple sclerosis (a disease affecting the brain and spinal cord), paraplegia (paralysis of the lower body), Parkinson's disease (a neurological disorder affecting movement), spinal stenosis (narrowing of the spaces in spine causing pain), stage 4 pressure ulcer (deep open wound), muscle wasting and atrophy (loss of muscle mass), and acute osteomyelitis (bone infection). A review of Resident 2's Care Plan Report, dated October 24, 2025, indicated .acute on chronic pain as evidenced by: verbalization of pain (generalized, lumbar [lower back], back, R [right] knee), neuropathy (nerve damage leading to pain], muscle spasm (sudden painful contraction of muscle). Ask and assess pain symptoms. Identify frequency, location, quality, onset and manner of expressing pain.Monitor effectiveness of. pain meds (medications).Monitor for pain and provide medication.Notify physician if ineffective. A review of Resident 2's physician orders indicated oxycodone (a controlled medication for pain) 10 mg (milligram - unit of measurement) was ordered on December 25, 2025, to be given one tablet by mouth four times a day for pain management. A review of Resident 2's Medication Administration Record (MAR), dated December 2025 and January 2026, indicated Resident 2 received oxycodone 10 mg from December 1, 2025, through December 21, 2025, and from December 25, 2025, through January 28, 2026. A review of Resident 2's Weights and Vitals Summary, dated December 2025 and January 2026, indicated Resident 2's pain assessment was documented only seven times during December 2025 and once during January 2026, as follows: - December 10, 2025, at 23:10 (11:10 p.m.), pain scale 5;- December 11, 2025, at 00:20 (12:20 a.m.), pain scale 0;- December 12, 2025, at 07:16 (7:16 a.m.), pain scale 0;- December 20, 2025, at 07:38 (7:38 a.m.), pain scale 0;- December 26, 2025, at 07:19 (7:19 a.m.), pain scale 0; - December 27, 2025, at 07:43 (7:43 a.m.), pain scale 0;- December 28, 2025, at 12:14 (12:14 p.m.), pain scale 0; and- January 2, 2026, at 22:33 (11:33 p.m.), pain scale 0. A review of Resident 2's Physical Medicine & Rehab (rehabilitation) Follow-up, dated December 18, 2025, and December 21, 2025, indicated, .Pain management .Monitor for any breakthrough pain (sudden increase in pain) that may interfere with therapy engagement . On January 30, 2026, at 10:18 a.m., during a concurrent interview and record review with Director of Nursing (DON), the DON verified the findings and stated the residents receiving routine scheduled narcotic pain medications require ongoing pain assessment, monitoring, and documentation to evaluate whether pain is adequately controlled, or requires dose adjustment. The DON stated pain assessment should have been performed and documented at least every shift as part of routine nursing assessments, including vital sign checks with pain level assessment, regardless of whether pain medication was ordered on a scheduled or PRN (as needed) basis. The DON further stated due to the resident being admitted , discharged , and readmitted multiple times, the order for every shift pain assessment had fallen out of the system and should have been re-entered. On January 30, 2026, at 2:19 p.m., during a phone interview with the facility's Consultant Pharmacist (CP), the CP stated residents receiving scheduled narcotic pain medications, such as oxycodone, require routine pain assessments to evaluate medication effectiveness and to determine the ongoing need for the medication. A review of the facility's policies and procedures (P&P) titled, Pain Assessment and Management, dated April 2025, indicated: .Ask the resident if he/she is experiencing pain.Assessing Pain. 1. Assess the resident.during ongoing assessments. 2. Monitor the resident for the presence (or worsening) of pain.3. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.When opioids are used for pain management, the resident is monitored for medication effectiveness.Monitoring and Modifying Approaches. 1. Monitor the resident's pain and consequences of pain at least each shift for acute or sub-acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail and as needed, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms). 3. Monitor the following factors to determine if the resident's pain is being adequately controlled: a. The resident's response to administered pain medications. A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, .As required or indicated for a medication, the individual administering the medication records in the resident's medical record.any complaints or symptoms for which the drug was administered.Any results achieved and when those results were observed.

Based on observation, interview, and record review, the facility failed to implement a safe discharge for one of three sampled residents (Resident 1), who uses a wheelchair and required partial to moderate assistance with mobility and ADLs (Activities of Daily Living-basic self-care task such as bathing, dressing, toileting, getting in and out of bed), when the facility failed to assess the resident for appropriate discharge placement. The resident was discharged to a two-story room and board without personal care assistance and was given a bedroom on the second floor. The facility also failed to verify and ensure the receiving facility could meet the resident's care needs. This failure resulted in Resident 1 sleeping in the dining room without privacy, experiencing multiple falls and had caused psychological distress (state of mental and emotional discomfort characterized by negative feelings). The resident was eventually transferred to the general acute care hospital (GACH) due to inability of the room and board to provide the required services. Findings:On October 2 and 8, 2025, an unannounced visit was made to the facility to investigate a discharge rights concern. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke-medical emergency that occurs when blood flow to the brain is interrupted or reduced) and a history of falls. A review of Resident 1's, History of Physical, dated, July 19, 2025, indicated the resident was admitted to the facility for physical therapy and occupational therapy, has general weakness, and has the capacity to understand and make decisions.A review of Resident 1's Brief Interview of Mental Status (BIMS- a cognitive assessment tool), dated, July 25, 2025, indicated a score of 12 (meaning moderate cognitive impairment). A review of Resident 1's, Minimum Data Set (MDS-A comprehensive assessment of resident's healthcare), section GG (Functional Abilities), dated, July 25, 2025, indicated the following: a. Resident 1 uses a wheelchair for mobility, is impaired on one side of lower extremities; b. Requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or support trunks or limbs, but provides less than half the effort) to complete oral/personal hygiene and dressing upper body;c. Requires Substantial/maximal assistance (helper does more than half the effort) to complete showering, lower body dressing, putting on and off footwear and toileting hygiene;d. Requires partial/moderate assistance with lying to sitting in bed; and e. Requires Substantial/maximal assistance with sitting to standing, tub/shower transfers and transfers to and from the toilet. A review of Resident 1's, Progress Notes, dated August 11, 2025, at 2:40 p.m., by the Case Manager (CM), . Resident met with CM requesting to be (discharged ) and would like assistance with placement .On October 2, 2025, at 3:42 p.m., during an interview with the CM, she stated the following: a. Her role in resident discharges is finding and planning resident placements in the community, which included meeting with the resident to determine the resident's healthcare needs such as required caregiver services, and reviewing medical records, such as physical therapy (PT) notes;b. At times she would refer the resident's discharge to a 3rd party agency (not contracted with the facility) for assistance in finding appropriate/safe placement in the community; c. She would document when she requests assistance from a 3rd party agency, and all the correspondence with the 3rd party agency involving residents;d. Resident 1 approached her on August 11, 2025, and requested to be discharged from the facility, as he (Resident 1) wanted more of a private room;e. On August 26, 2025, she referred Resident 1 to a 3rd party agency to assist with finding community placement, and she informed the 3rd party agency that the resident was requesting a room downstairs that could accommodate his wheelchair; f. On August 27, 2025, the 3rd party agency came to the facility to assess resident for Compatibility (healthcare needs) for a specific room and board, and she provided the 3rd party agency with the resident's (Resident 1) medical records such as the history and physical and the IDT functional abilities collaboration documents; g. On September 17, 2025, the 3rd party agency informed the CM that the resident (Resident 1) was appropriate for placement at the room and board, and the room and board would provide caregiver services to meet the resident's daily mobility and ADL needs, and that resident would have a room downstairs;h. The 3rd party agency did not specify how many caregiver hours were available daily to assist the resident (Resident 1) at the room and board, and she did not know how many caregiver hours would be provided at the room and board, as she had not contacted or verified this information with the room and board;i. On September 18, 2025, the resident (Resident 1) was discharged to a room and board. The CM explained that this room and boards are for more independent residents, and PT notes confirmed the resident is independent with transfers;j. The CM verified she did not have any documentation reflecting Resident 1's referral to the 3rd party, and there was no documentation of correspondence she had with this 3rd party agency related to the resident's discharge.A review of Resident 1's progress notes did not indicate any documentation that an assessment was conducted by the facility to determine the appropriate placement for discharge. A review of Resident 1's, IDT (Interdisciplinary Team) Functional Abilities, assessment, with the effective date of August 7, 2025, at 5:11 p.m., indicated the following:a. Self-care .toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement .Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or support trunk or limbs, or holds trunk or limbs but provides less than half the effort) .Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear that is appropriate for safe mobility .Partial/moderate assistance .; and b. Mobility .Sit to Stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed .Supervision or touching assistance .Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) .supervision or touching assistance .Toilet Transfer: The ability to get on and off a toilet or commode .Supervision or touching assistance .Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space .Partial/moderate assistance .12 steps: The ability to go up and down 12 steps with or without rail .Not attempted due to medical condition or safety concerns . A review of Resident 1's IDT Functional Abilities assessment, dated September 18, 2025, at 9:01 a.m., indicated the same assessment on self-care and mobility as the assessment conducted on August 7, 2025.A review of Resident 1's, Discharge Summary and Post-Care Instruction, dated September 17, 2025, at 4:42 p.m., by Registered Nurse (RN) 1 indicated that the resident will be discharged from the facility on September 18, 2025, at approximately 11 a.m. to a room and board with home health services. Further review of the document indicated that the resident requires some assistance with activities of daily living, has functional limitations, is chairfast with slightly limited mobility and is a fall risk. On October 2, 2025, at 3:42 p.m., during an interview, the CM stated the discharge process also would include a follow-up call to the resident by the Social Worker (SW), the day after discharge to Make sure everything's O.K., with the resident.On October 6, 2025, at 11:56 a.m., during an interview with SW 1, she stated the following:a. She is not involved in discharge planning for a resident, but she is responsible for giving the resident the notice of proposed discharge;b. She follows-up with a phone call to the resident within 72 hours after their discharge, to find out how the resident is adjusting to their new living arrangements, and If they are doing ok.;c. If a resident is their own representative (Deemed able to make their own decisions), she would attempt to contact the resident by making 2-3 calls and leaving a voicemail if necessary. SW stated she will document her follow-up calls and attempts;d. After the resident (Resident 1) was discharged from the facility to the room and board, she did not document her attempted calls, but she believed attempting to call him 2 times on September 19, 2025, and believed she left two voice mails. However, SW 1 stated she could not remember if Resident 1 returned calls.On October 6, 2025, at 12:19 p.m., during an interview with Resident 1 via telephone call, the resident's speech was noticed to be slow and slurred, and stated the following: a. A CM at the facility, he was unsure of the name, and a 3rd party agency arranged his discharge (September 18, 2025) to the room and board;b. He wanted to be discharged to a room and board because he was told by the facility that he would have a room downstairs, and caregiver available to help him;c. When he arrived at the room and board, his room was upstairs, and he could not walk upstairs because he was wheelchair bound;d. He slept downstairs in the dining room with no privacy; e. A caregiver was not available to help him transfer to and from his wheelchair to the toilet, and the bathroom could not accommodate the size of his wheelchair, so he had to use the bathroom with the door open, which made him feel bad because there was no privacy; f. He had two falls during his stay at the room and board while he was trying to transfer himself from the bed to his wheelchair, he slid to the ground, and a maintenance person helped him up. He did not have any injuries from the fall;g. He was not happy and the situation at the room and board was upsetting; andh. He was unsure if the facility called to follow up with him while at the room and board where he stayed for approximately four and a half days, until the owner of the room and board drove him to the GACH and left him there for no reason. On October 6, 2025, at 12:54 p.m., during an interview with the Director of Nursing (DON), the DON stated the following: a. She does not have a direct role in the facilities discharge process, but pending resident discharges are discussed during a stand-up meeting with the department heads;b. The process to discharge a resident to a room and board would usually include a 3rd party agency assessing the resident's care needs to ensure the room and board would be able to provide appropriate care for the resident and would discuss with resident any concerns they may have;c. Prior to discharge, the facility has a responsibility to ensure the room and board can provide the caregiver services needed to care for the resident, and this should be done by the CM contacting the room and board to verify the required caregiver services would be provided;d. After a resident is discharged , the social worker (SW) is expected to follow up with the resident within 72 hours by making 2-3 calls to the resident, and if unable to contact the resident, a follow-up call should be made to the room and board to ensure the discharge was appropriate for the resident with no complaints or concerns; ande. Resident 1's discharge was discussed during a stand-up meeting prior to resident's discharge on [DATE], and it was stated resident was going to have caregiver services provided by the room and board.On October 6, 2025, at 2:49 p.m., an interview was conducted with the CM who stated when a 3rd party agency assesses a resident for discharge to a room and board the 3rd party agency does not provide the CM with a copy of their (3rd party agency) assessment. The CM stated she, Just takes their (the 3rd party agency) word for it, when the 3rd party agency stated the resident is appropriate for a safe discharge to the room and board. The CM further stated, she did not speak to the owner of the room and board until the day the resident (Resident 1) was discharged from the facility, on September 18, 2025, at which time, she informed the owner that the resident was on his way to the room and board via transport van. On October 6, 2025, at 3:15 p.m., during an interview with the owner of the room and board, the owner stated the following:a. Residents who stayed in her room and board were required to be independent with the ability to walk;b. The 3rd party agency reported that the resident (Resident 1) was very independent and could walk with a walker (Assistive device);c. Resident 1 presented to the room and board in a wheelchair and could not walk;d. The minute the resident arrived at the room and board, she told the resident he was not going to be able to stay at the room and board because they did not have the caregiver services the resident would require, and the resident could only stay for a few days;e. She originally arranged for the resident (Resident 1) to have a bedroom upstairs because she was told by the 3rd party agency he could walk, but the resident could not walk up the stairs, so she had to make a space for resident to sleep in a common area of the house, by placing a twin bed in the living room; f. The resident (Resident 1) was unsteady on his feet and would fall every day. She did not believe the resident hurt himself during falls, as he was a light guy and she would have to pick the resident up and put him back in the wheelchair;g. She did not speak to anyone at the facility regarding the resident being inappropriate to live in the room and board, because she thought resident would need a referral to go back to the facility; andh. She took the resident (Resident 1) to hospital because she could not provide care for him. A review of Resident 1's GACH Emergency Department Record dated September 25, 2025, at 3:23 p.m., (8 days after the resident was discharged to the room and board from the skilled nursing facility), indicated, .male patient presents to the ER (Emergency Room) via EMS (Emergency Medical Services) for evaluation of weakness .Patient reports having frequent falls and is unable to walk .Patient came from a board and care facility but is not receiving any care or assistance from staff .A review of Resident 1's GACH History and Physical dated September 25, 2025, indicated .male patient presents to the ER (Emergency Room) via EMS (Emergency Medical Services) for evaluation of weakness .Patient reports having frequent falls and is unable to walk .Patient came from a board and care facility but is not receiving any care or assistance from staff .Patient admitted to the medical floor daily with recurrent TIA (Transient Ischemic Attack-mini-stroke) old CVA (Cerebrovascular Accident-stroke) generalized weakness and falls for evaluation treatment. A review of Resident 1's, GACH records, titled, CT (image of) Brain, dated, September 25, 2025, at 3:24 p.m., indicated . Detailed Symptoms: slurred speech (and) fall . Impressions: . likely . chronic infarcts (TIAs) .Further review of Resident 1's, GACH Discharge Instructions, dated, October 2, 2025, at 1:02 p.m., indicated resident was being discharged back to the facility (Skilled Nursing Facility) with education provided on TIAs, weakness and fall prevention.A review of Resident 1's Skilled Nursing facility Admission/readmission Summary Note, dated, October 2, 2025, at 11:17 p.m., by RN 2, indicated (Resident) admitted . from (GACH) . Primary diagnosis of Weakness, TIA . Needs assistance in all ADL(s) .On October 8, 2025, at 1:00 p.m., a concurrent observation and interview was conducted with Resident 1 in his bedroom at the skilled nursing facility, and the resident was observed lying in bed, neatly dressed and groomed. Resident 1's speech was slow and slurred. Resident 1 stated the living arrangements at the room and board made him feel terrible and confused because what he was told at the facility (Skilled Nursing Facility) about the room and board prior to his discharge (on September 18, 2025) was totally different than what was provided at the room & board. A review of the facility Policy and Procedure, titled, Discharge Summary and Plan, revised March 2025, indicated, . Discharge Planning 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan .3. The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g. care giver support and education, rehabilitation .) 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identified the discharge destination and ensures that it meets the resident's health and safety needs as well as preferences. 6. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place .Discharge to the Community . 2. If the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place. This may include the capacity of the resident's caregivers at home .5. If a resident wishes to be discharge to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility treats this situation similarly to refusal of care, and will: a. discuss with the resident .and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable locations equipped to meet the needs of the resident were presented and discussed .

Based on interview and record review, the facility failed to ensure a system of safeguarding personal belongings, such as bank card and Identification (ID) card, were in place, for one of three residents reviewed (Resident 1). This failure resulted to unauthorized bank transactions on Resident 1's bank cards while at the facility without her knowledge. Findings: On April 14, 2025, at 9:20 a.m., an unannounced visit was conducted to investigate a facility reported incident regarding Resident 1 ' s missing ID Card and bank card with unauthorized transactions. On April 14, 2025, at 10:37 a.m., an interview was conducted with Social Worker 1 (SW 1). SW 1 stated during a resident's admission, an inventory list of personal belongings were conducted by the facility staff. SW 1 stated she was then notified by the staff if the resident had a cash money or bank and/or debit cards in their possession. SW 1 stated she would then let the resident know that the facility ' s safe can be used to store their valuables or personal belongings of value. SW 1 stated was aware Resident 1 had bank cards and ID card in her possession but Resident 1 did not want to put these in the facility safe. On April 14, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facilility on March 10, 2025 and was discharged on [DATE]. The HISTORY AND PHYSICAL EXAMINATION, dated March 11, 2025, indicated Resident 1 had the capacity to understand and make decisions. The INVENTORY OF PERSONAL POSSESSIONS, signed by Resident 1 and facility staff, dated March 10, 2025, indicated Resident 1 had a wallet/purse but the list did not indicate Resident 1 had bank cards and an ID card in her possession. The WAIVER OF RESPONSIBILITY FOR MONEY AND VALUABLES, signed by Resident 1 and a facility staff on March 11, 2025, did not indicate what personal belonging or valuable Resident 1 decided to keep in her possesion and not store at the facility safe for safe-keeping. On April 14, 2025, at 11:08 a.m., Family Member 1 (FM 1) was interviewed via telephone. FM 1 stated Resident 1's bank cards and ID cards went missing during her stay at the facility from March 10, 2025 to April 1, 2025. FM 1 stated several unauthorized transactions were made on Resident 1 ' s missing bank cards within the facility's surrounding area from March 26, 2025, through March 27, 2025. During her stay, FM 1 stated Resident 1 ' s bank cards and ID were in her wallet, which was placed inside her purse and at her bedside. FM 1 said Resident 1 did not know about these unauthorized bank transactions and her bank cards were missing until after her discharge in April 1, 2025. On April 14, 2025, at 2:31 p.m., an interview was conducted with the Director of Nursing (DON). the DON stated if a resident was admitted with valuables, such as jewelry, cash, bank cards, or ID Cards, the facility offers to keep them in a safe. The DON stated the resident will sign a waiver if they preferred to keep their valuable in their posession. The DON further stated they were made aware of the unauthorized transactions on Resident 1's bank cards after she was discharged on [DATE]. The DON stated these unauthorized transactions were made during Resident 1's stay in the facility and they were not able to identify the individual who conducted this unauthorized transactions. On April 16, 2025, at 2:41 p.m., and interview was conducted with SW 1. SW 1 stated Resident 1 had a signed a waiver indicating she preferred to keep her wallet in her possession at her bedside and not the facility safe. SW 1 stated she did not inspect the contents of Resident 1's wallet. SW 1 stated she was aware Resident 1 had bank cards and ID her card in her possessions and this was not documented in her personal belongings list. SW 1 further stated the staff was responsible for ensuring that residents ' items were kept safe. SW 1 stated that facility should safeguard the resident ' s possessions. SW 1 stated they knew Resident 1 had a wallet and that it was in her purse. SW 1 stated the facility should have had safeguards in place such as monitoring of personal belongings in a resident's posession. SW 1 stated the personal belongings inventory lists were used to keep track of resident's personal items. On April 17, 2025, at 1:43 p.m., a telephone interview was conducted with the DON. The DON stated the facility did not have specific monitoring system in place for residents who chose to keep their valuables. The DON stated Resident 1's personal belonging inventory lists should have been itemized and specific. The facility's policy and procedure titled, Personal Property, dated August 2022 was reviewed. The policy indictaed, .Resident belongings are treated with respect by facility staff, regardless of perceived value . The facility's undated policy and procedure titled, ' Safekeeping of Personal Funds and Valuables of Residents in the Facility, was reviewed. The policy indicated, .Personal funds or valuables may include: cash, checks, jewelries, ID Cards, wallet, credit/debit cards, etc . The facility shall have the responsibility to implement written procedures to prevent misappropriation of resident personal funds or valuables . The facility shall provide a resident a receipt for the personal funds or valuables, and retain a copy for its records . Upon admission, resident ' s belongings shall be itemized in the Inventory List . Resident's personal funds or valuables itemized during admission or at any time during the resident's stay int he facility, shall be turned over to the family or responsible party, and shall be accounted for, signed out, and witnessed in the Inventory List accordingly .

Based on observation, interview, and record review, the facility failed to ensure for one of two residents, Resident 1, a medication ordered by the doctor was given as prescribed. This failure had the potential for Resident 1 to have hypokalemia (low potassium level in the blood) which could cause Resident 1 to experience muscle cramps and abnormal heart rhythms. Findings: On January 22, 2024, at 9:28 a.m., at the north unit of the facility, a med pass (administration of medications) observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 prepared Resident 1 ' s medications which included potassium chloride. LVN 1 placed the box of potassium chloride oral packets, which were labeled for Resident 1 and dated October 24, 2024, on top of the medication cart. LVN 1 removed one oral potassium chloride packet from the box, prepared it, and administered it to Resident 1. A review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke with right sided weakness. A review of Resident 1 ' s physician ' s orders indicated .Potassium Chloride Oral Packet 20 MEQ (mEq-milliequivalent, a unit of measurement used to express number of electrolytes and medications) .Give 20 mEq by mouth one time a day for hypokalemia admin (administer) it with food/snack and full glass of water or other juices . was ordered on July 16, 2024. On January 22, 2024, at 10:00 a.m., during an interview with LVN 1, LVN 1 was asked to retrieve the box of potassium chloride packets for Resident 1. LVN 1 stated the box indicated it had 30 packets inside, it was opened on October 24, 2024. LVN 1 was asked to count how many packets were still in the box, LVN 1 stated there were 15 packets in the box. LVN 1 stated all of the packets should have been used by at least November 23, 2024. LVN 1 stated maybe Resident 1 refused the medication even before it was prepared for her, with the other licensed nurses. On January 22, 2024, at 10:10 a.m., a review of Resident 1 ' s Medication Administration Record for October and November 2024 was conducted with LVN 1. There was no documented evidence that Resident 1 refused potassium chloride packets in October and November 2024. LVN 1 stated the potassium chloride oral packets were administered to Resident 1 in October and November 2024. On January 23, 2024, at 4:15 p.m., during an interview, LVN 2 stated there were no other residents who were on potassium chloride oral packets in the north unit. On January 27, 2025, at 2:55 p.m., during a telephone interview with the Director of Nursing (DON), the DON stated she assumed Resident 1 ' s potassium chloride oral packets were not given as ordered. The DON stated the box of potassium chloride packets that was opened on October 24, 2024, should have already been empty, and that she expected the licensed nurses to administer the medications as ordered. The DON further stated if Resident 1 was not given her potassium chloride, she could have hypokalemia. A review of the facility ' s policy and procedure titled, Administering Medications, dated 2001, indicated .Medications are administered in a safe and timely manner .in accordance with prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure infection prevention protocols were implemented, for two of two residents, Residents 1 and 2, when a facility staff member did not perform hand hygiene in between residents ' care, and did not disinfect the automatic blood pressure cuff (BP cuff) before and after residents ' use. These failures had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: On January 22, 2024, at 9:24 a.m., a medication pass was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 carried an automatic BP cuff machine from the top of the medication cart and went to Resident 1 ' s room. LVN 1 applied the BP cuff to Resident 1 ' s left wrist. After obtaining Resident 1 ' s BP reading, LVN 1 removed the automatic BP cuff from Resident 1 ' s wrist and place it on top of the medication cart. LVN 1 did not perform hand hygiene and did not disinfect the automatic BP cuff machine after use on Resident 1. LVN 1 prepared Resident 1 ' s medications, went back to Resident 1 and administered the medications. LVN 1 did not perform hand hygiene after preparing the medications and after administration of Resident 1 ' s medications. During the same medication pass observation, LVN 1 was observed taking the same BP machine from the top of the medication cart and go to Resident 2 ' s room. LVN 1 applied the BP machine on Resident 2 ' s left wrist. LVN 1 removed the BP machine from Resident 2 after obtaining Resident 2's BP reading. LVN 1 placed the BP machine on top of the medication cart. LVN 1 did not disinfect the BP machine and did not perform hand hygiene. LVN 1 prepared Resident 2 ' s medications and went back to Resident 2 and administered the medications. LVN 1 did not perform hand hygiene after preparing the medications and after administration of Resident 2 ' s medications. On January 22, 2024, at 10:00 a.m., during an interview, LVN 1 stated hand hygiene should be performed in between residents. LVN 1 stated she did not perform hand hygiene before and after preparing and after administering medications for Residents 1 and 2. LVN 1 stated she did not know that she had to perform hand hygiene before and after preparing medications. LVN 1 stated she should have performed hand hygiene in between Resident 1 and Resident 2. LVN 1 stated the BP cuff should be disinfected between residents ' use. LVN 1 stated she did not disinfect the BP cuff after using it on Resident 1. LVN 1 stated she should have disinfected the BP cuff after using it on Resident 1. On January 23, 2024, at 2:32 p.m., during an interview, the Director of Nursing (DON) stated hand hygiene and disinfection of the BP cuff should be performed between provision of care of residents, as this can lead to a possible spread of infection. A review of the facility ' s undated policy and procedure titled, Policy and Procedures for Med Pass indicated .Cleanse hands before handling medication and before contact with resident . A review of the facility ' s policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001 indicated .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC (Centers for Disease Control and Prevention- a nationally recognized disease control and prevention organization) recommendations for disinfection .Non-critical items are those that come in contact with intact skin but not mucous membrane .Non-critical resident-care items include .blood pressure cuffs . According to the CDC article titled, Disinfection and Sterilization Guideline for Disinfection and Sterilization in Healthcare Facilities, dated June 2024, .non-critical patient-care devices are disinfected when visibly soiled and on a regular basis .such as after use on each patient .

Based on observation, interview, and record review, the facility failed to ensure for one of four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine), the urinary catheter drainage bag was covered with a dignity bag (a bag that covers and holds a catheter drainage to keep it out of sight). This failure resulted in violation of Resident 37's rights to be treated with dignity and respect. Findings: On November 4, 2024, at 10:17 a.m., Resident 37 was observed with the urinary catheter drainage bag not covered with a dignity bag. On November 4, 2024, at 10:20 a.m., during an interview with Certified Nursing Assistant (CNA) 1, she stated there should be a dignity bag over the urinary catheter drainage bag. CNA 1 stated not covering the drainage bag could cause embarrassment to the resident. On November 4, 2024, at 10:25 a.m., during an interview with the Licensed Vocational Nurse (LVN) 1, she stated the dignity bag should be placed over the urinary catheter drainage bag. LVN 1 stated the policy of the facility was to place a dignity bag over the urinary catheter drainage bag. On November 7, 2024, at 2:40 p.m., during an interview with the Director of Nursing (DON), she stated it was the facility policy to cover the urinary catheter drainage bag to provide dignity and respect to the resident. A review of Resident 37's admission record indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included Type 2 diabetes (chronic disease that occurs when the body does not use insulin properly), benign prostatic hyperplasia (BPH - enlarged prostate gland), hypertension (high blood pressure), and cerebrovascular accident (occurs when blood flow to the brain is suddenly cut off). A review of Resident 37's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool), dated October 3, 2024, indicated Resident 37 had a BIMS (Brief Interview for Mental Status - a tool used to screen and identify cognitive condition of residents) score of 12 (moderate cognitive impairment). A review of Resident 37's physician orders dated September 27, 2024, indicated to change urinary catheter bag every 14 days for urinary retention secondary to BPH. A review of the facility's policy and procedure titled, Dignity, revised February 2021 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered .

Based on observation, interview, and record review, the facility failed to ensure the care plan for the care of resident's surgical site and left hip dressing was initiated and developed for one of 19 residents reviewed (Resident 141). This failure had the potential for Resident 141 not to receive the necessary care and services if the surgical site developed infection and/or the resident experienced other complications. Findings: On November 4, 2024, at 12:15 p.m., Resident 141 was observed awake, alert, lying in bed. Resident 141 stated she fell at home and broke her left hip. She stated she had left hip surgery. Resident 141 stated the surgeon applied a special type of dressing and it should not be removed for seven days. On November 5, 2024, a record review was conducted for Resident 141. Resident 141 was admitted to the facility on [DATE], with diagnoses which included fracture of the left hip. The history and physical (H&P) indicated Resident 141 had the capacity to understand and make decisions. The physician's order dated November 1, 2024, indicated, .L (left) Hip Aquacel Dressing (a type of dressing that provides a moist environment that supports the growth of new blood vessels) .do not change for 7 days . The facility's document titled, NURSING-ADMISSION/READMISSION EVALUATION ASSESSMENT, dated October 31, 2024, indicated, .L (left) hip surgical incision . The nurse's notes from October 31, 2024 to November 5, 2024, were reviewed. There was no documented evidence the surgical site was assessed and monitored. There was no documented evidence the care plan was initiated and developed for the care of the left hip dressing and the surgical site. On November 6, 2024, at 9:45 a.m., a concurrent interview and record review was conducted with the Registered Nurse Supervisor (RNS) 1. RNS 1 stated Resident 141 was admitted with the left hip dressing and acknowledged the physician's order not to be removed for seven days. RNS 1 stated a care plan for Resident 141's aquacel left hip dressing should have been initiated and developed to monitor the integrity of the surgical site and the dressing. She stated the licensed nurse who performed the admission assessment for Resident 141 should have developed the care plan. A review of the facility's policy and procedure titled, Care Plans, dated April 2009, indicated, .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level .care plan goals and objectives are derived from information contained in the resident's comprehensive assessment .

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for two (Residents 45 and 12) of 19 residents reviewed, when: 1. For Resident 45, one opened tube of Voltaren cream (medication used to treat arthritis pain) and one opened bottle of Magnesium Ashwagandha tablets (a medication that supports mental health and sleep) were observed on top of the resident's bedside table; and 2. For Resident 12, one opened bottle of Calcium Carbonate (medication used to relieve heartburn, acid indigestion, and stomach upset) was observed on top of the resident's bedside table. These failures had the potential for Residents 45 and 12 to receive medications without a physician's order. Findings: 1. On November 4, 2024, at 11:46 a.m., Resident 45 was observed lying in bed. One opened tube of Voltaren cream and one opened bottle of Magnesium Ashwagandha tablets were observed on top of Resident 45's bedside table. During a concurrent interview with Resident 45, she stated the staff were aware she was using the Voltaren cream and the Magnesium Ashwagandha tablet. She stated she would apply the Voltaren cream to her right hip and right leg daily to treat her pain. On November 6, 2024, at 10:34 a.m., Resident 45 was observed with LVN (Licensed Vocational Nurse) 1. Resident 45 was observed lying in bed. Two tubes of Voltaren cream (one opened tube and one unopened tube) and one opened bottle of Magnesium Ashwagandha tablets were observed on top of Resident 45's bedside table. Resident 45 stated she was taking the Magnesium Ashwagandha tablet once a day for one and a half months. Resident 45 also stated she applied the Voltaren cream to her right hip and right leg once a day to treat her pain. In a concurrent interview with LVN 1, she stated medications were not allowed to be left at the resident's bedside. She stated Resident 45 did not have a physician's order for the Voltaren cream and the Magnesium Ashwagandha . She also stated the residents were not allowed to self-administer a medication without a physician's order. She stated medications from home should be verified with the physician and if ordered, the resident will receive the medications dispensed by the facility pharmacy. Resident 45's record was reviewed. Resident 45 was admitted to the facility on [DATE], with diagnoses which included muscle spasms and lower back pain. A review of the history and physical dated July 16, 2024, indicated Resident 45 did not have the capacity to understand and make decisions. 2. On November 4, 2024, at 3:03 p.m., Resident 12 was observed in the room sitting in the wheelchair. One opened bottle of calcium carbonate tablets was observed on top of Resident 12's bedside table. During a concurrent interview with Resident 12, he stated he was taking one tablet of calcium carbonate tablet daily to prevent heartburn. On November 6, 2024, at 11:05 a.m., Resident 12 was observed with LVN 2. One opened bottle of calcium carbonate was observed on top of Resident 12's bedside table. In a concurrent interview with LVN 2, she stated residents were not allowed to keep home medications at bedside and there should be a screening for medication self-administration. Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses which included gastroesophageal reflux disease (GERD - acid reflux). A review of Resident 12's medication self-administration safety screen dated March 20, 2019, indicated all medications will be administered by licensed nurse staff. On November 6, 2024, at 11:10 a.m., during an interview with Registered Nurse Supervisor (RNS) 2, he stated the residents were not allowed to keep their own medications at bedside. He also stated when a family member brought in a medication, the staff should call the physician for an order and the staff will only administer medications dispensed by the facility pharmacy. On November 6, 2024, at 11:20 a.m., during an interview with the Director of Nursing (DON), she stated the residents were not allowed to have medications left at bedside. She stated there should be a resident assessment for medication self-administration. She also stated when a family brought in medication from home or the hospital, the staff should verify the medication with the resident's physician and if ordered, the medication will be sent home with the family and removed from the resident's bedside. She stated the facility will provide all resident medications ordered by the physician. The facility policy and procedure titled, ADMINISTERING MEDICATIONS, dated, April 2019, indicated, .Medications are administered in accordance with prescriber orders .Residents may administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . The facility policy and procedure titled, STORAGE OF MEDICATIONS, dated, April 2007, indicated, .Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems . The facility policy and procedure titled, SELF-ADMINISTRATION OF MEDICATIONS, revised February 2021, indicated, .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party .

Based on observation, interview, and record review, the facility failed to ensure for one of 19 residents (Resident 66) reviewed who smoked in the facility did not have a lighter in her possession. This failure had the potential to result in injury or accident related to unsupervised smoking. Findings: On November 14, 2024, at 10:54 a.m., during a concurrent observation and interview with Resident 66, Resident 66 was brought back to her room in a wheelchair by a facility staff. Resident 66 stated she smokes four times a day and just came back from the smoking patio. Resident 66 stated she was allowed to keep her smoking materials with her and pulled out a pack of cigarettes and a lighter from her pocket. An oxygen concentrator (a machine that supplies oxygen) was observed at Resident 66's bedside. Resident 66 stated she used oxygen during the night. Resident 66 stated she was aware not to smoke in her room. On November 6, 2024, at 12:15 p.m., during an interview with the Activities Director (AD), the AD stated the residents were allowed to keep their cigarettes but not the lighter at bedside. The AD stated she was aware Resident 66 had a lighter in her possession and did not want to give it up. She stated Resident 66's lighter had been confiscated before and was not sure how she got a new one. The AD stated there was a safety issue with Resident 66 having an oxygen concentrator at the bedside and a lighter in her possession. On November 6, 2024, at 12:20 p.m., during an interview with Registered Nurse Supervisor (RNS) 1, she stated the residents were not allowed to keep smoking materials at bedside. She stated Resident 66's lighter had been previously confiscated and she was not aware the resident had a lighter in her possession. On November 6, 2024, at 12:28 p.m., during an interview with the Director of Nursing (DON), she stated the activity department should keep all the smoking materials. The DON stated the residents were not allowed to keep their smoking materials for safety reasons. Resident 66's record was reviewed. Resident 66 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure, hypertension (high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). The history and physical dated September 11, 2024, indicated Resident 66 had intermittent (not continuous or steady) capacity to make decisions. The care plan dated June 25, 2024, indicated, .Resident is a smoker and is at risk for smoking related injury as evidenced by poor safety awareness .All matches and lighters will be kept in the activity office .Interventions .Smoking paraphernalia will be stored per facility guidelines . The undated facility policy and procedure titled, SMOKING POLICY, indicated, .No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents .All smoking materials will be retained by staff .The facility reserves the right to immediately confiscate smoking materials .

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population. Findings: On [DATE], at 9:55 a.m., an initial tour of the kitchen was conducted with the Dietary Supervisor (DS). A one gallon size pitcher of water, that was almost full, dated [DATE], was observed in the refrigerator, readily available for use. In a concurrent interview, the DS stated the water was used for residents who preferred cold water and [DATE] was the use-by-date. The DS stated the water should have been discarded on or before the use-by-date. Additionally, a one-gallon pitcher with a thickened liquid, approximately a quarter-full, dated [DATE], was observed in the refrigerator, readily available for use. In a concurrent interview, the DS stated the liquid in the pitcher was used for residents who are on a diet with thick liquids and [DATE] was the use-by-date. The DS stated the thickener should have been discarded on or before the use-by-date and not stored in the refrigerator, readily available for use. The facility policy and procedure, titled, Storage of Food and Supplies, revised 2020, was reviewed. The policy and procedure indicated, .Food and supplies will be stored properly and in a safe manner .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented for three of 19 residents reviewed (Residents 69, 86, and 140) when: 1. For Resident 69, the hand held nebulizer mouthpiece (a device that contains medication that turns into a mist) was left exposed on top of the bedside table near the resident's urinal; 2. For Resident 86, the Enhanced Barrier Precaution (EBP - infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms) was not followed when the resident was admitted with the colostomy (an operation in which a piece of the colon is diverted to an artificial opening in the abdomen that allows stool to pass through); and 3. For Resident 140, the Physical Therapy Assistant (PTA) was not wearing a gown when performing physical therapy exercises at the resident's bedside. Resident 140 was identified for EBP. These failures had the potential to increase the risk for cross contamination and the development of infection from staff to vulnerable residents. Findings: 1. On November 4, 2024, at 12:50 p.m., Resident 69 was observed awake, alert, sitting up at the edge of his bed with oxygen on at 5Liters/minute through nasal cannula (a plastic tubing with two prongs used to deliver oxygen through the nose). Resident 69 stated he was short of breath this morning, and had to use the hand held nebulizer for his breathing treatment. The hand held nebulizer mouth piece attached to a plastic tubing was observed on top of the resident's bedside table close to his urinal. On November 4, 2024, at 1:10 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated the hand held nebulizer should be kept inside the plastic bag when not in use and should not be left above the bedside table next to the urinal. She stated Resident 69 was at risk for infection. On November 5, 2024, a review of Resident 69's record indicated Resident 69 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a lung disease). The physician's order dated October 27, 2024, indicated Resident 69 had an order for Albuterol Sulfate (a medication used for breathing treatment) 2.5milligram (mg- a unit of measurement) per 3 milliliter (ml), 1 inhalation via (through) nebulizer every 4 hours as needed for SOB/Dyspnea (shortness of breath/difficulty of breathing). On November 8, 2024, at 10:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the hand held nebulizer should be kept inside the plastic bag after use to prevent infection. She stated licensed staff who administered the nebulizer treatment for Resident 69 should have placed the nebulizer kit inside the plastic bag after cleaning. On November 8, 2024, at 12:25 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated the hand held nebulizer mouth piece should not be on top of the bedside table, and the urinal should be kept at the urinal holder. The IP stated the hand held nebulizer should be kept inside the plastic bag after use to prevent cross contamination and infection. A review of the facility's policy and procedure titled, Prevention of Infection Respiratory Equipment, dated November 2011, indicated.Infection Control Considerations Related to Medication nebulizers .Store the circuit in plastic bag, marked with date, and resident's name . 2. On November 4, 2024, at 12:25 p.m., Resident 86 was observed awake, lying in bed, alert and able to verbalize her needs. Resident 86 stated she had diarrhea at home for 3 weeks, and she lived alone, was getting weak and she called 911. She stated she had an emergency surgery for her bowel and had a colostomy. Resident 86 voluntarily pulled her shirt and showed her left colostomy. She stated the nurse changes the bag and the certified nursing assistant (CNA) would empty the stool from the bag. She stated it might be temporary and the surgeon might reverse it later. The colostomy bag was observed with brownish stool. Resident 86's room had no designated EBP sign and there was no Personal Protective Equipment (PPE - protective clothing, gloves, faceshields, goggles, facemasks and/or respirator designed to protect the wearer from tyhe spread of infection or illnesses) cart outside the room. On November 4, 2024, at 1p.m., Resident 86's room was observed without the EBP signage and PPE outside the door. On November 4, at 1:30 p.m., a concurrent observation and interview was conducted with the Infection Preventionist (IP) nurse. The IP stated Resident 86 should be on EBP on admission for her colostomy. The IP acknowledged Resident 86 had a bowel surgery and EBP should have been implemented to avoid cross contamination. On November 6, 2024, a review of Resident 86's record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses which included diverticulitis of the intestines (inflammation or infection of small pockets on the inside of the colon). Resident 86 was at the acute facility on September 29, 2024, for large bowel obstruction and repair of the colovesicular fistula (an abnormal connection between the colon and urinary bladder) and a colostomy. The facility's admission assessment on October 12, 2024, indicated Resident 86 was admitted with a colostomy on the left lower area of her abdomen. The physician's history and physical dated October 13, 2024, indicated Resident 86 had the capacity to understand and make decisions. The care plan indicated Ostomy (opening)- Bowel: Resident has ileostomy and is at risk for complications .Observe signs and symptoms of complications .ostomy care . On November 8, 2024, at 10:15 a.m., an interview was conducted with the DON. The DON stated the licensed nurse who admitted Resident 86 on October 12, 2024, should have identified and placed the resident on EBP to avoid cross contamination and spread of infection. A review of the facility policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022, indicated, .Enhanced Standard precautions . The facility will follow the current guidance .Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk .contamination of staff hands, clothes, and the environment such as .device care . 3. On November 4, 2024, at 11:10 a.m., Resident 140 was observed with Enhanced Barrier Precaution (EBP) signage outside his room, and a cart containing the PPE. The PTA was observed at the bedside assisting Resident 140 with upper and lower exercises. The PTA was observed having direct contact with the resident, and was not wearing the disposable gown. Resident 140 was sitting at the edge of the bed with the indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). On November 4, 2024, at 11:20 a.m the PTA was interviewed. He stated he just realized Resident 140 was on EBP for the indwelling urinary catheter. He stated he came in fast in the room without looking at the sign outside the residents' room. He stated he should have followed the EBP process. On November 4, 2024, at 11:45 a.m., an interview was conducted with RN Supervisor (RNS) 1. RNS 1 stated the PTA should have followed the EBP protocol. She acknowledged PTA was not wearing the disposable gown when having direct contact with Resident 140. On November 5, 2024, Resident 140's record was reviewed. Resident 140 was admitted to the facility on [DATE], with diagnoses which included history of falling, benign prostatic hypertrophy (BPH - enlarged prostate), and retention of urine. The physician's history and physical indicated Resident 140 had an indwelling urinary catheter in place. A Physician order indicated, .Observed Enhanced Barrier Precaution (EBP) Resident has Indwelling Foley Catheter for Urinary Retention due to Obstructive Uropathy Related to BPH every shift . On November 7, 2024, at 10:01 a.m., The DON was interviewed. The DON stated the PTA should have checked the EBP sign before entering Resident 140's room. On November 7, 2024, at 12:18 p.m., the IP was interviewed. She stated the PTA should have looked at the EBP sign at the door. The PTA should have donned (put on) the disposable gown prior to entering the room. A review of facility's policy and procedure titled Isolation- Categories of Transmission - Based Precautions, dated September 2022, indicated, .The facility will follow current guidance .regarding Enhanced Standard Precaution .Wear gowns and gloves while performing the high-contact tasks associated with the greatest risk .any care activity where close contact with the resident is expected to occur .

Based on interview and record review, the facility failed ensure the resident's representative was informed of an incident of fall for one of six resident reviewed (Resident C). This failure has the potential to result in the resident's representative to be unaware of the resident's condition which could delay the involvement of the representative in planning the care for their family member (Resident C). Findings: On May 24, 2024, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint of quality of care. On May 28, 2024, Resident C ' s medical record was reviewed. Resident C was admitted to the facility on [DATE], with diagnoses which included Myocardial Infarction (heart attack) and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood). A review of Resident C ' s SBAR (stands for Situation, Background, Assessment, Recommendation- a form used to communicate)/Summary for Providers, dated for May 15/2024, at 7:15 a.m., indicated .falls .CNA (certified nursing assistant) informed writer resident was found on the floor next to her bed .lying on her right side .denies hitting head .MD (medical doctor) made aware .informed resident .Recommendations: no new orders at this time . On May 28, 2024, at 3:30 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated Resident C ' s family should have been notified about the fall, the nurse should have called the family. A review of the facility ' s protocol titled Acute Condition Changes, dated March 2018, indicated .the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation .discussion should consider the patient ' s overall condition .wishes (either direct or as conveyed by a substitute decision-maker) . A review of the facility ' s policy titled Falls/Fall Risk Management, dated September 2012, indicated .Staff will ask the resident and the caregiver or family about a history of falling .the nurse shall assess and document/report the following .recent injury .change in condition .neurological status .details on how fall occurred .Risk factors for subsequent falling .

Based on observation, interview, and record review the facility failed to ensure the safety of one sampled resident out of 14 sampled, (Resident 1). During a transfer from gurney to bed, Resident 1 sustained a right hip fracture. The failure to protect Resident 1 with transfer resulted in Resident 1 being admitted to the emergency room for right hip surgery. This failure had the potential to cause increased pain, risk of infection, risk of blood clots, respiratory depression (decreased respirations-risk from anesthesia (medications used to induce sleep)), and death. Findings: 1. A record review was conducted on Resident 1 on September 4, 2013. Resident 1 was readmitted to the facility on [DATE]. Resident 1 had the following Diagnoses: [REDACTED]. Resident 1's Minimum Data Set (MDS-a method to evaluate the status of a resident) dated July 22, 2013 indicated, Resident 7's cognitive status as "severely impaired" and her mobility (ability to move in bed) and transfer (ability to move from gurney to bed) status as "total dependance" of staff. The nursing note dated, August 30, 2013, 2:15 p.m., indicated, "CNA (certified Nursing Assistant) noted res (resident) (R-right leg, swell and femur, zero (unable to read written word) no dislocation. MD (doctor) notified and received order for STAT (immediate) x-ray." The nursing note dated, August 30, 2013, 2:20 p.m., indicated, "Interviewed CNA assigned to resident during incident. CNA accounted that while transferring resident with help of two ambulance drivers, resident's (R) leg was still on gurney after transfer was complete. Female EMT (Emergency Medical Technichian) then put resident's (R) leg back in bed. At this point (R) femur noted swollen and hard when touched. Pain upon palpation of site. When resident moves leg, a protrusion is seen coming from under skin..." During an interview conducted with CNA 1 on September 4, 2013, at 10:55 a.m., CNA 1 described Resident 1's transfer. CNA 1 and the surveyor viewed Resident 1's empty bed as CNA 1stated, "I did not do any hands on (assist physically with transfer). Resident 1, CNA 1 stated," was transferred from gurney to bed by two paramedics and two certified nursing assistants." CNA 1 stated," Resident 1's foot and heel got caught in a gap (space) between the mattress of the gurney and the gurney (metal frame) itself". CNA 1 described Resident 1's legs as "frog like" or "diamond shaped" (because of the contractures). CNA 1 stated she heard a"bone crack noise" with the transfer. CNA 1 stated Resident 1 was previously transferred by the Hoyer Lift ( a mechanical electrical powered lift with a sling) to a geri chair (a reclining chair). CNA 1 further stated that the (facility's) Hoyer lift (usually) stayed with the resident. CNA 1 stated,..."if a resident is transferred in a Hoyer( lift) they have to go back to bed with a Hoyer (lift)." The surveyor asked CNA 1 who was responsible for checking the extremities (arms and legs) of Resident 1, CNA 1 stated "we all were...there were three CNAs in the room and two paramedics." CNA further stated that several minutes had passed when she re-checked Resident 1 and discovered Resident 1's right leg bent back in the (opposite direct of frog position). During an interview with CNA 2 on September 4, 2013, at 11:25 a.m., CNA 2 stated, "No Hoyer was used to transfer her (Resident 1) back to bed...only a sling (Hoyer lift device without the actual lift) and four workers...two CNAs and two paramedics." CNA 2 further stated if a resident "get(s) up with a Hoyer they have to go back with a Hoyer..I did not wait for the Hoyer because I was afraid she (Resident 1) would pull her dialysis catheter out...usually I wait for the machine." Another interview was conducted with CNA 3 on September 17, 2013, at 11 a.m. CNA 3 stated that the day of the incident, August 30, 2013, it was her first day working at the facility and that she did not have training for the Hoyer lift yet by the facility. CNA 3 stated, "Nobody said to use the Hoyer lift...but I know we were supposed to use the Hoyer lift. CNA 3 further stated if a resident is out of bed with a Hoyer lift then they should go back with a Hoyer lift. CNA 3 was asked about the assistance of the paramedics with Resident 1's transfer, she stated, "Paramedics are not supposed to tell us (CNAs) how to transfer a resident...the facility is responsible for the resident because the paramedics are going in and out (of the facility). CNA 3 further stated the "staff and the paramedics transferred the resident with the sheet only...nobody touched the feet." An observation was conducted of Resident 1 on September 4, 2013, at 3:15 p.m., at the hospital (name withheld) where she was admitted . Resident 1 was observed in an ICU (intensive care unit) isolation room (staff and visitors must wear gown and gloves to protect against bacteria). Resident 1 had contractures (permanent bent/flexion) to the upper and lower extremities, bilateral wrist restraints, a gastric tube (tube in abdomen for liquid nutrition), a dialysis double lumen catheter in her right chest wall, and a right hip dressing. Resident 1's lower extremities had a frog-like appearance. Resident 1 had difficulty communicating. Most of the sounds heard from Resident 1 were nonsensical (no clear meaning). A record review was conducted on September 4, 2013, at the hospital (Name Withheld) where Resident 1 was admitted . Resident 1's "emergency room Report" indicated under "Clinical Impression...3. Acute right mid shaft femur fracture." A review of the facility policy and procedure was conducted on September 4, 2013. The policy titled, "Hoyer Lift Usage," indicated, "Do not use Hoyer lift equipment if unfamiliar with the procedure and/or training on use of equipment was not provided." The policy also indicated, "29. return resident to bed using the same procedure." A review of the company manual of the Hoyer lift product on September 17, 2013 indicated," Do Not lift a patient unless you are trained and competent to do so." During an interview with the Director of Staff Development (DSD) on September 4, 2013, at 15:30 p.m., the DSD stated that CNA 3 did not have one to one training (demonstration) on the Hoyer lift yet. The DSD further stated CNA 3 did not have documented training on the Hoyer lift. When the DSD was asked by the surveyor if Emergency Medical Technicians (EMTs) who transfer residents are given training by the facility for the use of the Hoyer lift, the DSD stated,"No." The DSD further stated, "they (CNAs) are trained that is a resident is removed from bed with a Hoyer device, the resident should go back to bed with a Hoyer lift."

Based on observation, interview, and record review the facility failed to ensure: 1. The safety of one resident out of 14 sampled residents, (Resident 1), during a transfer from gurney to bed on August 30, 2013. Resident 1 sustained a fractured right femur/hip, when she was transferred from the gurney to her bed, by two ambulance staff and two facility Certified Nursing Assistants (CNAs) on August 30, 2013, when her right foot/heel became entrapped between the bed and the gurney. CNAs 1, 2, and 3 did not ensure a Hoyer lift was utilized to transfer the resident back to bed, even though there was a Hoyer lift sling under Resident 1 at the time of the transfer. CNAs 1, 2, and/or 3 did not manually control the resident's legs during the transfer, even though the resident had no voluntary movement of her lower extremities, due to contractures and paralysis (lack of voluntary movement) of her lower extremities. This failure had the potential to cause increased pain, risk of infection, risk of blood clots, respiratory depression (decreased respirations-risk from anesthesia (medications used to induce sleep)), sepsis (generalized infection), coma, and death. 2. a. The chemical storage closet at the North Station was locked, in order to prevent the accidental chemical ingestion (to drink) or topical (to the skin) exposure of potentially hazardous liquid cleaning agents. This failure had the potential to cause accidental topical exposure or poisoning of residents with the potential for skin dermatitis (inflammation), skin burns, infection, gastric illness (nausea, vomiting, and diarrhea), hospitalization , coma or death. 2. b. The maintenance storage supply room was locked in order to prevent accidental injury from sharp objects and tools in the storage room. Sharp tools were left unattended and exposed to residents and visitors. This failure had the potential to cause bodily injury, skin tears, lacerations, infection, or sepsis (generalized infection) to residents and/or visitors. Findings: 1. A record review was conducted of the facility's "Admission and Discharge Summary," dated September 9, 2013, for Resident 1 on September 4, 2013. Resident 1 was readmitted to the facility on [DATE]. Resident 1 had the following Diagnoses: [REDACTED]. Resident 1's Minimum Data Set (MDS-a method to evaluate the status of a resident) dated July 22, 2013, indicated, Resident 7's cognitive status as "severely impaired" and her mobility (ability to move in bed) and transfer (ability to move from gurney to bed) status as "total dependance" of staff. The nursing note dated, August 30, 2013, at 2:15 p.m., indicated, "CNA (Certified Nursing Assistant) noted res (resident) (R-right), leg swell and femur, zero (unable to read written word) no dislocation. MD notified and received order for STAT (immediate) x-ray." The nursing note dated, August 30, 2013, 2:20 p.m., indicated, "Interviewed CNA assigned to resident during incident. CNA accounted that while transferring resident with help of two ambulance drivers, resident's (R) leg was still on on gurney after transfer was complete. Female EMT (Emergency Medical Technician) then put resident's (R) leg back in bed. At this point (R) femur noted swollen and hard when touched. Pain upon palpation of site. When resident moves leg, a protrusion is seen coming from under skin...." During an interview conducted with CNA 1 on September 4, 2013, at 10:55 a.m., CNA 1 described Resident 1's transfer on August 30, 2013, at approximately 2:15 p.m. CNA 1 and the surveyor viewed Resident 1's empty bed as CNA 1 stated, "I did not do any hands on (assist physically with transfer). CNA 1 stated,"(Resident 1's) was transferred from gurney to bed by two paramedics and two certified nursing assistants." CNA 1 stated," Resident 1's foot and heel got caught in a gap (space) between the mattress of the gurney and the gurney's (metal frame) itself". CNA 1 described Resident 1's legs as "frog like" or "diamond shaped" (because of the contractures-permanent bending of her legs in a fixed position). CNA 1 stated she heard a"bone crack noise" during the transfer. CNA 1 stated Resident 1 was previously transferred by the Hoyer Lift (a mechanical hydraulic powered lift with a sling) to a geri chair (a reclining chair). CNA 1 further stated that the (facility's) Hoyer lift (usually) stayed with the resident. CNA 1 stated,..."if a resident is transferred in a Hoyer (lift) they have to go back to bed with a Hoyer (lift)." The surveyor asked CNA 1 who was responsible for checking the extremities (arms and legs) of Resident 1, CNA 1 stated "we all were...there were three CNAs in the room and two paramedics." CNA 1 further stated that several minutes had passed when she re-checked Resident 1 and discovered Resident 1's right leg bent back in the (opposite direction of her frog-like position). During an interview with CNA 2 on September 4, 2013, at 11:25 a.m., CNA 2 stated, "No Hoyer was used to transfer her (Resident 1) back to bed (on August 30, 2013)...only a sling (Hoyer lift device sling without the actual lift) and four workers...two CNAs and two paramedics." CNA 2 further stated if a resident "get(s) up with a Hoyer they have to go back (to bed) with a Hoyer..I did not wait for the Hoyer because I was afraid she (Resident 1) would pull her dialysis catheter out...usually I wait for the machine (Hoyer lift)." An interview was conducted with CNA 3 on September 17, 2013, at 11 a.m. CNA 3 stated that the day of the incident, August 30, 2013, it was her first day working at the facility and that she had not had training for the Hoyer lift by the facility. CNA 3 stated, "Nobody said to use the Hoyer lift...but I know we were supposed to use the Hoyer lift. CNA 3 further stated if a resident is transferred out of bed with a Hoyer lift then they should go back to bed using a Hoyer lift. CNA 3 was asked about the assistance of the paramedics with Resident 1's transfer, she stated, "Paramedics are not supposed to tell us (CNAs) how to transfer a resident...the facility is responsible for the resident because the paramedics are going in and out (of the facility)." CNA 3 further stated, "the staff and the paramedics transferred the resident with the sheet only...nobody touched the feet (to guide the resident's lower extremities during the transfer)." CNAs 1 and 2 had their names listed for in-service training on "Safe lifting/Transfers/Hoyer Lift transfer" on the facility's documented record "In-Service Attendance Record," dated July 2, 2013. An observation was conducted of Resident 1 on September 4, 2013, at 3:15 p.m., at the hospital where she was admitted . Resident 1 was observed in an ICU (intensive care unit) room. Resident 1 had contractures to the upper and lower extremities. Resident 1's lower extremities had a frog-like appearance/position. Resident 1 had difficulty communicating. Resident 1 was not interviewable. A record review was conducted on September 4, 2013, at the hospital where Resident 1 was admitted . Resident 1's "emergency room Report," dated August 30, 2013, indicated under "Clinical Impression...3. Acute right mid shaft femur fracture." A review of the facility undated policy and procedure was conducted on September 4, 2013. The policy titled, "Hoyer Lift Usage," indicated, "Do not use Hoyer lift equipment if unfamiliar with the procedure and/or training on use of equipment was not provided." The policy also indicated, "29. return resident to bed using the same procedure." A review of the company manual dated July 8, 2011, of the Hoyer lift product on September 17, 2013 indicated," Do Not lift a patient unless you are trained and competent to do so." During an interview with the Director of Staff Development (DSD) on September 4, 2013, at 3:30 p.m., the DSD stated that CNA 3 did not have one to one training (demonstration) on the Hoyer lift yet. The DSD further stated CNA 3 did not have documented training on the Hoyer lift. When the DSD was asked by the surveyor if Emergency Medical Technicians (EMTs) who transfer residents are given training by the facility for the use of the Hoyer lift, the DSD stated,"No." The DSD further stated, "they (CNAs) are trained that if a resident is removed from bed using a Hoyer device, the resident should go back to bed using a Hoyer lift." 2. A review of the Resident Census and Condition of Residents form dated September 9, 2013, provided to the survey team on September 9, 2013, by the administrator, indicated the following concerning the facility's residents: Mobility: 45 residents in chairs all or most of the time and 19 residents ambulate with assistance or with an assistive device. Mental Status: Two residents with intellectual and/or developmental disability, 12 residents with documented signs of depression, five residents with psychiatric diagnoses, 18 residents with dementia, and 17 residents with behavioral healthcare needs. Medications: Four residents on antipsychotic (psychiatric mind/mood altering) medications, five residents on antianxiety medications, and 12 residents on antidepressant medications. Other: Six residents who do not communicate in the dominant language of the facility and eight residents who used non-oral communication devices. During the environmental facility tour conducted on September 11, 2013, at 9:05 a.m., with the Environment Specialist (ES) and Maintenance worker, the following observations were made: a. Chemical storage room at the North Station was observed unlocked, and inside the chemical storage room contained an automatic dispenser for 2 gallons of Ultra Septic 885 (cleaner disinfectant), 1 gallon of tub and grout cleaner (tile and grout Cleaner), and 1 gallon of Ultra Carpet and Clean (carpet and upholstery cleaner). In a concurrent interview with the ES, He stated " it's should be locked, "the housekeepers and janitors should have the keys to the chemical storage supply room." The ES asked the housekeepers and janitors if they had the key(s) to the chemical supply storage closet. He informed this HFEN that the housekeepers, janitors and he did not have any keys to that chemical storage closet. He indicated he would need to purchase a new lock for that door and provide the housekeeping and janitorial staff and himself with keys to the chemical storage closet. On September 11, 2013, at 11:10 a.m., the undated form titled Material Safety Data Sheet was reviewed for Section 3 - Hazards Identification as follows: 1. "Ultra Septic 885, (prolonged exposure causes irritation to skin and membranes)..." 2. "Ultra Carpet and Clean, (prolonged or repeated exposure can cause drying, defatting (chemical removal of the fat layer under the skin), and dermatitis (inflammation) of skin)..." 3. "Floor Care and Grout Cleaner, (may cause burns to exposed tissue)..." On September 11, 2013, at 11:30 a.m., review of the facility undated policy titled "Chemical/Hazardous Material ", indicated," 10. storage room for housekeeping supplies should always be kept secured and locked." b. On September 11, 2013, at 9:28 a.m., the main maintenance storage supply room was unlocked. In the storage room, there were the following hazardous items: multiple screw drivers, a carpenter saw, a hack saw, a dry wall saw, a hammer, and scissors. In a concurrent interview with the environmental specialist, he stated " it's my mistake" it should be locked. He indicated he had the key. On September 11, 2013, at 11:40 a.m., a review of the facility undated policy titled, " Physical Plant Policy Safety," indicated," 5. Storage room for maintenance tools, equipment and supply should always be kept secured and locked in order to restrict resident access."