Every finding on record at San Juan Hills Healthcare Center

Based on interview, closed medical record review, and facility P&P review, the facility failed to to provide reasonable accommodations to meet the needs for one of four sampled residents (Resident 1). * The facility failed to ensure the facility's staff assisted Resident 1 to the bathroom on the day she was admitted to the facility. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay of care.Findings: Review of the facility's P&P titled Quality of Life - Accommodation of Needs revised 8/2009 showed our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. Under the Policy Interpretation and Implementation section, the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. Closed medical record review for Resident 1 was initiated on 7/24/26. Resident 1 was admitted to the facility on [DATE], and discharged on 7/23/26. Review of Resident 1's Physical Therapy Treatment Note from the acute care hospital dated 7/10/26, showed continued with ambulation 100 feet twice. In addition, the Transfers section showed for bed to chair, Resident 1's level of independence was contact guard assist. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 7/24/26 at 0957 hours, a telephone interview was conducted with Resident 1. Resident 1 stated she was admitted to the facility on Friday 7/10/26, and had to go to the bathroom herself because the staff refused to help her. Resident 1 stated the staff told her it was a government regulation and they could not help her to go to the bathroom. Resident 1 further stated it was late in the afternoon and the physical therapy was not there. Resident 1 stated physical therapy evaluated her on Saturday at 0930 hours. On 7/24/26 at 1513 hours, an interview was conducted with CNA 1. CNA 1 denied he refused to provide assistance to Resident 1 to go to the bathroom. CNA 1 stated he told Resident 1 he could offer her a bed pan or a brief. CNA 1 further stated he explained to Resident 1 regarding the facility's policy that the staff were not allowed to ambulate the residents without a physical therapy evaluation. CNA 1 stated Resident 1 got really mad at him. On 7/24/26 at 1618 hours, an interview was conducted with RN 2. When RN 2 was asked about the process of helping a newly admitted resident to the bathroom, RN 2 stated she would explain to a newly admitted resident the staff could not get them out of bed until they were seen by the physical therapist. RN 2 stated the staff could only offer a diaper or a bed pan. On 7/29/26 at 1047 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the Director of Rehabilitation Services. The Director of Rehabilitation Services reviewed the Physical Therapy Treatment Note when Resident 1was transferred from Hospital 1 to the facility on 7/10/26. When the Director of Rehabilitation Services was asked (based on Resident 1's Physical Therapy Treatment Note from the Acute Care Hospital) what would she recommend to the staff if the newly admitted resident asked to use the restroom, the Director of Rehabilitation Services stated Resident 1 could get up using a walker with assistance from the staff and she could walk to the bathroom. The Director of Rehabilitation Services stated for bed to chair transfer Resident 1 was contact guard assist, which meant a hand on the person for safety and to steady the resident if they needed it. The Director of Rehabilitation Services stated the facility had no policy that the staff were not allowed to ambulate the residents without a physical therapy evaluation. The Director of Rehabilitation Services stated nurses should look at the residents' physical therapy notes, diagnosis, discharge summary, and the discharge order to check the weight bearing, check if there was any precautions so they could see what the residents were doing with their mobility in the acute care hospital. On 7/29/26 at 1155 hours, an interview was conducted with the AIT and DON. The AIT and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident's care needs for one of four sampled residents (Resident 2). * The facility failed to complete a Change of Condition (COC) report and corresponding documentation related to Resident 2's new physician's order for the intravenous fluids due to poor oral intake. This failure had the potential for the resident to not receive adequate and timely care.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical and/or mental condition and/or status (such as changes in level of care, billing and/or payments, resident rights, etc.). The P&P further showed the nurse will record in the resident's medical record information relative to changes in the resident's medical and/or mental condition or status. Review of the facility's P&P titled General Policies for IV Therapy revised on 3/2023 showed documentation of IV therapy should include but is not limited to: - Intake and ouput;- Vital signs every shift;- IV medication administration; - Response of therapy; and- IV site assessment. Medical record review for Resident 2 was initiated on 5/22/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 2/18/26, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Order Summary Report for May 2026 showed a discontinued physician's order dated 5/15/26, and an active physician's order dated 5/22/26, to administer sodium chloride solution 0.9%, one liter at 50 ml/hr intravenously every shift for poor oral intake. However, review of Resident 2's medical record failed to show a COC report and 72-hour documentation monitoring were completed related to the resident's poor oral intake and IV fluid orders. On 5/2626 at 1348 hours, an interview and concurrent medical record review of Resident 2 was conducted with LVN 4. LVN 4 verified the above findings and stated the resident's new IV fluid orders would be considered a COC. LVN 4 stated there was no documented evidence of a COC or 72-hour monitoring for the COC. On 5/26/26 at 1545 hours, an interview and concurrent medical record review of Resident 2 was conducted with the DON. The DON verified Resident 2 started on IV fluids 5/15/26, and received a new order on 5/22/26. The DON acknowledged there was no COC or 72-hour documentation monitoring completed. The DON stated there should have been a COC to identify the reason for IV fluids and 72-hour monitoring to ensure the interventions were effective. On 5/26/26 at 1625 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure medications were not left unattended at the bedside for one of four sampled residents (Resident 1. * Multiple medications including oral, topical, and subcutaneous medications were left unattended at Resident 1's bedside without authorization for beside storage. This failure had the potential for Resident 1 to inaccurately self-administer the medications.Findings: Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Review of the facility's P&P titled Self-Administration of Medications dated 4/2008 showed residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a routine basis. a. The resident is instructed in the use of the package, purpose of the medication, reading of the label, and scheduling of medication dose.b. The resident is then requested to read the label on each package and indicate at what time the medication should be taken and any other special instructions for use.c. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms such as an inhaler, to verbalize the steps involved in administration.The results further showed the following conditions are met for bedside storage to occur:-The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. - Notation of each dose self-administered is documented on the MAR The facility's P&P also showed all nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Medical record review for Resident 1 was initiated on 5/22/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/29/26, showed Resident 1 had the capacity to understand and make decisions. On 5/22/26 at 0839 hours, an observation and concurrent interview was conducted with Resident 1, in the resident's room. Multiple medications were observed unattended at Resident 1's bedside table including the following: - One medication cup with two blue and red capsules and half of a white tablet, unlabeled;- One tube of diclofenac sodium gel 1% (pain medication);- One tube of Voltaren topical gel 1% (pain medication), unlabeled;- One bottle Trulance 3mg (bowel management medication); and- One case of Repatha SureClick injection.Resident 1 stated the licensed nurses were aware these medications were kept at bedside and stated she needed assistance applying the diclofenac and Voltaren topical medications to her back area, which she could not reach on her own. Review of Resident 1's medical record failed to show documented evidence an IDT meeting was conducted to determine Resident 1's cognitive, physical, and visual ability to carry out the self-administration of medications and the ability to self-administer medications by means of a skilled assessment conducted on a routine basis as per the facility's P&P. Review of Resident 1's Order Summary Report for May 2026 showed no documented evidence of a physician's order for Repatha SureClick injection (cholesterol medication). On 5/22/26 at 0907 hours, an observation, interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated Resident 1 had an order for supervised self-administration of Trulance but did not have self-administration orders for the other medications. LVN 1 verified there was no physician's order for Repatha SureClick injection medication. LVN 1 stated there should be a physician's order and the medications should be labeled to ensure the staff knew who the medication belonged to, along with the medication direction and expiration. LVN 1 further stated the licensed nurses should not leave medications unattended at bedside and must observe self-administration when permitted. On 5/22/25 at 1019 hours, an interview was conducted with LVN 2. LVN 2 verified she administered Resident 1's morning medications at 0630 hours and acknowledged she left the Tylenol (pain medication) and famotidine (acid reflux medication) at the bedside. LVN 2 stated medications should not be left unattended to prevent inaccurate dosing and to ensure other residents or visitors do not access them. On 5/26/26 at 1545 hours, an interview and concurrent medical record review of Resident 1 was conducted with the DON. The DON acknowledged the above findings and stated medications should not be kept unattended at bedside and must be stored in the medication carts. The DON stated medications approved for self-administration could be stored inside the resident's bedside drawer. The DON verified Resident 1 had a self-administration assessment completed by the licensed nurse who received the order for the self-administration; however, the DON stated the facility did not conduct an IDT assessment to determine Resident 1's ability to self-administer her medications and conduct a skilled assessment per the facility's P&P. On 5/26/26 at 1625 hours, an interview with was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the DHPPD nurse staffing forms were accurate and posted daily. * The facility failed to ensure the DHPPD staffing information was posted daily on 5/22 and 5/26/26, and failed to complete and obtain required signatures on the forms dated 5/20 and 5/22/26. These failures had the potential to result in inaccurate staffing information provided to the public.Findings: Review of the facility's P&P titled Posting Direct Care Daily Staffing Numbers revised 7/2016 showed the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The P&P further showed within two hours of the beginning of each shift, the number of licensed Nurses (RNs, LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition. Moreover, the P&P showed within two hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Residet Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator. Review of the AFL 19-16 dated 4/9/19, showed facilities must use CDPH forms 530 and 612. The facility was responsible for ensuring all entries are accurate and legible. Unacceptable documentation includes, but is not limited to: - Census forms (CDPH Form 612) without the original verifying signature from the Administrator, DON or DON designee. Review of the CDPH 612 form dated 7/2019 showed to verify this form is complete, true, and accurate, the DON or designee must sign this form. Review of the facility's document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) [CDPH 612 form] dated 5/20/26, showed no documented evidence of the Actual Direct Care Service Hours and no documented signature of the DON or assigned designee. Review of the facility's document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) [CDPH 612 form] dated 5/22/26, showed no documented evidence of the Actual Direct Care Service Hours and no documented signature of the DON or assigned designee. On 5/22/26 at 0811 hours, an interview and concurrent facility document review was conducted with LVN 1. LVN 1 verified the DHPPD posting at the nurse's station was not current and dated 5/20/26. LVN 1 stated the Actual Direct Care Nursing Hours should be completed and the form should be signed by the DON or DON designee. On 5/22/26 at 1527 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD verified the DHPPD form dated 5/20/26, did not show the Actual Direct Care Service Hours and did not show the DON or designee's signature. The DSD stated the DON or DSD signed the DHPPD form and it was required to be posted daily. The DSD further stated the DHPPD form informed families or visitors the staffing levels had met the needs of the census. On 5/26/26 at 0730 hours, an interview and concurrent facility document review was conducted with LVN 3. LVN 3 verified the DHPPD form posted at the nurses' station was dated 5/22/26, and was not signed by the DON or designee. LVN 3 further verified the form did not include the Actual Direct Care Service Hours. LVN 3 stated there were no other DHPPD postings from 5/22 through 5/26/26. LVN 3 stated the DSD usually updated the forms daily. On 5/26/26 at 0752 hours, a follow interview and concurrent facility document review was conducted with the DSD. The DSD verified the DHPPD form dated 5/22/26, did not show the Actual Direct Care Service Hours and was not signed by the DON or assigned designee. The DSD further verified there were no DHPPD posted from 5/23 to 5/26/26. The DSD stated the DHPPD form should be posted daily, including weekends. On 5/26/26 at 1625 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure information regarding the administration of psychotherapeutic medications was provided for one of eight sampled residents (Resident 1). * Resident 1's psychotherapeutic drug informed consent form for Depakote (anticonvulsant) was incomplete and inaccurate. * Resident 1's psychotherapeutic drug informed consent form for mirtazapine (antidepressant) was incomplete. * Resident 1's psychotherapeutic drug informed consent form for seroquel (antipsychotic) was incomplete * Resident 1's psychotherapeutic drug informed consent form for olanzapine (Zyprexa Zydis, antipsychotic) was incomplete These failures posed the risk of Resident 1's Responsible Party to not understand the risks, benefits, and purpose of the medications she was consenting for the facility to administer to Resident 1.Findings: Review of the facility's P&P titled Antipsychotic Medication Use dated 2016 showed PRN orders for psychotropic medications should have a duration of 14 days and a practitioner must reevaluate the resident for appropriateness of that medication if extending the PRN medication beyond 14 days. Review of the facility's P&P titled Psychotherapeutic Drug Informed Consent Form Instruction Sheet dated 2/2026 showed the informed consent is the voluntary agreement of a resident or a resident's representative to accept a treatment or procedure after receiving information. Additionally, the P&P showed the following required information be entered:- Drug category;- Dosage prescribed;- Frequency of use;- Duration of use; and- Possible side effects and any significant risks associated with the use of the medication. Review of the Psychotherapeutic Drug Informed Consent Form (undated) showed the probable side effects and significant risks associated with the use of a particular type of psychotherapeutic drug was categorized according to the drug classification including anti-psychotic, anti-anxiety, anti-depressant, anti-convulsant/mood stabilizer, and sedative/hypnotic. Medical record review for Resident 1 was initiated on 4/7/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 3/18/26, for Depakote Sprinkles oral capsule delayed release sprinkle 125 mg (divalproex sodium), give two capsules by mouth two times a day for psychosis manifested by angry outburst;- dated 3/18/26, for mirtazapine oral tablet 7.5 mg (mirtazapine), give one tablet by mouth two times a day for depression manifested by poor oral intake;- dated 3/18/26, for Seroquel oral tablet 100 mg (quetiapine fumarate), give one tablet by mouth in the evening for psychosis manifested by striking out; and - Zyprexa Zydis oral tablet 2.5 mg disintegrating (olanzapine), give 2.5 mg by mouth every four hours as needed for psychosis manifested by agitation. Review of Resident 1's Psychotherapeutic Drug Informed Consent form for Depakote dated 3/18/26, showed it was signed by Resident 1's Responsible Party. The consent further showed the following:- The drug category was left blank;- The drug duration was left blank;- The off-label use caution and warning summary indicated it was not an off-label use of the drug; and- The probable side effects and significant risks associated with the use of Depakote was indicated in the anti-psychotic category not the anti-convulsant category. Review of Resident 1's Psychotherapeutic Drug Informed Consent form for Mirtazapine dated 3/18/26, showed it was signed by Resident 1's Responsible Party. The consent further showed the drug category and duration was left blank. Review of Resident 1's Psychotherapeutic Drug Informed Consent form for Seroquel dated 3/18/26, showed it was signed by Resident 1's Responsible Party. The consent further showed the drug category and duration was left blank. Review of Resident 1's Psychotherapeutic Drug Informed Consent form for Olanzapine dated 3/18/26, showed it was signed by Resident 1's Responsible Party. The consent further showed the drug category and duration was left blank. Review of Resident 1's H&P examination dated 3/20/26, showed Resident 1 had no capacity to understand and make medical decisions. Resident 1 had diagnoses including dementia with agitation, urinary tract infection, and encephalopathy. Review of Resident 1's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. On 4/14/26 at 1533 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 3. RN 3 stated the Depakote medication was an anticonvulsant. RN 3 stated the Depakote medication was being used as an antipsychotic which was an off-label use of the drug. RN 3 stated the probable side effects and risks associated with the use of the Depakote medication were designated on the form under the anti-psychotic section but should have been indicated under the classification of anticonvulsant/ mood stabilizer. RN 3 stated the side effects for an anticonvulsant and antipsychotic were different. RN 3 confirmed the off-label use was selected as no but should have been yes. RN 3 stated the sections on drug category, duration, and reason for use of psychotherapeutic drug should have been completed. On 4/14/26 at 1624 hours an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated the Psychotherapeutic Drug Informed consent forms were to be completed prior to the resident or the resident's responsible party signing the form. The DON stated the Psychotherapeutic Drug Informed Consent form for the mirtazapine medication was missing the drug category and duration. The DON stated the Psychotherapeutic Drug Informed Consent form for the olanzapine medication was missing the drug category and duration information. The DON stated the olanzapine medication was ordered as needed therefore the duration should have been 14 days, because it required a physician reevaluation within 14 days. The DON stated the Psychotherapeutic Drug Informed Consent form for the Seroquel medication were missing the drug category and duration information. The DON stated the expectation was the Psychotherapeutic Drug Informed Consent form was to be completed in full and the information accurate so the resident or the resident's responsible party was aware of the risks and benefits of the medication the resident was taking so an informed decision could be made. The DON stated if the complete and accurate information was not provided, then it was not informed consent. On 4/20/26 at 1450 hours an interview was conducted with RPh 2 and the DON. RPh 2 stated the side effects for anticonvulsants and antipsychotics were different. The RPh 2 stated Depakote was an anticonvulsant, and the side effects included weight gain, lethargy, sleepiness, and liver abnormalities. RPh2 stated the side effects for an antipsychotic was neurological symptoms, elevated blood pressure, and elevated cholesterol. The DON confirmed the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the expired food items in the main & satellite kitchen were discarded. * One of one ice machine was not clean. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure the cutting board was kept in a sanitary condition. * The kitchen utensils and dishware were not stored in a sanitary condition. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The floor in the walk-in refrigerator was littered with various rubbish of vegetables and fruits. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen.Findings: Review of the facility's Diet Type Report dated 1/20/26, showed 42 of 42 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Food Receiving and Storage revised 10/2017 showed all foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Other opened containers must be dated and sealed or covered during storage. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Review of the facility's P&P titled Food Preparation and Service revised 10/2017 showed potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. The Rapid Cooling section showed potentially hazardous foods should be cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and then to a temperature of below 41 degrees Fahrenheit within the next 4 hours. The total cooling time between 135 degrees Fahrenheit and below 41 degrees Fahrenheit is not to exceed 6 hours. a. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, an observation of the walk-in refrigerator and concurrent interview was conducted with the Food Services Director and the Co-Food Services Manager. The following food items were observed:- One opened jar of kalamata pitted olives dated 1/6/26, no use by date;- One opened jar of sweet & sour sauce, labeled with prep date 11/28/25 and opened 12/29/25, no use by date;- One opened jar of mild chunky salsa, the white lid was labeled with 1/9/26, no use by date;- One opened jar of premium sweet pickle relish dated 1/13/26, no use by date;- One opened jar of coleslaw dressing, the red lid was labeled with R 12/16/25, no use by date;- One opened jar of tomato ketchup, not labeled with open and use by date;- One opened jar of heavy duty mayonnaise dated 1/13/26, no use by date;- One pack of cage free peeled hard cooked eggs, the package was left open, and had no open and use by date;- Two trays of sliced cauliflowers covered with plastic wrap dated 1/19/26, no use by date;- One box of pork sausage skinless links dated 1/13/26, no use by date; and- One tray of cooked turkey covered with plastic wrap, not labeled when it was cooked and use by date. The Food Services Director verified the above findings. The Food Services Director stated all food items which were opened or prepared should have been properly labeled with use by date. The Food Services Director stated the opened package of eggs should also be kept tightly closed as well. The Co-Food Services Manager stated R meant received. The Food Services Director stated no cool down process was recorded for the turkey. b. On 1/20/26 at 0920 hours, during the initial tour of the satellite kitchen, an observation of the refrigerator and concurrent interview was conducted with the Food Services Director. The following food items were observed:- One opened box of thickened lemon flavored water labeled R 12/5/25, no use by date;- One container covered with plastic wrap, containing light green pureed food, no label of what kind of pureed food and no use by date;- One small brown bowl containing cut-up peaches was not labeled with use by date;- One opened jar of tomato ketchup labeled with arrived 11/14, no open & use by date;- One opened bottle of caramel dessert sauce labeled with prep date 11/14, no use by date; and- One quart of open chocolate ice cream labeled with RM [ROOM NUMBER], was not labeled with the resident's name and use by date. The Food Services Director verified the above findings. 2. a. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, an observation of the walk-in refrigerator and concurrent interview was conducted with the Food Services Director and the Co-Food Services Manager. There was one tray of red berries jam covered with plastic wrap labeled with prep date 1/16/26 and use by date 1/19/26. The Food Services Director stated the expired food should not be kept in the refrigerator and should be disposed. b. On 1/20/26 at 0920 hours, during the initial tour of the satellite kitchen, an observation of the refrigerator and concurrent interview was conducted with the Food Services Director. There was one open bottle of Hershey's chocolate syrup labeled with date 11/14 and use by 11/30. The Food Services Director stated when labeling the food items, the year should be included. 3. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Sanitization revised 10/2008 showed ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. Review of the facility document titled Monthly Cleaning Ice Machine showed the ice machine was last cleaned on 1/4/26. On 1/20/26 at 0945 hours, an observation of the ice machine located in the satellite kitchen and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated there was only one ice machine being used for the SNF residents. The interior of the white water dispenser was observed with slimy yellowish and brownish residue. The Maintenance Director verified the findings. The Maintenance Director stated the maintenance department was responsible for cleaning the ice machine. The Maintenance Director stated they did standard cleaning of the ice machine every month which included wiping the interior and exterior of the machine and cleaning the filters. The Maintenance Director stated the outside vendor would come every six months to perform the chemical cleaning, descaling, and sanitizing of the ice machine. 4. Review of the facility's P&P titled Food Receiving and Storage revised 10/2017 showed the non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. On 1/20/26 at 0900 hours, an inspection of the dry storage room and concurrent interview was conducted with the Food Services Director. One transparent plastic container with walnut halves was observed partly covered with plastic wrap. The Food Services Director verified the findings and stated it should be covered with closed tight lid. 5. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Review of the facility's P&P titled Sanitization revised 10/2008 showed all utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, two scoops with black handles were observed discolored with white sediments and had melted handles. The Food Services Director verified the findings. 6. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, showed surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, one green chopping board was observed heavily marred with knife marks and had black and yellowish stain. The Food Services Director acknowledged the cutting board needed to be replaced. 7. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. a. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, three rectangular containers containing the scoops, spatulas, and other kitchen utensils were observed dirty with food debris, and white and brown substance. The Food Services Director verified the findings. b. On 1/20/26 at 0920 hours, during the initial tour of the satellite kitchen, the following items were observed:- rectangular container 1 containing scoops was dirty with white & brown substance; and- rectangular container 2 containing scoops had a black disposable glove inside. The Food Services Director verified the findings. 8. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. Review of the facility's P&P titled Sanitization revised 10/2008 showed food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. a. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, two water jars were observed wet with water visible inside the jars and not completely dried. The Food Services Director verified the findings. b. On 1/20/26 at 0920 hours, during the initial tour of the satellite kitchen, one scoop with white handle was observed wet with water visible inside the scoop. The Food Services Director verified the finding. 9. Review of the facility's P&P titled Sanitization revised 10/2008 showed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. On 1/20/26 at 0750 hours, during the initial tour of the main kitchen, an observation of the walk-in refrigerator and concurrent interview was conducted with the Food Services Director and the Co-Food Services Manager. The space below the metal rack shelving in the walk-in refrigerator was observed littered with various rubbish of vegetables and fruits. The Food Services Director verified and acknowledged the findings. On 1/21/26 at 1438 hours, an interview was conducted with the Regional RD Consultant and the Food Services Director. The Regional RD Consultant and the Food Services Director were informed and acknowledged the above findings. On 1/22/26 at 1355 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to implement the infection control surveillance program for the months of January 2025 through August 2025. The facility conducted surveillance of resident infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications, or had not been diagnosed with an infection, met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the clean laundry in the laundry room was stored properly. Additionally, the facility failed to ensure the housekeeping staff did not store their personal items on the resident clean linen sorting counter. * The facility failed to ensure the Hoyer lift was cleaned in between usage for Residents 35 and 81. * The facility failed to ensure LVN 2 performed hand hygiene before administering eye drops to Resident 78. These failures posed the risk of not identifying resident infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2025 showed an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is coordinated and overseen by the IP. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. The information obtained from infection control surveillance activities is compared with acknowledged standards and used to assess effectiveness of established infection prevention and control practices. Standard criteria (McGeer's and Lobes's Criteria) are used to distinguish CAIs from HAIs. On 1/21/26 at 1007 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's resident infection surveillance program. The IP stated when a resident was prescribed antimicrobial medications or was diagnosed with an infection, the facility would then initiate a McGeer's Criteria and/or Loeb's Criteria form. The IP stated the McGeer's Criteria was utilized to determine if a resident had a true infection. The IP stated the Loeb's Criteria was utilized to determine whether a resident met the minimum criteria for the use of the antibiotics. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from January 2025 through August 2025 showed the following infection surveillance data for HAIs, CAIs, and the residents who did not meet McGeer's Criteria (DNMC): - for 1/2025: HAI – 31, CAI – 26, and DNMC – 0; - for 2/2025: HAI – 3 , CAI – 29, and DNMC – 0; - for 3/2025: HAI – 8 , CAI – 18 , and DNMC – 0; - for 4/2025: HAI – 10, CAI – 19, and DNMC – 0; - for 5/2025: HAI - 11 , CAI – 19, and DNMC – 0; - for 6/2025: HAI - 7 , CAI – 16, and DNMC – 0; - for 7/2025: HAI – 7, CAI – 16, and DNMC – 0; and - for 8/2025: HAI - 8, CAI – 0, and DNMC – 0. Further review of the facility's monthly Infection Prevention and Control Surveillance Logs from January 2025 through August 2025 showed that all the residents included in the facility's infection surveillance program were determined to have either a HAI or CAI (with prescribed antimicrobial medications or having been diagnosed with an infection). The Infection Prevention and Control Surveillance logs failed to show any residents that did not meet McGeer's criteria. The IP verified no residents in the facility were classified as having not met the McGeer's Criteria between the months of January 2025 through August 2025. When the IP was asked if the facility included the residents in the facility's infection surveillance program when a resident at the facility exhibited signs and/or symptoms of an infection and was not prescribed antimicrobial medications (or was not diagnosed with an infection) when the facility initiated the McGeer's criteria form, the IP stated the facility did not initiate the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications (or were not diagnosed with an infection). The IP was asked how many residents had met the McGeer's criteria and were not prescribed antimicrobial medications from January 2025 through August 2025 (excluding residents who were diagnosed with an infection). The IP stated she was uncertain, as the facility did not initiate the McGeer's criteria form for those residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications (or had not been diagnosed with an infection). 2. On 1/22/26 at 0908 hours, an observation of the facility's laundry room and concurrent interview was conducted with Housekeeping 1. The counter designated for clean laundry sorting was observed with a facility binder and a used paper cup with a food wrapper stuffed inside of the cup. Additionally, a clean linen cart was observed adjacent to the clean laundry sorting counter. The top shelf of the clean linen cart contained clean resident linens. A stack of facility paperwork was observed on the top shelf of the clean linen cart adjacent to the clean resident linen. Housekeeping 1 verified the findings and stated the facility staff personal cups and food wrappers should not be stored on the clean laundry sorting counter, for infection control purposes. Housekeeping 1 also stated the facility paperwork should not be stored inside of the resident clean linen cart, for infection control purposes. 3. Review of the facility's P&P titled Cleaning and Disinfecting Non-Critical Resident-Care Items revised 6/2011 showed under the General Guidelines section, reusable items are cleaned and disinfected or sterilized between residents (example is the durable medical equipment). On 1/20/26 at 1135 hours, during the initial tour of the facility, CNA 3 was observed transferring Resident 35 from the wheelchair to the bed using the Hoyer lift equipment. CNA 2 came to Resident 35's room and borrowed the Hoyer lift equipment from CNA 3. CNA 3 was then observed bringing the Hoyer lift equipment to Resident 81's room and used it to transfer Resident 81 from the bed to the wheelchair without cleaning the Hoyer lift equipment prior to using it for the resident. a. Medical record review for Resident 35 was initiated on 1/20/26. Resident 35 was admitted to the facility on [DATE]. Review of Resident 35's MDS assessment dated [DATE], showed Resident 35 had moderate cognitive impairment and dependent with mobility. b. Medical record review for Resident 81 was initiated on 1/20/26. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's MDS assessment dated [DATE], showed Resident 81 had severe cognitive impairment and dependent with mobility. On 1/20/26 at 1150 hours, an interview was conducted with CNA 2 and LVN 3. CNA 2 verified she did not clean the Hoyer lift equipment prior to using it for Resident 81. CNA 2 stated she should have wiped the lift equipment with the disinfecting wipes prior to using it. LVN 2 stated any reusable equipment like the durable medical equipment the facility staff used for the residents should be cleaned in between use for the residents. LVN 2 further stated the facility used the Sani-Cloth germicidal wipes to clean the equipment used for residents who were not on any isolation precautions and the Sani-Cloth bleach wipes would be used to clean the equipment used for residents who were on isolation precautions. On 1/22/26 at 0907 hours, an interview was conducted with the IP. The IP stated the licensed nurses and CNAs were provided regularly with an in-service training regarding the cleaning of all reusable medical equipment after being used with a resident and which germicidal wipes to use depending on whether the resident was on isolation precautions or not. The IP further stated if the cleaning process was missed, a potential outcome of spreading the infection could occur. The IP was informed and acknowledged the above findings. On 1/22/26 at 1355 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Review of the facility's P&P titled Handwashing/Hand Hygiene dated 10/2017 showed to medications are administered as prescribed in accordance with good nursing principles and practices and only by person authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions: - medications are administered without unnecessary interruptions; and - hands are washed before and after administration of topical (direct application of medication to a specific body surface, such as the skin), ophthalmic (administration of medications to the eye), optic (direct application of medication into the external ear canal), parenteral (medications administered into the tissues by injection), enteral (medication administered directly into the gastrointestinal system), rectal (through the anus into the rectum) and vaginal medications. Medical record review for Resident 78 was initiated on 1/20/26. Resident 78 was admitted to the facility on [DATE]. On 1/21/26 at 0907 hours, a medication administration observation was conducted with LVN 2 for Resident 78. LVN 2 was observed preparing the following medications: - one tablet of carvedilol (antihypertensive) 25 mg; -one tablet of doxazosin (antihypertensive) 8 mg; - one tablet of Eliquis (anticoagulant) 5 mg; - one tablet of furosemide (diuretic) 40 mg; - one tablet of hydralazine (antihypertensive) 25 mg; - one tablet of multi-vitamin (supplement); - two tablets of senna (laxative) 8.6 mg; - two tablets of Klor-Con (to treat low potassium) 20 meq; - 30 ml of Milk of Magnesia (relieve constipation); and - bottle of dorzolamide-timolol (prescription eyedrop to lower high eye pressure) one drop to left eye. LVN 2 was observed performing hand hygiene, donning a pair of gloves and administering Resident 78's oral medications. LVN 4 knocked on the door and asked LVN 2 for the key to Medication Cart 1. After administering Resident 78's oral medications, LVN 2 removed his gloves and gave the key to Medication Cart 1 to LVN 4. LVN 2 then donned a pair of gloves and while LVN 2 was explaining the eyedrop to Resident 78, LVN 4 gave the keys for Medication Cart 1 back to LVN 2 and LVN 2 was observed putting the keys in his pocket. LVN 2 was then observed administering the eye drop to Resident 78 left eye. However, LVN 2 was not observed performing hand hygiene. On 1/21/26 at 1236 hours, an interview was conducted with LVN 2. LVN 2 verified he did not perform hand hygiene prior to administering the eyedrop to Resident 78 and after LVN 4 gave back keys for Medication Cart 1. On 1/22/26 at 1318 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for two of three final sampled residents (Residents 72 and 75) reviewed for side rails use. * The facility failed to ensure the entrapment assessment of bed rails were completed for Residents 72 and 75. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is potential for entrapment are:- Zone 1: within the rail;- Zone 2: under the rail, between the rail supports or next to a single rail support;- Zone 3: between the rail and the mattress;- Zone 4: under the rail, at the ends of the rail;- Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and- Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Rails - Safe Use Policy revised 10/2025 showed bed rails will be installed, secured, and maintained according to manufacturer instructions and the facility shall assess spaces for unsafe gaps between mattress and bed rails and bed system components to reduce entrapment risks in consideration of resident's size, weight, and behavioral patterns. 1. On 1/20/26 at 1148 hours, during the initial tour of the facility, Resident 72 was observed awake and lying in bed with the right upper bed rail elevated. Resident 72 stated he used the bed rail to grab when he was being turned or cleaned. On 1/20/26 at 1210 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 72 was dependent on mobility and verified the resident's use of the right upper bed rail while in bed since the resident was admitted to the facility. CNA 3 stated Resident 72 was able to grab the rail during repositioning and cleaning. Medical record review for Resident 72 was initiated on 1/20/26. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72's Order Summary Report showed a physician's order dated 1/9/26, for the use of bilateral assist handrail for bed mobility and repositioning and transfers, and with a discontinued date of 1/19/26. Review of Resident 72's Side Rails Screening Tool V.2 dated 1/9/26, under Section III. Alternative Measures showed the bilateral assist handles were recommended at this time. Review of Resident 72's MDS assessment dated [DATE], showed Resident 72 had moderate cognitive impairment and was dependent on mobility. Review of the facility's Bed System Measurement Device Test Results Worksheet Log for January 2026 did not show evidence the entrapment assessment for Resident 72 was completed prior to the use of bed rails. On 1/20/26 at 1400 hours, an observation was conducted for Resident 72. Resident 72 was sleeping in bed with the right upper bed rail elevated. 2. On 1/20/26 at 1307 hours, during the initial tour of the facility, Resident 75 was observed awake and lying in bed with the bilateral upper bed rails elevated. Resident 75 stated he could help with turning in bed and used the bed rails to hold on to. Medical record review for Resident 75 was initiated on 1/20/26. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's Order Summary Report showed a physician's order dated 1/12/26, for the use of bilateral assist handrail for bed mobility and repositioning and transfers. Review of Resident 75's Side Rails Screening Tool V.2 dated 1/12/26, under Section III. Alternative Measures showed bilateral assist handles were recommended at this time. Review of Resident 75's MDS assessment dated [DATE], showed Resident 75 had moderate cognitive impairment and needed partial or moderate assistance with mobility. On 1/21/26 at 0907 hours, an observation was conducted for Resident 75. Resident 75 was awake and lying in bed with the bilateral upper bed rails elevated. On 1/22/26 at 1113 hours, an interview was conducted with CNA 5 for Resident 75. CNA 5 stated Resident 75 could turn and get out of bed with supervision. CNA 5 stated Resident 75 used the bilateral upper bed rails to grab during repositioning and transferring. On 1/22/26 at 1142 hours, an interview and concurrent medical record review was conducted with LVN 2 for Residents 72 and 75. LVN 2 stated Resident 72 had the right upper bed rail which the resident used during repositioning. LVN 2 stated Resident 75 used the bilateral upper bed rails during repositioning, transferring and when getting out of bed. LVN 2 stated the use of the bed rails was determined by the physical therapist's evaluation. LVN 2 stated the use of the bed rails could cause entrapment and injuries to the residents. LVN 2 stated he was not familiar with the different zones of entrapment of the bed and measurement. LVN 2 stated the maintenance department was responsible for the bed rail installation but he did not know how the department was notified. On 1/22/26 at 1308 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated the physical therapist determined the resident's need of the use of bed rail(s) and would install it since the bed rails were kept at the resident's room. The Maintenance Director stated the maintenance department then would be notified by the medical records department to inspect the installation of the bed rail(s). The Maintenance Director stated he would complete the entrapment assessment by measuring the bed Zones 1, 2, 3, and 4, and would check the fitment and locking. The Maintenance Director further stated he did weekly check for the bed rails. Reviewed the facility's Bed System Measurement Device Test Results Worksheet Log for January 2026 with the Maintenance Director and the Maintenance Director verified the log did not show evidence the entrapment assessment for Residents 72 and 75 were completed prior to the use of bed rails. On 1/22/26 at 1355 hours, an interview was conducted with the DON. The DON stated if the entrapment assessment was not completed for those residents with the bed rails, then the residents had high risk for injury, like strangulation. The DON was informed and acknowledged the above findings for Residents 72 and 75.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing and safe temperatures. * The food temperatures were above the recommended temperature for cold desserts. This failure posed the risk of not providing safe food for the residents receiving a meal tray from the kitchen.Findings: Review of the facility's Diet Type Report dated 1/20/26, showed 42 of 42 residents consumed the food prepared in the kitchen. According to the USDA Food Code 2022 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degrees Celsius to 57 degrees Celsius (41 degrees Fahrenheit to 135 degrees Fahrenheit) too long. Maintaining temperature controlled foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness. Review of the facility's P&P titled Food Preparation and Service revised date 10/2017 showed the danger zone for food temperatures is between 41 degrees Fahrenheit to 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses. On 1/21/26 at 1220 hours, a tray line observation and concurrent interview was conducted with the Food Service Director, Regional RD Consultant, and Dietary Aides 1 and 2. Dietary Aide 1 checked and verified the following temperatures for the following:- first plate of banana pie was 63 degrees Fahrenheit- second plate of banana pie was 54.8 degrees Fahrenheit Dietary Aides 1 and 2 stated the banana pie desserts were transferred to the satellite kitchen from the main kitchen around 1200 hours. The Food Service Director and the Regional RD Consultant stated the banana pie dessert was not holding the cold temperature of below 41 degrees Fahrenheit. The Food Service Director and the Regional RD Consultant acknowledged the dessert temperatures varying from 54.8 to 63 degrees Fahrenheit were above the recommended temperatures for cold food.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one non-sampled resident (Resident 68) was assessed, had a care plan and a physician's order to self-administer the medications. * Resident 68's bedside table had Neosporin (antibiotic medication) ointment. There were no assessment, care plan or physician's order to self-administer this medication. This failure had the potential for the resident to administer the medication inaccurately and negatively impact the residents' physiological well-being. Findings: Review of the facility's P&P titled Self-Administration of Medication revised 12/2016 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.- As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.- Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. During the initial tour of the facility on 1/20/26 at 0833 hours, an observation and concurrent interview was conducted with Resident 68. Resident 68 was sitting on his wheelchair. There was a tube of Neosporin ointment on the resident's bedside table. Resident 68 stated he asked his son to bring the Neosporin ointment for him to apply to his skin tear. Medical record review for Resident 68 was initiated on 1/20/26. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's MDS admission assessment dated [DATE], showed a BIMS score of 12 indicating the resident was cognitively impaired. Review of Resident 68's medical record failed to show documented evidence of the following for Resident 68 to safely self-administer the medication:- a physician's order for Neosporin ointment;- an assessment to self-administer the medications; and- a care plan addressing Resident 68's self- administration of the medication. On 1/20/26 at 0930 hours, an interview and concurrent medical record review for Resident 68 was conducted with LVN 2. LVN 2 verified the Neosporin ointment was on the resident's bedside table. LVN 2 verified Resident 68 did not have an assessment, physician's order or care plan developed to self-administer the medication. LVN 2 stated it was not safe for the resident to keep the medications at bedside. On 1/22/26 at 0948 hours, an interview and concurrent medical record review for Resident 68 was conducted with the DON. The DON verified Resident 68 did not have an assessment, physician's order or care plan developed to self-administer the Neosporin medication. On 1/22/26 at 1318 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a resident-centered care plans to reflect the individual care needs for two of 12 final sampled residents (Residents 67 and 72). * The facility failed to develop a comprehensive person-centered care plan to address Resident 67's right upper arm midline catheter and the administration of Dextrose - NaCl solution 5-0.45% (an IV fluid used for hydration and electrolyte replenishment). * The facility failed to develop a comprehensive person-centered care plan to address Resident 72's use of siderails. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.Findings: Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan would include the following:-include measurable objectives and timeframes;-describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. On 1/20/26 at 0827 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 67 was conducted with LVN 1. Resident 67 was lying in bed with a midline catheter to the right upper arm. A one-liter bag of Dextrose – NaCl solution 5-0.45% was hanging and connected to Resident 67's right upper arm midline catheter via IV tubing. The Dextrose solution was infusing at 100 ml/hr. LVN 1 stated Resident 67's right upper arm midline catheter was used for his antibiotic and IV fluids. Medical record review for Resident 67 was initiated on 1/20/26. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's MDS assessment dated [DATE], showed Resident 67 had a BIMS score of 9 indicating the resident was moderately impaired. Review of Resident 67's Order Summary Report showed the following physician's orders:- dated 1/7/26, to change the catheter site dressing every Wednesday; and- dated 1/19/26, to administer Dextrose – NaCl solution 5-0.45% at 100 ml/hr intravenously for poor meal intake times 5 liters. Review of Resident 67's care plans failed to show an individualized care plan was developed to address the resident's right upper arm midline catheter and Dextrose – NaCl solution 5-0.45% administration. On 1/22/26 at 0902 hours, an interview and concurrent medical record review for Resident 67 was conducted with the DON. The DON verified there was no care plan developed to address the resident's right upper arm midline catheter and Dextrose – NaCl solution 5-0.45% administration. On 1/22/26 at 1318 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. (Cross reference to F694) 2. Review of the facility's P&P titled Bed Rails – Safe Use Policy revised 10/2025 showed bed rail use and safety provisions shall be included in resident's care plan. During the initial tour of the facility on 1/20/26 at 1148 hours, Resident 72 was awake and lying in bed with the right upper bed rail elevated. Resident 72 stated he would use the bed rail to grab on when he was being turned or cleaned. On 1/20/26 at 1210 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 72 was dependent on mobility and verified the resident's use of the right upper bed rail while in bed since the resident was admitted to the facility. CNA 3 stated Resident 72 was able to grab the rail during repositioning and cleaning. Medical record review for Resident 72 was initiated on 1/20/26. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72's MDS assessment dated [DATE], showed Resident 72 had moderate cognitive impairment and was dependent on mobility. Further review of Resident 72's medical record failed to show a plan of care was formulated or initiated to address the use of right upper bed rail for the resident. On 1/20/26 at 1400 hours, a follow-up observation was conducted with Resident 72. Resident 72 was observed sleeping in bed with the right upper bed rail elevated. On 1/22/26 at 1142 hours, an interview and concurrent medical record review for Resident 72 was conducted with LVN 2. LVN 2 stated Resident 72 had the right upper bed rail which the resident used for grabbing when being repositioned. LVN 2 stated the use of bed rails was determined by the physical therapist's evaluation. LVN 2 stated the use of bed rails could cause entrapment & injuries. LVN 2 stated a care plan for the use of bed rail should have been initiated to establish a plan for care and formulate interventions to avoid injuries caused by using bed rail since it could cause entrapment and risk for fall. On 1/22/26 at 1355 hours, an interview and concurrent medical record review for Resident 72 was conducted with the DON. The DON verified the above findings and acknowledged there was no plan of care formulated for the use of right upper bed rail for Resident 72. Cross reference to F700 and F909, example #1.

Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of 12 final sampled residents (Resident 64).* Resident 64's care plan for alteration in functional mobility and presence of pain related to nondisplaced type III odontoid (neck bone) fracture was not revised to address the use of the neck collar brace as ordered by the physician. This posed the risk of not providing the resident with individualized and person-centered care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated 12/2016 showed the areas of concern are identified during the resident assessment will be evaluated before the interventions are added to the care plan. Interventions are chosen only after careful data gathering, proper sequencing of events, careful considerations of the relationship between the resident's problem areas and their causes, and relevant decision making. The Interdisciplinary team must review and update the care plan. On 1/20/26 at 0926 hours, an observation and concurrent interview was conducted with Resident 64. Resident 64 was observed in bed, alert and verbally responsive wearing a neck collar brace. Resident 64 stated he fell and broke a bone in his neck. Resident 64 stated he needed to wear the neck collar brace at all times except when he showered. Resident 64 stated he had pain in the neck and the pain medication help him a lot. Medical record review for Resident 64 was initiated on 1/21/26. Resident 64 was admitted to the facility on [DATE] with diagnosis of non-displaced fracture. Review of Resident 64's Order Summary Report for January 2026 showed the following physician's orders:- dated 1/8/26, to wear a C collar on for 6 weeks, may remove when showering only every shift;- dated 1/8/26, to monitor for placement of the neck brace every shift. Review of Resident 64's care plan for alteration in functional mobility and presence of pain related to fracture dated 1/7/26, showed the interventions including to administer the prescribed medication for pain, gentle handling of the resident during care, and support fractured site during turning and repositioning. However, the wearing and monitoring of the neck collar brace as ordered by the physician for Resident 64 were not included in the interventions. Review of Resident 64's medical record failed to show the neck collar brace was monitored per the physician's order. On 1/21/26 at 1128 hours, an interview and concurrent medical record review for Resident 64 was conducted with LVN 1. LVN 1 stated Resident 64 was admitted to the facility with a neck collar brace with a physician's order. LVN 1 verified the above findings and stated the care plan should have been revised to reflect Resident 64's most current plan of care. On 1/22/26 at 0948 hours, an interview and concurrent medical record review for Resident 64 was conducted with the DON. The DON stated she expected the plan of care should be comprehensive based on physician's order and the interdisciplinary team input in developing the care plan. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Residents 67) reviewed for IV care. * The facility failed to ensure Resident 67's parenteral fluids were administered in accordance with the physician's order, and the right upper arm midline catheter was changed as per the facility's P&P. These failures had the potential for Resident 67 to not maintain adequate hydration and/or electrolyte levels and delay the identification of catheter related complications.Findings: Review of the facility's P&P titled Midline Catheter Dressing Change dated 3/2023 showed the catheter dressing changes are to be performed by RNs and IV certified LVNs according to state law and facility policy. Dressing changes using transparent dressings are performed at least weekly. On 1/20/26 at 0827 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 67 was conducted with LVN 1. Resident 67 was observed lying in bed with a midline catheter on the right upper arm with a dressing dated 1/7/26. A one-liter bag of Dextrose - NaCl solution 5-0.45% (an IV fluid used for hydration and electrolyte replenishment) was hanging and connected to Resident 67's right upper arm midline catheter via an IV tubing. The Dextrose solution was infusing at 100 ml/hr. LVN 1 stated Resident 67's right upper arm midline catheter was used for his antibiotic and IV fluids. Medical record review for Resident 67 was initiated on 1/20/26. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's MDS assessment dated [DATE], showed Resident 67 had a BIMS score of 9 indicating the resident's cognition was moderately impaired. Review of Resident 67's Order Summary Report showed the following physician's orders:- dated 1/7/26, to change the catheter site dressing every Wednesday; and- dated 1/19/26, to administer Dextrose - NaCl solution 5-0.45% at 100 ml/hr intravenously for poor meal intake for 5 liters. On 1/20/26 at 1536 hours, an observation, interview and concurrent medical record review for Resident 67 was conducted with RN 1. RN 1 verified there was approximately 400 ml of Dextrose - NaCl solution 5-0.45% solution remaining in the one-liter bag (600 ml was infused). RN 1 stated Dextrose - NaCl solution 5-0.45% solution was supposed to be infused at 100 ml per hour. RN 1 verified the Dextrose - NaCl solution 5-0.45% infusion was started on 1/20/26 at 0700 hours (8 hours had lapsed since the IV bag was hung). RN 1 acknowledged 800 ml of the Dextrose - NaCl solution 5-0.45% should have been infused since the time the bag was hung, but only 600 ml was infused. RN 1 verified there was no documentation or physician's order to hold the Dextrose - NaCl solution 5-0.45% infusion. RN 1 further verified the right upper arm midline dressing was dated 1/7/26 and should have been changed. On 1/22/26 at 1318 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. (Cross reference to F656)

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the monitoring of output and fluid restriction were followed for two of two final sampled residents (Residents 71 and 72) reviewed for dialysis. * The facility failed to ensure the output was properly monitored for Resident 71. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 72. These failures had the potential of not identifying potential negative outcomes for the dialysis residents.Findings: Review of the facility's P&P titled Intake, Measuring and Recording revised 10/2010 showed the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. If the resident is medically capable of understanding the procedure, ask him or her to assist you in telling you when he or she drank some fluid and how much he or she drank. Record the fluid intake as soon as possible after the resident has consumed the fluids. At the end of the shift, total the amounts of all liquids the resident consumed. Record the amount noted on the intake side of the intake and output record. Record the time the intake was measured. Review of the facility's P&P titled Output, Measuring and Recording revised 10/2010 showed the purpose of this procedure to accurately determine the amount of urine that a resident excretes in a 24-hour period. Be sure that the intake and output record is available. Record the time the output was measured. Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Be sure an intake and output record is maintained in the resident's room. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid intake in mls. 1. On 1/21/26 at 0830 hours, an observation and concurrent interview was conducted with Resident 71. Resident 71 stated he had hemodialysis every Tuesday, Thursday, and Saturday. Resident 71 stated he was still producing urine and would use the restroom to void. Resident 71 stated he did not think his urine was being measured. Resident 71 further stated no one had informed him about his urine output needed to be measured. Medical record review for Resident 71 was initiated on 1/22/26. Resident 71 was admitted to the facility on [DATE]. Review of Resident 71's MDS assessment dated [DATE], showed Resident 71 was cognitively intact. Review of Resident 71's plan of care revised on 1/20/26, showed a care plan problem addressing Resident 71's risk for dehydration or potential fluid deficit related to IV fluids received in acute hospital, acute kidney injury on hemodialysis, and variable oral intake. The interventions included monitoring the intake and output. Review of Resident 71's Task: B&B - Bladder Elimination for January 2026 showed only a check mark for continent. Further review of Resident 71's medical record failed to show the urine output was properly monitored. On 1/22/26 at 0931 hours, an interview and concurrent medical record review for Resident 71 was conducted with LVN 1. LVN 1 verified Resident 71 was receiving dialysis. LVN 1 stated Resident 71 still voided and independent with bladder and bowel elimination. LVN 1 stated when the resident had an order for monitoring of the intake and output, they would provide the resident with graduated cup with measurements in order for them to be able to measure exactly how much the resident's intake was. LVN 1 stated for the output, they would just ask the resident how many times the resident voided for the shift. LVN 1 stated for the residents who had renal failure or on dialysis, measuring the intake and output should be more accurate by measuring the exact amount to determine if the resident was retaining fluid, and this could assist them in reporting immediately to the physician as well as the dialysis center for any changes in the condition of the residents. LVN 1 verified the output was not being measured properly by not accurately measuring the exact amount of the urine output for Resident 71. 2. During the initial tour of the facility on 1/20/26 at 1148 hours, Resident 72 was observed awake and lying in bed. Resident 72 stated he had dialysis every Monday, Wednesday, and Friday. Resident 72 stated he was drinking water and juice but not a lot although he liked coffee. Medical record review for Resident 72 was initiated on 1/20/26. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72's MDS assessment dated [DATE], showed Resident 72 had moderate cognitive impairment Review of Resident 72's Order Summary Report showed a physician's order dated 1/15/26, for fluid restriction of 1500 ml/24 hours as follows:* Nursing to provide 540 ml of fluid: - 200 ml for the AM shift - 200 ml for the PM shift - 140 ml for the NOC shift* Dietary to provide 960 ml of fluid: - 360 ml at breakfast - 360 ml at lunch - 240 ml at dinner Review of Resident 72's MAR for January 2026 showed the fluid restriction record for nursing to provide 540 ml of fluids for 24 hours. The MAR showed:- on 1/15/26 for the NOC shift, the recorded fluid intake was 400 ml;- on 1/16/26 for the NOC shift, the recorded fluid intake was 300 ml;- on 1/18/26 for the NOC shift, the recorded fluid intake was 200 ml; and- on 1/19/26 for the PM shift, the recorded fluid intake was 400 ml. Further review of Resident 72's medical record failed to show documented evidence of the fluid intake from the dietary to provide 960 ml of fluids in 24 hours. On 1/22/26 at 1000 hours, an interview for Resident 72 was conducted with CNA 4. CNA 4 verified Resident 72 had dialysis and a fluid restriction. CNA 4 stated she measured the amount of fluid intake of Resident 72 by the cup they used for hot drinks. CNA 4 stated the cup was approximately 250 ml and she would give a pitcher of water to the resident which was approximately 500 ml. CNA 4 stated she would ask Resident 72 how many cups of fluid he had for breakfast and lunch then she would record it in the CNA's task for nutrition-fluids. On 1/22/26 at 1015 hours, an interview and concurrent medical record review for Resident 72 was conducted with LVN 2. LVN 2 verified Resident 72 was a dialysis resident and on fluid restriction of 1500 ml per day as per the physician's order. LVN 2 stated when documenting the fluid intake of the resident in the MAR, he would refer to the CNA's nutrition-fluids record and add the amount of fluids he provided if he did. LVN 2 was asked about the documentation of fluid intake coming from the dietary. LVN 2 verified and acknowledged there was no fluid intake recorded from the dietary. In addition, LVN 2 verified Resident 72 received more than the fluid restriction as per the physician's order on 1/15, 1/16, 1/18, and 1/19/26. On 1/22/26 at 1355 hours, an interview and concurrent medical record review for Residents 71 and 72 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 72) reviewed for the use of bed rails remained free from accident hazards associated with the use of elevated bed rails. * The facility failed to ensure the physician's order was obtained for the use of the right upper bed rail for Resident 72. In addition, an IDT assessment was not conducted prior to the use of the right upper bed rail. This failure had the potential to put the resident at risk for serious injuries.Findings: Review of the facility's P&P titled Bed Rails - Safe Use Policy revised 10/2025 showed the following:- when bed rail use is desired/considered, Resident's sleeping environment shall be assessed by the Interdisciplinary Team, considering safety needs, entrapment risks, medical conditions/symptoms, cognitive/behavioral status, functional needs, comfort, freedom of movement, and input from the resident and family regarding previous sleeping habits and bed environment; and- when bed rails are indicated for use, physician will be consulted to establish concurrence/orders. On 1/20/26 at 1148 hours, during the initial tour of the facility, Resident 72 was awake and lying in bed with the right upper bed rail elevated. Resident 72 stated he used the bed rail to grab when he was being turned or cleaned. On 1/20/26 at 1210 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 72 was dependent on mobility and verified the resident's use of the right upper bed rail while in bed since the resident was admitted to the facility. CNA 3 stated Resident 72 was able to grab the rail during repositioning and cleaning. Medical record review for Resident 72 was initiated on 1/20/26. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72's Side Rails Screening Tool V.2 dated 1/9/26, under Section VII. Interdisciplinary Team Recommendation showed the IDT believed that the use of a bilateral assist rail will further enhance the resident's ability to participate in the completion of his activities of daily living (repositioning, transfers and bed mobility). The use of the rail did not limit the resident's freedom of movement. Review of Resident 72's Order Summary Report showed a physician's order dated 1/9/26, for the use of bilateral assist handrail for bed mobility and repositioning and transfers, and with a discontinued date of 1/19/26. Review of Resident 72's MDS assessment dated [DATE], showed Resident 72 had moderate cognitive impairment and was dependent on mobility. Review of Resident 72's medical record failed to show a physician's order was obtained for the use of the right upper bed rail and if an IDT assessment was conducted prior to the use of the right upper bed rail. On 1/20/26 at 1400 hours, an observation was conducted of Resident 72. Resident 72 was sleeping in bed with the right upper bed rail elevated. On 1/22/26 at 1142 hours, an interview and concurrent medical record review for Resident 72 was conducted with LVN 2. LVN 2 stated Resident 72 had the right upper bed rail which the resident used for grabbing when being repositioned. LVN 2 stated the use of bed rails was determined by the physical therapist's evaluation. LVN 2 stated prior to the use of the bed rails, a physician's order should be obtained, an informed consent should be obtained, and an assessment using the Side Rails Screening Tool should be completed. LVN 2 stated the screening was done by the IDT. LVN 2 verified there was no physician's order obtained, and no IDT assessment was conducted for the use of right upper bed rail for Resident 72. On 1/22/26 at 1355 hours, an interview and concurrent medical record review for Resident 72 was conducted with the DON. The DON stated Resident 72's bed rails were discontinued on 1/19/26. The DON was informed that during the initial tour of the facility on 1/20/26, Resident 72 was observed with the right upper bed rail and the resident verbalized he used the bed rail during repositioning and cleaning. Furthermore, the DON was informed the facility's staff verified the use of Resident 72's right upper bed rail. The DON acknowledged the above findings for Resident 72. Cross reference to F656 and F909, example #1.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the active involvement of required individuals in developing the Facility Assessment and resources necessary to care for residents including weekends. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's assessment dated [DATE], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment and the resources necessary to care for the residents including weekends. On 1/22/26 at 1003 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with Administrator. The Administrator verified the Facility Assessment was dated 9/25/25, and acknowledged he was not aware of the new update of the Facility Assessment from the CMS. The Administrator verified there were no direct care representatives, residents, resident representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no resources necessary to care for the residents including weekends and emergencies. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest guidance from the CMS.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory services for two of two final sampled residents (Residents 12 and 63) reviewed for respiratory care. * The facility failed to ensure Resident 12's nasal cannula tubing was changed as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use. * The facility failed to ensure Resident 63's nebulizer tubing and mask were changed every week as per the facility's P&P. These failures posed the risk of complications and negative health outcomes to Resident 12 and 63.Findings: 1. Review of the facility's P&P titled Respiratory Therapy – Prevention of Infection dated 11/15/23, showed the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Change the oxygen cannula and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing used as needed in a bag when not in use. On 1/20/26 at 0909 hours, an observation of Resident 12 and concurrent interview was conducted with the DON. Resident 12 was sitting in her bed with an oxygen concentrator and the nasal canula tubing was in Resident 12's nostrils. There was another portable oxygen concentrator was observed by Resident 12's bedside table with an oxygen tubing dated 12/13/25, hanging on the portable oxygen concentrator. Resident 12 stated that she used the portable oxygen concentrator when she goes out. The DON verified Resident 12's nasal canula tubing was dated 12/13/25 and was not stored inside the bag. The DON further stated the nasal cannula tubing needed to be inside a bag to prevent dirt and dust contaminating the tubing. Medical record review for Resident 12 was initiated on 1/20/26. Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed the following physician's orders: - dated 1/27/24, to change oxygen cannula tubing every Saturday and as needed for soilage; and - dated 8/19/25, for oxygen at a rate of 4-6 LPM via nasal canula cannula continuously for COPD (chronic obstructive pulmonary disease - a progressive lung disease which blocks air flow making breathing difficult). On 1/22/26 at 1318 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P tilted Respiratory Therapy - Prevention of Infection dated 11/15/23, showed to store the nebulizer administration set up in plastic bag, marked with date and resident's name and to change the set up every seven days. During the initial tour of the facility on 1/20/26 at 0922 hours, Resident 63 was observed on her wheelchair and watching on her television set. Resident 63's nebulizer machine was observed on top of the bedside drawer, and the mask and tubing were placed on a clear plastic bag dated 1/3/26. Medical record review for Resident 63 was initiated on 1/20/26. Resident 63 was admitted to the facility on [DATE]. Review of Resident 63's Order Summary Report showed a physician's order dated 12/23/25, to administer albuterol sulfate (breathing treatment) nebulization solution (2.5 mg/3ml) 0.083% 3 ml inhale orally via nebulizer every four hours as needed for shortness of breath or wheezing. On 1/20/2026 at 1224 hours, an observation and concurrent interview was conducted with LVN 3 at Resident 63's bedside. LVN 3 verified Resident 63 had an order for nebulizer machine use. LVN 3 was asked for the clear plastic bag label where the nebulizer tubing and mask were stored. LVN 3 verified the plastic bag storage was labeled of date 1/3/26. LVN 3 stated the night shift nurses were usually the one responsible for changing the oxygen tubing including the nebulizer tubing and the mask once a week on Saturdays. LVN 3 verified the clear plastic bag was not changed every week and it was last changed more than two weeks ago. On 1/22/2026 at 0952 hours, an interview and concurrent medical record review for Resident 63 was conducted with the DON. The DON was informed and stated she expected the oxygen tubing including the nebulizer mask and tubing to be changed every week or as needed as per the facility's protocol. The DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 12 final sampled residents (Resident 62). * The facility failed to ensure the call light for Residents 62 was within the residents' reach. This failure had the potential to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 10/2025 showed the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Staff should facilitate call light placement within reach of resident and secure it as needed. Call system should be accessible to Residents while in bed or other sleeping accommodations in room. During the initial tour of the facility on 1/20/26 at 0912 hours, Resident 62 was in bed, awake, and covered with a blanket. Resident 62 did not answer when asked if she knew how to call the nurse. The call light button was observed clipped and the cable was hanging on the wall. The call light was out of Resident 62's reach. On 1/20/26 at 1034 hours, a follow-up observation of Resident 62 and concurrent interview was conducted with CNA 1 at Resident 62's bedside. CNA 1 verified the call light button was clipped and the cable was hanging on the wall, out of Resident 62's reach. Medical record review for Resident 62 was initiated on 1/20/26. Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's Face Sheet dated 1/9/26, showed the resident was self-responsible for her care. On 1/22/26 at 0956 hours, an interview was conducted with the DON. The DON stated she expected the residents' call lights to be placed always near the residents so they could call for help right away if they needed assistance. The DON was informed and verified the above findings.

Based on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. * One of four dumpsters was overflowing with garbage which prevented the lid to be fully closed. This failure posed the risk for the development of odors, attract and harborage or breeding place of insects and rodents, and a possible source of contamination of food, equipment, and utensils.Findings: According to the USDA Food Code 2022, 5-501.113, Covering Receptacles, showed receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: Inside the food establishment if the receptacles and units contain food residue and are not in continuous use; or after they are filled; and with tight-fitting lids or doors if kept outside the food establishment. Review of the facility's P&P titled Food-Related Garbage and Refuse Disposal revised 10/2017 under the Policy Interpretation and Implementation section, showed all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use, garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests, and outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 1/20/26 at 1430 hours, an observation of the trash disposal and concurrent interview was conducted with the Maintenance Director. One of the four dumpsters was overfilled with trash, preventing the lid from being closed. The Maintenance Director stated he always reminded the facility staff who deal with the garbage/dumpsters to make sure the lids were completely closed to prevent harboring of rodents or pests. The Maintenance Director verified and acknowledged the above findings. On 1/22/26 at 1355 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to notify the physician when the resident had a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify the physician when Resident 1 had low blood pressure readings. This had the potential for a delay in the physician prescribing necessary treatments and interventions for the resident.Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician of the facility's Medical Director to discuss the concerns. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 showed our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Medical record review for Resident 1 was initiated on 10/15/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/31/24, showed Resident 1 had a capacity. Review of Resident 1's MAR for June 2024 showed a physician's order dated 5/31/24, for Benazepril HCL (medication to lower high blood pressure) oral tablet 10 mg, give one tablet by mouth one time a day for high blood pressure, to hold if the SBP is less than 110 mmHg. The MAR showed the following dates and blood pressure readings: - dated 6/3/24, 100/60 mmHg;- dated 6/4/24, 106/62 mmHg;- dated 6/6/24, 104/63 mmHg;- dated 6/7/24, 102/60 mmHg;- dated 6/8/24, 104/60 mmHg;- dated 6/9/24, 107/64 mmHg;- dated 6/10/24, 109/68 mmHg;- dated 6/12/24, 100/57 mmHg;- dated 6/13/24, 105/56 mmHg;- dated 6/14/24, 108/56 mmHg; and- dated 6/15/24, 100/60 mmHg. Review of Resident 1's Physical Therapy Treatment Encounter Note dated 6/15/24 at 0724 hours, showed Resident 1's blood pressure was obtained on lying, sitting, and standing positions. Resident 1's blood pressure readings were as follows:- supine position and the BP was 91/62 mmHg;- sitting position and the BP was 83/57 mmHg; and- standing position and the BP was 106/64 mmHg. Further review of Resident 1's medical record failed to show a change of condition was initiated when Resident 1's blood pressures were low. In addition, there was no documented evidence to show if Resident 1's physician was made aware. On 10/15/25 at 1333 hours, an interview and concurrent record review were conducted with PT 1. PT 1 verified the PT note dated 6/15/24, showed Resident 1 had low blood pressure readings. PT 1 acknowledged Resident 1's physician should have been made aware of Resident 1's low blood pressures readings. On 10/15/25 at 1411 hours, an interview and concurrent record review was conducted with the DON. The DON reviewed Resident 1's MAR for June 2024 and verified Resident 1 had multiple systolic blood pressures below 110 mmHg. The DON reviewed the PT note dated 6/15/25, and verified Resident 1's low blood pressures readings. The DON stated that when the blood pressure medication was held consecutively for three days in a row, the physician needed to be notified. The DON verified there was no documentation to show the change of condition and physician notification when Resident 1 had abnormal blood pressures.

Intakes: CA00872022 Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residen (Resident 1) remained free from accident hazards. * Resident 1 sustained 6 falls while having resided in the facility. Resident 1 sustained the falls on 9/15 (twice), 9/21, 9/26, 10/11, and 10/24/23. After Resident 1 ' s fourth fall in the facility, the facility ' s IDT recommended and implemented the 1 to 1 staff supervision on Resident 1. However, the 1 to 1 supervision was not always provided to Resident 1. As a result, Resident 1 sustained another fall on 10/24/23, resulting in multiple fractured ribs which required the ORIF surgery for Resident 1 ' s right seventh through 10thribs. Findings: Review of the facility ' s P&P titled Falls Management Program revised 1/2019 showed the purpose of the fall management program is to provide residents with a hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. The facility will provide residents with adequate supervision to prevent accidents. It is also the policy of the facility to investigate the circumstances surrounding the resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The Interdisciplinary Team (IDT) will reassess the risk factors contributing to falls and (implement) interventions to minimize recurrence of falls and injury during the initial, quarterly, and annual assessment, post fall, and when a significant change of condition is identified. Review of the facility ' s P&P titled Safety and Supervision of Residents revised 7/2017 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision. Implementing interventions to reduce accident risks and hazards shall include the following: communication specific interventions to all relevant staff, assigning responsibility for carrying out interventions, and ensuring that interventions are implemented. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. Closed medical record review for Resident 1 was initiated on 12/4/23. Resident 1 was admitted to the facility on [DATE], and discharged on [DATE], to the acute care hospital. Review of Resident 1 ' s Baseline Admission Screening dated 8/25/23 at 2205 hours, showed Resident 1 was admitted to the facility with a diagnosis of status post right femur fracture and dementia. Review of Resident 1 ' s MDS dated [DATE], showed Resident 1 had severely impaired cognition. Resident 1 ' s Morse Fall Risk Screen dated 8/25/23, showed Resident 1 was ahigh risk for falls. Resident 1 ' s fall risk included a history of falls, impaired gait, and an overestimation of limits of abilities to ambulate safely. Review of Resident 1 ' s care plan titled Altered Thought Process initiated on 9/12/23, showed Resident 1 had a short-term memory problem, poor decision making, problems understanding others, and problems making her needs known. Review of Resident 1 ' s care plan titled High Risk for Falls and Injury related to the right femur fracture, difficulty walking, and multiple falls showed an intervention initiated 10/17/23, to instruct the resident ' s responsible party and visitors not to leave the resident unattended during the visits and call the staff ' s attention before ending the visitation. Review of Resident 1 ' s medical record showed Resident 1 had sustained 6 falls while residing in the facility. Documentation in Resident 1 ' s medical record showed Resident 1 fell on ,d+[DATE] (twice), 9/21, 9/26, 10/11, and 10/24/23. * Review of Resident 1 ' s SBAR dated 9/15/23 at 1740 hours, showed Resident 1 had an unwitnessed fall in her room. Resident 1 was found lying on her left side on the floor. Per Resident 1 ' s interview, she rolled out of bed onto the floor looking for her family member. Resident 1 complained of the pain level of 3 of 10 (on the 0-10 pain scale with 0 = no pain and 10 = worst pain) on her left forehead and right hip surgery site. * Review of Resident 1 ' s SBAR dated 9/15/23 at 2100 hours, showed Resident 1 had an unwitnessed fall. Resident 1 was found lying on the floor. Per Resident 1 ' s interview, she rolled out of her bed, looking for her family member. Resident 1 complained of pain on her right hip and was transferred to the acute care hospital. * Review of Resident 1 ' s IDT Note dated 9/18/23 at 1335 hours, showed the IDT had met and discussed Resident 1 ' s fall incident. The IDT ' s recommendations included to closely supervise the resident and put Resident 1 on the hourly checks. Resident 1 ' s family member was interviewed and stated Resident 1 had the same behaviors at home, trying to get out of bed unassisted. * Review of Resident 1 ' s SBAR dated 9/21/23 at 2011 hours, showed Resident 1 had an unwitnessed fall. Resident 1 stated she was trying to grab something; however, Resident 1 was unable to specifically identify what she had attempted to grab. * Review of Resident 1 ' s SBAR dated 9/26/23 at 1226 hours, showed Resident 1 sustained a fall. Resident 1 rolled out of her bed and landed on her knees. * Review of Resident 1 ' s IDT Note dated 9/27/23 at 1326 hours, showed the IDT had met and discussed Resident 1 ' s fall incident. The IDT recommended to continue with the PT/OT services, encourage Resident 1 to use the call light at all times, and provide 1:1 supervision. * Review of Resident 1 ' s SBAR dated 10/11/23 at 1330 hours, showed Resident 1 sustained a fall. The nurse immediately went into Resident 1 ' s room after receiving a report that Resident 1 was observed to be agitated. A nurse witnessed Resident 1 trying to crawl out of bed, however, too late to intervene, and Resident 1 fell on her knees onto the floor. Resident 1 was looking for her family member. Resident 1 observed with a right knee abrasion and having pain on her lower back and neck at the pain level of 6. * Review of Resident 1 ' s IDT Note dated 10/12/23 at 1401 hours, showed the IDT had met and discussed Resident 1 ' s fall incident. The IDT recommended to continue PT/OT services, encourage to use the call light at all times, and provide 1:1 supervision. * Review of Resident 1 ' s SBAR dated 10/24/23 at 2330 hours, showed Resident 1 sustained a fall. Facility staff heard a noise and immediately went to Resident 1 ' s room and found Resident 1 on the floor. Resident 1 ' s right trunk was leaning against the chair next to her bed. Resident 1 was interviewed and said she wanted to use the bathroom, and when she stood up, she lost her balance and fell , hitting her rib/chest on the chair handle. Resident 1 stated, ouch my rib, it hurts when I breath. Resident 1 was in extreme pain and was subsequently transferred to Acute Care Hospital 1. Review of the Acute Care Hospital 1 Hospitalist Discharge Summary dated 10/25/23 - 10/31/23, showed Resident 1 was admitted to Acute Care Hospital 1 on 10/25/23. Hospital course/significant findings showed Resident 1 had another mechanical fall at the skilled nursing facility, resulting in fractures of the right seventh through 10th ribs. Resident 1 subsequently underwent the ORIF surgery to treat her rib fractures. On 12/11/23 at 1500 hours, an interview was conducted with Resident 1 ' s DPOA for healthcare (Family Member 1). Family Member 1 stated LVN 1 contacted her and informed her Resident 1 sustained a fall at the facility on 10/24/23 at approximately 2330 hours. Family Member 1 stated she asked LVN 1 how Resident 1 fell , being Resident 1 was supposed to receive 1 to 1 supervision. Family Member 1 stated LVN 1 informed her that CNA 1 had left Resident 1 for a moment, at which time Resident 1 then fell . The interviews were conducted with the facility staff who observed Resident 1 after she fell on [DATE] at 2330 hours. On 12/5/23 at 1307 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 had fallen several times, and as a result of multiple falls at the facility, Resident 1 was provided with 1 to 1 staff supervision. The 1 to 1 staff was assigned to provide constant supervision of Resident 1, in order to prevent Resident 1 from sustaining another fall. LVN 1 stated at the time of Resident 1 ' s fall on 10/24/23 at 2330 hours, CNA 1 was assigned as Resident 1 ' s 1 to 1 staff. LVN 1 was asked to describe what he observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. LVN 1 stated at the time of Resident 1 ' s fall, CNA 1 (1 to 1 staff) had left Resident 1 ' s room and had gone to obtain a blanket. LVN 1 stated when CNA 1 left Resident 1 alone, Resident 1 sustained a fall. LVN 1 stated Resident 1 was to receive constant supervision, and Resident 1 should not have been left unsupervised. LVN 1 stated after Resident 1 had fallen, he entered Resident 1 ' s room. LVN 1 stated he saw Resident 1 hunched over a chair located next to her bed, and Resident 1 was clutching her right rib. LVN 1 stated Resident 1 was then transferred to the acute care hospital. On 12/5/23 at 1330 hours, an interview was conducted with RN 1. RN 1 stated she was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. RN 1 stated Resident 1 was assigned a 1 to 1 sitter at the time of her fall. RN 1 stated the 1 to 1 sitter was to provide constant supervision, always having Resident 1 within sight of the assigned 1 to 1 staff. RN 1 stated constant supervision was provided to Resident 1 due to Resident 1 having episodes of confusion, forgetfulness, and being a fall risk with multiple falls in the facility. RN 1 stated if staff was not with Resident 1, Resident 1 would try to get up from her bed. RN 1 was asked to describe what she observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. RN 1 stated at the time of Resident 1 ' s fall, CNA 1 (1 to 1 staff) left Resident 1 to obtain linens, at which time Resident 1 sustained a fall. RN 1 stated Resident 1 had tried to get up to use the bathroom and Resident 1 stated she fell and hit her ribs on the armchair in her room. Resident 1 complained of pain with breathing and was subsequently transferred to the acute care hospital. RN 1 stated CNA 1 should not have left Resident 1 unsupervised. On 12/5/23 1444 hours, an interview was conducted with CNA 1. CNA 1 stated he was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. CNA 1 stated he was assigned as Resident 1 ' s 1 to 1 staff. CNA 1 stated Resident 1 required constant supervision, and he was required to keep Resident 1 within his sight as Resident 1 was a fall risk and had the tendency to get up out of bed on her own without assistance. CNA 1 stated at the time of Resident 1 ' s fall, he was also assigned to care for other residents in addition to Resident 1. CNA 1 stated if he had to leave Resident 1 to provide care for other residents, CNA 1 would ensure another staff member would provide 1 to 1 observation of Resident 1 while he provided care to other residents. CNA 1 was asked to describe what had occurred on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. CNA 1 stated another resident had activated a call light, at which time CNA 1 left Resident 1. CNA 1 stated he went to the nursing station, to locate another staff member who could provide 1 to 1 supervision for Resident 1, as to allow CNA 1 to answer the call light. CNA 1 stated he went into the nursing station for approximately one minute at which time Resident 1 fell . CNA 1 stated he could not see Resident 1 from the nursing station at the time Resident 1 fell . On 12/5/23 at 1338 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she had attended Resident 1 ' s IDT meetings on 9/27/23 at 1326 hours, and 10/12/23 1401 hours. The DON verified the IDT recommended Resident 1 would be provided 1 to 1 supervision. The DON stated Resident 1 was to be provided constant visual 1 to 1 supervision by the facility staff. The DON stated 1 to 1 constant supervision was implemented due to Resident 1 ' s episodes of confusion, unsteady gait, and history of multiple falls at the facility. The DON stated Resident 1 ' s responsible party was also informed Resident 1 was to receive constant 1 to 1 supervision by the facility staff as per the IDT meetings on 9/27 and 10/23/23. The DON stated the facility had conducted an investigation specific to Resident 1 ' s fall sustained on 10/24/23 at 2330 hours. The DON stated CNA 1 should not have left Resident 1 unsupervised at the time of Resident 1 ' s fall. The DON stated her expectation was CNA 1 should have ensured another staff member was in place to provide constant supervision of Resident 1 before CNA 1 left Resident 1 and/or when Resident was no longer within CNA ' s sight. Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. * Resident 1 sustained 6 falls while having resided in the facility. Resident 1 sustained the falls on 9/15 (twice), 9/21, 9/26, 10/11, and 10/24/23. After Resident 1's fourth fall in the facility, the facility's IDT recommended and implemented the 1 to 1 staff supervision on Resident 1. However, the 1 to 1 supervision was not always provided to Resident 1. As a result, Resident 1 sustained another fall on 10/24/23, resulting in multiple fractured ribs which required the ORIF surgery for Resident 1's right seventh through 10thribs. Findings: Review of the facility's P&P titled Falls Management Program revised 1/2019 showed the purpose of the fall management program is to provide residents with a hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. The facility will provide residents with adequate supervision to prevent accidents. It is also the policy of the facility to investigate the circumstances surrounding the resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The Interdisciplinary Team (IDT) will reassess the risk factors contributing to falls and (implement) interventions to minimize recurrence of falls and injury during the initial, quarterly, and annual assessment, post fall, and when a significant change of condition is identified. Review of the facility's P&P titled Safety and Supervision of Residents revised 7/2017 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision. Implementing interventions to reduce accident risks and hazards shall include the following: communication specific interventions to all relevant staff, assigning responsibility for carrying out interventions, and ensuring that interventions are implemented. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Closedmedical record review for Resident 1 was initiated on 12/4/23. Resident 1 was admitted to the facility on [DATE], and discharged on [DATE], to the acute care hospital. Review of Resident 1's Baseline Admission Screening dated 8/25/23 at 2205 hours, showed Resident 1 was admitted to the facility with a diagnosis of status post right femur fracture and dementia. Review of Resident 1's MDS dated [DATE], showed Resident 1 had severely impaired cognition. Resident 1's Morse Fall Risk Screen dated 8/25/23, showed Resident 1 was ahigh risk for falls. Resident 1's fall risk included a history of falls, impaired gait, and an overestimation of limits of abilities to ambulate safely. Review of Resident 1's care plan titled Altered Thought Process initiated on 9/12/23, showed Resident 1 had a short-term memory problem, poor decision making, problems understanding others, and problems making her needs known. Review of Resident 1's care plan titled High Risk for Falls and Injury related to the right femur fracture, difficulty walking, and multiple falls showed an intervention initiated 10/17/23, to instruct the resident's responsible party and visitors not to leave the resident unattended during the visits and call the staff's attention before ending the visitation. Review of Resident 1's medical record showed Resident 1 had sustained 6 falls while residing in the facility. Documentation in Resident 1's medical record showed Resident 1 fell on ,d+[DATE] (twice), 9/21, 9/26, 10/11, and 10/24/23. * Review of Resident 1's SBAR dated 9/15/23 at 1740 hours, showed Resident 1 had an unwitnessed fall in her room. Resident 1 was found lying on her left side on the floor. Per Resident 1's interview, she rolled out of bed onto the floor looking for her family member. Resident 1 complained of the pain level of 3 of 10 (on the 0-10 pain scale with 0 = no pain and 10 = worst pain) on her left forehead and right hip surgery site. * Review of Resident 1's SBAR dated 9/15/23 at 2100 hours, showed Resident 1 had an unwitnessed fall. Resident 1 was found lying on the floor. Per Resident 1's interview, she rolled out of her bed, looking for her family member. Resident 1 complained of pain on her right hip and was transferred to the acute care hospital. * Review of Resident 1's IDT Note dated 9/18/23 at 1335 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT's recommendations included to closely supervise the resident and put Resident 1 on the hourly checks. Resident 1's family member was interviewed and stated Resident 1 had the same behaviors at home, trying to get out of bed unassisted. * Review of Resident 1's SBAR dated 9/21/23 at 2011 hours, showed Resident 1 had an unwitnessed fall. Resident 1 stated she was trying to grab something; however, Resident 1 was unable to specifically identify what she had attempted to grab. * Review of Resident 1's SBAR dated 9/26/23 at 1226 hours, showed Resident 1 sustained a fall. Resident 1 rolled out of her bed and landed on her knees. * Review of Resident 1's IDT Note dated 9/27/23 at 1326 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT recommended to continue with the PT/OT services, encourage Resident 1 to use the call light at all times, and provide 1:1 supervision. * Review of Resident 1's SBAR dated 10/11/23 at 1330 hours, showed Resident 1 sustained a fall. The nurse immediately went into Resident 1's room after receiving a report that Resident 1 was observed to be agitated. A nurse witnessed Resident 1 trying to crawl out of bed, however, too late to intervene, and Resident 1 fell on her knees onto the floor. Resident 1 was looking for her family member. Resident 1 observed with a right knee abrasion and having pain on her lower back and neck at the pain level of 6. * Review of Resident 1's IDT Note dated 10/12/23 at 1401 hours, showed the IDT had met and discussed Resident 1's fall incident. The IDT recommended to continue PT/OT services, encourageto use the call light at all times, and provide 1:1 supervision. * Review of Resident 1's SBAR dated 10/24/23 at 2330 hours, showed Resident 1 sustained a fall. Facility staff heard a noise and immediately went to Resident 1's room and found Resident 1 on the floor. Resident 1's right trunk was leaning against the chair next to her bed. Resident 1 was interviewed and said she wanted to use the bathroom, and when she stood up, she lost her balance and fell , hitting her rib/chest on the chair handle. Resident 1 stated, ouch my rib, it hurts when I breath. Resident 1 was in extreme pain and was subsequently transferred to Acute Care Hospital 1. Review of the Acute Care Hospital 1 Hospitalist Discharge Summary dated 10/25/23 - 10/31/23, showed Resident 1 was admitted to Acute Care Hospital 1 on 10/25/23. Hospital course/significant findings showed Resident 1 had another mechanical fall at the skilled nursing facility, resulting in fractures of the right seventh through 10th ribs. Resident 1 subsequently underwent the ORIF surgery to treat her rib fractures. On 12/11/23 at 1500 hours, an interview was conducted with Resident 1's DPOA for healthcare (Family Member 1). Family Member 1 stated LVN 1 contacted her and informed her Resident 1 sustained a fall at the facility on 10/24/23 at approximately 2330 hours. Family Member 1 stated she asked LVN 1 how Resident 1 fell , being Resident 1 was supposed to receive 1 to 1 supervision. Family Member 1 stated LVN 1 informed her that CNA 1 had left Resident 1 for a moment, at which time Resident 1 then fell . The interviews were conducted with the facility staff who observed Resident 1 after she fell on [DATE] at 2330 hours. On 12/5/23 at 1307 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 had fallen several times, and as a result of multiple falls at the facility, Resident 1 was provided with 1 to 1 staff supervision. The 1 to 1 staff was assigned to provide constant supervision of Resident 1, in order to prevent Resident 1 from sustaining another fall. LVN 1 stated at the time of Resident 1's fall on 10/24/23 at 2330 hours, CNA 1 was assigned as Resident 1's 1 to 1 staff. LVN 1 was asked to describe what he observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. LVN 1 stated at the time of Resident 1's fall, CNA 1 (1 to 1 staff) had left Resident 1's room and had gone to obtain a blanket. LVN 1 stated when CNA 1 left Resident 1 alone, Resident 1 sustained a fall. LVN 1 stated Resident 1 was to receive constant supervision, and Resident 1 should not have been left unsupervised. LVN 1 stated after Resident 1 had fallen, he entered Resident 1's room. LVN 1 stated he saw Resident 1 hunched over a chair located next to her bed, and Resident 1 was clutching her right rib. LVN 1 stated Resident 1 was then transferred to the acute care hospital. On 12/5/23 at 1330 hours, an interview was conducted with RN 1. RN 1 stated she was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. RN 1 stated Resident 1 was assigned a 1 to 1 sitter at the time of her fall. RN 1 stated the 1 to 1 sitter was to provide constant supervision, always having Resident 1 within sight of the assigned 1 to 1 staff. RN 1 stated constant supervision was provided to Resident 1 due to Resident 1 having episodes of confusion, forgetfulness, and being a fall risk with multiple falls in the facility. RN 1 stated if staff was not with Resident 1, Resident 1 would try to get up from her bed. RN 1 was asked to describe what she observed on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. RN 1 stated at the time of Resident 1's fall, CNA 1 (1 to 1 staff) left Resident 1 to obtain linens, at which time Resident 1 sustained a fall. RN 1 stated Resident 1 had tried to get up to use the bathroom and Resident 1 stated she fell and hit her ribs on the armchair in her room. Resident 1 complained of pain with breathing and was subsequently transferred to the acute care hospital. RN 1 stated CNA 1 should not have left Resident 1 unsupervised. On 12/5/23 1444 hours, an interview was conducted with CNA 1. CNA 1 stated he was assigned to care for Resident 1, at the time of her fall on 10/24/23 at 2330 hours. CNA 1 stated he was assigned as Resident 1's 1 to 1 staff. CNA 1 stated Resident 1 required constant supervision, and he was required to keep Resident 1 within his sight as Resident 1 was a fall risk and had the tendency to get up out of bed on her own without assistance. CNA 1 stated at the time of Resident 1's fall, he was also assigned to care for other residents in addition to Resident 1. CNA 1 stated if he had to leave Resident 1 to provide care for other residents, CNA 1 would ensure another staff member would provide 1 to 1 observation of Resident 1 while he provided care to other residents. CNA 1 was asked to describe what had occurred on 10/24/23 at 2330 hours, at the time Resident 1 sustained a fall. CNA 1 stated another resident had activated a call light, at which time CNA 1 left Resident 1. CNA 1 stated he went to the nursing station, to locate another staff member who could provide 1 to 1 supervision for Resident 1, as to allow CNA 1 to answer the call light. CNA 1 stated he went into the nursing station for approximately one minute at which time Resident 1 fell . CNA 1 stated he could not see Resident 1 from the nursing station at the time Resident 1 fell . On 12/5/23 at 1338 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she had attended Resident 1's IDT meetings on 9/27/23 at 1326 hours, and 10/12/23 1401 hours. The DON verified the IDT recommended Resident 1 would be provided 1 to 1 supervision. The DON stated Resident 1 was to be provided constant visual 1 to 1 supervision by the facility staff. The DON stated 1 to 1 constant supervision was implemented due to Resident 1's episodes of confusion, unsteady gait, and history of multiple falls at the facility. The DON stated Resident 1's responsible party was also informed Resident 1 was to receive constant 1 to 1 supervision by the facility staff as per the IDT meetings on 9/27 and 10/23/23. The DON stated the facility had conducted an investigation specific to Resident 1's fall sustained on 10/24/23 at 2330 hours. The DON stated CNA 1 should not have left Resident 1 unsupervised at the time of Resident 1's fall. The DON stated her expectation was CNA 1 should have ensured another staff member was in place to provide constant supervision of Resident 1 before CNA 1 left Resident 1 and/or when Resident was no longer within CNA's sight.

Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of the pressure ulcers to two of 12 final sampled residents (Residents 21 and 4). Residents 21 and 4 were admitted to the facility without pressure ulcers but developed pressure ulcers after admission to the facility. * Resident 21 developed a right heel Stage 3 pressure ulcer discovered on 9/4/19. The facility failed to ensure Resident 21's right heel was offloaded (floated off the mattress) to prevent further deterioration of the Stage 3 pressure ulcer on the right heel. This resulted in Resident 21's right heel developing a black blister with non-blanchable (deep tissue injury) discovered on 9/6/19, next to the current wound. The facility failed to assess the new pressure ulcer, notify the physician to obtain a wound treatment order, notify the family, and implement the necessary interventions to prevent further skin breakdown. * Resident 4 developed an unstageable pressure ulcer while at the facility. The facility failed to carry out the repeated orders from the Wound Specialist for a change in the treatment of [REDACTED]. In addition, the wound assessments by the licensed nurses did not match the assessments completed by the Wound Specialist. Findings: The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on (MONTH) 13, (YEAR). They are as follows: - Stage 2: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. - Stage 3: full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. - Deep Tissue Injury (DTI): intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Medical record review for Resident 21 was initiated on 9/3/19. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE], without a pressure ulcer. Review of the MDS dated [DATE], showed Resident 21 was cognitively intact. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/31/19, showed Resident 21 was a mild risk for developing a pressure ulcer. Review of an untitled wound assessment form dated 9/4/19, showed an initial exam of Resident 21's right heel pressure ulcer Stage 3 with 100% slough, measuring 2.1 cm (length) x 1.1 cm (width) x 0.3 cm (depth). The recommendations included to offload the pressure, reposition the resident every two hours, provide the low air loss mattress, and reposition the resident to the lateral position (lying on the side) in bed. Review of the SBAR Communication Form and Progress Note dated 9/4/19 at 1609 hours, showed Resident 21 had a new full thickness tissue loss to the right heel. Review of the Progress Notes showed an IDT entry dated 9/5/19 at 1918 hours, showing Resident 21 had a new right heel pressure ulcer, Stage 3. The IDT documentation showed to continue the physician's orders [REDACTED]. Review of the care plan showed a care plan problem dated 9/4/19, addressing Resident 21's impaired skin integrity related to the right heel full thickness tissue loss (Stage 3 pressure ulcer). The Interventions/Tasks included to provide the treatment as per the physician's orders [REDACTED]. On 9/5/19 at 0805 and 1030 hours, Resident 21 was observed lying on her back without the right heel being offloaded. On 9/6/19 at 0830 and 1412 hours, and on 9/9/19 at 1412 hours, Resident 21 was observed lying on her back with right heel placed on the mattress. On 9/6/19 at 1420 hours, a wound treatment observation was conducted with LVN 2 and CNA 1. Resident 21 was observed lying on her back with the right heel resting on the mattress. LVN 2 provided the treatment to Resident 21's right heel pressure ulcer. The wound on the right heel was measured 2 cm x 2 cm x UTD (unable to determine (depth)) with 50% eschar, 50% granular tissue (new tissue). Next to Resident 21's right heel wound a black blister was observed measuring 2 cm (length) x 2 cm (width) x UTD. LVN 2 stated now Resident 21's right heel had a blister with a dark area (DTI) next to the previous wound, and this blister was a new wound. After the wound treatment, LVN 2 and CNA 1 were observed placing Resident 21's right heel directly on the mattress. On 9/9/19 at 0709 hours, a concurrent observation and interview was conducted with RN 3. Resident 21 was observed lying on her back with the right heel resting directly on the mattress. RN 3 stated Resident 21 was supposed to be repositioned every two hours and the right heel was supposed to be elevated on pillows to prevent further skin breakdown. On 9/9/19 at 0853 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated the wound care physician discovered Resident 21's right heel pressure ulcer on 9/4/19, and the DTI was discovered on 9/6/19, during the wound treatment. The ADON stated when the nurse found a new pressure ulcer, she was supposed to assess the wound, inform the physician and family, fill out the Change of Condition and SBAR Communication Forms, and update the plan of care. The ADON called LVN 2 on the phone regarding Resident 21's pressure ulcer on the right heel discovered on 9/6/19. LVN 2 confirmed Resident 21's pressure ulcer on the right heel was not assessed, not documented in the Change of Condition and SBAR Communication Forms, and was not updated on the plan of care. LVN 2 stated she endorsed the finding to the evening shift licensed nurse, LVN 3. On 9/9/19 at 1400 hours, an observation of Resident 21's right heel pressure ulcer was conducted with the ADON, RN 2, and LVN 3. The ADON removed the soiled dressing on the right heel. The Stage 3 pressure ulcer and the black blister were adjacent and became one large pressure ulcer, measuring 4 cm (length) x 3.1 (width) x 0.2 cm depth. The right heel pressure ulcer was observed with separated skin, 30% black eschar, and 70% granular tissue. LVN 3 stated the wound had changed and was getting larger. 2. Medical record review for Resident 4 was initiated on 9/3/19. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's quarterly MDS dated [DATE], showed Resident 4 required extensive assistance from two persons for all ADL care. a. Review of the BD Change of Condition dated 6/6/19, showed Resident 4 developed an unstageable pressure ulcer to her mid back. Review of the Medication Review report showed an order dated 8/11/19, for Santyl ointment ([MEDICATION NAME] ointment) 250 unit/gm, apply to mid back topically every day shift for an unstageable pressure ulcer, offload the pressure, reposition the resident frequently everyday, and have the resident sit in the wheelchair no more than one hour at a time. Review of the Wound Specialist's progress notes dated 8/24/19, showed Resident 4 had a Stage 3 pressure ulcer at the mid back, measuring 1 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed had 100% granulation. An order was written to cleanse or irrigate the wound with normal saline or water and apply Manuka honey and cover with a foam dressing. Review of the medical record failed to show documentation this order was carried out. Review of the Wound Specialist's progress note dated 8/28/19, showed Resident 4 had a Stage 3 pressure ulcer at the mid back, measuring 0.8 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed was 60% granulation and 40% [MEDICATION NAME]. Another order was written to cleanse or irrigate the wound with normal saline or water and apply Manuka honey and cover with foam dressing. Review of the medical record failed to show documentation this repeated order was carried out. On 9/3/19 at 0751 hours, Resident 4 was observed in the dining room, sitting in her wheelchair with her back hunched over. The bony area of her back was observed resting on the back of the wheelchair. On 9/3/19 at 1028, 1104, 1217, and 1227 hours, Resident 4 was observed in her wheelchair in activities and dining room for lunch. On 9/5/19 at 0820 to 0935 hours, Resident 4 was observed sitting on her wheelchair in the dining room being fed breakfast. Resident 4 was then wheeled from the dining room to the activities room. On 9/5/19 at 1053 hours, an observation and concurrent interview was conducted with the Activities Director. Resident 4 was observed sitting in her wheelchair in the activities room. The Activities Director verified Resident 4 had been in activities for at least an hour now. On 9/5/19 at 1109 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 4 was brought to the dining room for breakfast at 0745 hours and was wheeled to the activities room after breakfast. On 9/5/19 at 1407 hours, a wound care observation of Resident 4 was conducted with LVN 1. LVN 1 was observed providing wound care to the bony area of Resident 4's mid back. LVN 1 was observed applying Santyl ointment to the wound and covering the wound with a foam dressing. On 9/6/19 at 1056 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated the current treatment order for Resident 4's pressure ulcer was the Santyl ointment and was never changed to Manuka honey which was ordered by the Wound Specialist on 8/24/19. LVN 1 stated the Wound Specialist's order or recommendation was not communicated to Resident 4's physician; therefore, the treatment order was not changed. On 9/6/19 at 1415 hours, a follow-up wound care observation of Resident 4 was conducted with LVN 1. LVN 1 measured Resident 4's wound at mid back as 0.5 cm (length) x 1 cm (width). The wound bed was observed to be 80% slough and 20% granulation. b. Review of the BD SBAR Communication Form and Progress Note dated 6/6/19, showed Resident 4's physician was notified of the development of an unstageable pressure ulcer to her back bony prominence, measuring 4 cm (length) x 2 cm (width). There was no other description of the wound. Review of the BD Weekly Wound Data Collection Flow Sheet dated 6/8/19, showed Resident 4 had a DTI at mid back, measuring 4 cm (length) x 2 cm (width). The area to document a description of the wound base was blank. The wound edges were purple and intact. There was no odor or drainage. Under the section for Summary, the Flow Sheet showed Resident 4 had a mid back unstageable pressure ulcer. Resident 4's wound at the mid back was described as both unstageable and DTI in one assessment. Review of the Wound Specialist's progress note dated 8/18/19, showed Resident 4's wound at the mid back was now a Stage 3 pressure ulcer, measuring 1.1 cm (length) x 0.7 cm (width) x 0.1 cm (depth). The wound bed was 20% slough and 80% granulation. However, review of the BD Weekly Wound Data Collection Flow Sheet dated 8/17/19, signed by the DCS showed Resident 4's wound at the mid back was unstageable/DTI, measuring 2.8 cm (length) x 1.6 cm (width). The areas to describe the wound base were blank. Review of the Wound Specialist's progress note dated 8/24/19, showed Resident 4's Stage 3 pressure ulcer at the mid back measured 1 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed was 100% granulation. However review of the BD Weekly Wound Data Collection Flow Sheet dated 8/24/19, signed by the DCS, showed Resident 4's wound at the mid back was unstageable/DTI measuring 2 cm (length) x 1.4 cm (width). The areas to describe the wound base were blank. On 9/6/19 at 1503 hours, an interview and concurrent medical record review was conducted with the DCS and ADCS. The ADCS stated the Wound Specialist assessed Resident 4's wound independently. No one from the nursing staff followed the Wound Specialist. The ADCS stated the nursing staff assessed Resident 4's wounds separately. They did not do it at the same time. The DCS verified the discrepancies in the wound assessments and stated all the wound assessments were done by the ADCS, and the DCS signed the assessments. When asked if she had seen or assess the wounds herself before signing, the DCS had no answer.