Every finding on record at Santa Paula Post Acute Center

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary cleaning of dishes and storage practices in the kitchen when:Clean plastic mugs were stored upside down on a tray, with the rims in contact with standing water.An expired bottle of Cayenne Pepper Hot spice was found on the shelf with an expiration date of 3/10/26.These failures had the potential to allow viruses and bacteria to grow and put the residents at risk of developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings:1. During a concurrent observation and interview on 7/6/26 at 2:50 PM with the Lead Kitchen Staff (LKS) at the kitchen's drying area, clean plastic mugs were stored upside down on a tray, with the rims in contact with standing water. When interviewed, the LKS stated the mugs were not considered clean. The LKS then proceeded to remove the tray of mugs and further stated that they should be drying on an open rack to properly dry.During a concurrent interview and record review on 7/8/26 at 9:28 AM with the certified Dietary Service Supervisor (DSS), the facility's undated Dishwashing policy and procedure (P&P) was reviewed. The P&P indicated, under .Procedure:.5. Dishes are to be air dried in racks before stacking and storing. The DSS stated that mugs being air-dried should not be sitting in water, to be considered clean and sanitized.During an interview on 7/8/26 at 9:44 AM with the Registered Dietician (RD), the RD confirmed mugs touching standing water on a tray were not considered clean. The RD further stated that dishes being air-dried should not be sitting in water.2. During a concurrent follow-up kitchen observation and interview on 7/6/2026 at 3:10PM with the LKS, an expired bottle of Cayenne Pepper Hot spice was found on the shelf with an expiration date of 3/10/26. The LKS stated it needed to be thrown out as the facility did not use expired food items.During a concurrent interview and record review on 7/8/2026 at 9:28 AM with the DSS, the facility's undated P&P titled Storage of Food and Supplies was reviewed. The P&P indicated .Procedures for Dry Storage:.8. No food will be kept longer than the expiration date on the product. The DSS stated expired food items needed to be immediately discarded to not cause any harm to residents.During an interview with the RD on 7/8/2026 at 9:44 AM, the RD stated I expect that we have no expired food items or spices in the kitchen.

Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when:1. Expired medications and medical supplies remained in the active medication storage areas in one of one Medication Room; and2. A resident-owned (Resident 31) medication with an unreadable expiration date was stored in one of four medication carts without physician review and authorization, and an insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen was stored beyond the manufacturer's recommended in-use (opened) period.These failures had the potential for residents to receive expired, ineffective, or unauthorized medications, which could compromise resident safety. Findings:1a. During a concurrent observation and interview on 7/6/26 at 8:49 AM with the Assistant Director of Nursing (ADON), medications and medical supplies stored in the Medication Room were inspected. The Medication Room contained five one-ounce bottles of Skintegrity Wound Cleanser (a wound cleansing solution used to clean wounds before dressing changes), and one eight-ounce bottle of Lubricating Deodorant spray (a skin protectant used to reduce friction and help protect the skin) with expiration dates of 5/31/25 and 8/1/25, respectively. The ADON verified both products were expired. The ADON stated expired medications and medical supplies should not be used after the expiration date, should be removed from active medication storage areas, and discarded in the medication waste container located in the Medication Room. The ADON stated the treatment nurses and central supply staff were responsible for checking the wound care supplies and the medications stored in the medication room weekly and should have identified and removed the expired products.b. During a concurrent observation and interview on 7/6/26 at 9:35 AM with the ADON, the medications stored in the Medication Room were further inspected. The Medication Room contained one opened bottle of Citrucel (methylcellulose, an oral laxative used to treat constipation) with an expiration date of June 2026. The ADON verified the product was expired and stated it should have been discarded.During a concurrent interview and record review on 7/7/26 at 8:47 AM with the Director of Nursing (DON), the DON confirmed the expired medications and medical supplies found in the Medication Room should have been removed from the active medication storage areas because they should not be used after the expiration date and might not maintain their intended effectiveness.A review of the facility's policy and procedures (P&P) titled, Medication Labeling and Storage, dated February 2023, indicated .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .2a. During a concurrent observation and interview on 7/6/26 at 3:34 PM with Licensed Vocational Nurse (LVN) 1, the medications stored in the South Wing Medication Cart were inspected. The medication cart contained one original manufacturer's package of MiraFast Soft Chews (magnesium hydroxide 1200 mg [milligram - unit of measurement], an oral laxative used to relieve constipation) for Resident 31. The manufacturer's expiration date printed on the package had been completely erased and was unreadable. The exterior packaging only displayed the resident's written name and room number. LVN 1 confirmed the expiration date was unreadable, and stated nursing staff were responsible for checking the expiration dates of medications stored in the medication cart.During a concurrent interview and record review on 7/7/26 at 8:47AM with the DON, the DON stated MiraFast was Resident 31's own medication. When asked to review the physician's order, the DON stated there was no physician's order for the medication. The DON explained that resident-owned medications should be reviewed by the physician, and a physician's order should be obtained before the medication was stored in the medication cart for administration. The DON further stated the nursing staff were responsible for checking expiration dates and removing medications with unreadable or expired expiration dates from the medication cart.A review of the facility's P&P titled, Labeling of Medication Containers, dated April 2019, indicated, .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .Any medication packaging or containers that are inadequately or improperly labeled as returned to the issuing pharmacy .Labels for individual resident medications include all necessary information, such as .the prescribing physician's name.the name, strength, and quantity of the drug. appropriate accessory and cautionary statements.the expiration date.and.directions for use . A review of the facility's P&P titled Medications Brought to the Facility by the Resident/Family, dated April 2007, indicated .If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the director of nursing services and nursing staff, with support of the attending physician and consultant pharmacist, shall check to ensure that.the medications have been ordered by the resident's attending physician, and documented on the physician's order sheet.the contents of each container are labeled in accordance with established policies; and.the contents of each container have been verified by a licensed pharmacist.2b. During a concurrent observation and interview on 7/6/26 at 3:34 PM with LVN 1, the medications stored in the South Wing Medication Cart were further inspected. The Medication Cart contained Resident 67's Insulin Lispro KwikPen (a rapid-acting insulin used to lower blood glucose levels) labeled with an open date of 6/1/26. LVN 1 stated the insulin pen expired 28 days after the open date, and they should have been removed from the medication cart and discarded into the medication waste container.During a concurrent interview and record review on 7/7/26 at 8:58 AM, the DON confirmed Resident 67's Insulin Lispro KwikPen exceeded the manufacturer's recommended 28-day in-use period and should have been removed from the medication cart. The DON stated use of an expired insulin pen could result in elevated blood glucose levels and hyperglycemia symptoms (high blood sugar symptoms such as constant thirst, frequent urination, etc.) because the medication might not maintain its intended effectiveness.A review of the manufacturer's package inserts (a document included in the package of a medication that provides information about the drug and its use), dated June 2025, indicated .When stored at room temperature, Insulin Lispro can only be used for a total of 28 days, including.in-use (opened) storage time.Do not use Insulin Lispro past the expiration date printed on the label or 28 days after you first use it.Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.A review of the facility's P&P titled Medication Labeling and Storage, dated February 2023, indicated .Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on interview and record review, the facility failed to ensure the Advance Directive (a written document specifying an individual's medical care wishes) process was completed according to the facility's policies and procedures (P&P) when: 1. There was no documented evidence indicating that 11 of 20 sampled residents (Residents 2, 4, 6, 7, 10, 19, 26, 37, 47, 58, and 91) who had not executed an Advance Directive were offered assistance to formulate one and whether such assistance was accepted or declined. 2. There was no documented evidence indicating that two of 20 sampled residents (Residents 42 and 43) were provided with written information of their rights to formulate an Advance Directive upon admission.This deficient practice had the potential to result in residents not having their health care wishes known, honored, or available during emergent medical situations.Findings:1a. A review of Resident 2's admission Record, (front page of the chart that contains a summary of basic information about the resident) dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of Resident 2's History and Physical (a medical document detailing a patient's current health status and medical background), dated 2/3/26, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Advance Directive Acknowledgment form, dated 2/9/26, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 2's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined. b. A review of Resident 4's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 4's History and Physical, dated 3/12/26, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's Advance Directive Acknowledgment form, dated 10/7/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 4's medical record showed no documented evidence indicating the resident or representative was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.c. A review of Resident 6's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of Resident 6's History and Physical, dated 3/23/26, indicated Resident 6 did not have the capacity to understand and make decisions. A review of Resident 6's Advance Directive Acknowledgment form, dated 4/16/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 6's medical record showed no documented evidence indicating the resident or representative was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.d. A review of Resident 7's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of Resident 7's History and Physical, dated 5/1/26, indicated Resident 7 had the capacity to understand and make decisions. A review of Resident 7's Advance Directive Acknowledgment form, dated 10/15/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 7's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.e. A review of Resident 10's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of Resident 10's History and Physical, dated 6/23/26, indicated Resident 10 did not have the capacity to understand and make decisions. A review of Resident 10's Advance Directive Acknowledgment form, dated 4/5/24, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.' In addition, the form was not signed by the facility representative. Further review of Resident 10's medical record showed no documented evidence indicating the resident or representative was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.f. A review of Resident 19's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 19's History and Physical, dated 7/3/26, indicated Resident 19 had the capacity to understand and make decisions. A review of Resident 19's Advance Directive Acknowledgment form, dated 6/12/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 19's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.g. A review of Resident 26's admission Record, dated 7/9/26, indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE].A review of Resident 26's History and Physical, dated 2/9/26, indicated Resident 26 had the capacity to understand and make decisions. A review of Resident 26's Advance Directive Acknowledgment form, dated 3/11/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.' Further review of Resident 26's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.h. A review of Resident 37's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of Resident 37's History and Physical, dated 11/12/25, indicated Resident 37 had the capacity to understand and make decisions. A review of Resident 37's Advance Directive Acknowledgment form, dated 1/26/23, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.' In addition, the form was signed by the facility representative, but it was not dated. Further review of Resident 37's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.i. A review of Resident 47's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 47's History and Physical, dated 12/10/25, indicated Resident 47 had the capacity to understand and make decisions. A review of Resident 47's Advance Directive Acknowledgment form, dated 12/11/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.' In addition, the form was not signed by the resident or resident representative. However, there was a written note indicating the facility spoke with the representative on 12/11/25.Further review of Resident 47's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.j. A review of Resident 58's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 58's History and Physical, dated 7/23/26, indicated Resident 58 had the capacity to understand and make decisions. A review of Resident 58's Advance Directive Acknowledgment form, dated 8/1/25, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 58's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.k. A review of Resident 91's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 91's History and Physical, dated 2/6/26, indicated Resident 91 had the capacity to understand and make decisions. A review of Resident 91's Advance Directive Acknowledgment form, dated 4/1/26, indicated a mark next to the statement I HAVE NOT executed 'Advance Directive.'Further review of Resident 91's medical record showed no documented evidence indicating the resident was offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined.2a. A review of Resident 42's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 42's History and Physical, dated 6/12/26, indicated Resident 42 had the capacity to understand and make decisions. Further review of Resident 42's medical record showed no documented evidence an Advance Directive Acknowledgment form was completed. b. A review of Resident 43's admission Record, dated 7/9/26, indicated the resident was initially admitted to the facility on [DATE].A review of Resident 43's History and Physical, dated 6/22/26, indicated Resident 43 had the capacity to understand and make decisions. Further review of Resident 43's medical record showed no documented evidence an Advance Directive Acknowledgment form was completed.A review of the facility's Advance Directive Log 2025 indicated the following:-The Advance Directive information was handed out to Resident 6 on 11/4/25.-The Advance Directive information was handed out to Resident 7 on 4/15/24.-The Advance Directive information was handed out to Resident 37 on 5/29/25.-The Advance Directive information was handed out to Resident 47 on 12/10/25.-The Advance Directive information was handed out to Resident 58 on 7/17/25.Residents 2, 4, 10, 19, 26, 42, 43, and 91 were not listed in the log, and there was no documented evidence indicating the residents were offered assistance to formulate an Advance Directive and whether the assistance was accepted or declined. During an interview on 7/8/2026 at 3:14 PM with the Social Services Director (SSD), the SSD was asked to explain the Advance Directive process. The SSD explained that during the initial assessment, residents were asked whether they had an Advance Directive or Durable Power of Attorney (DPOA - a legal document that lets a person name someone he or she trusts to make medical, legal, or financial decisions when he or she becomes unable to make decisions). The SSD stated if the residents indicated they did not have one, the facility provided and reviewed the form with them. The SSD further stated she would go through the process of completing the form and assisted the residents as needed. During an interview on 7/9/26 at 9:14 AM with the admission Director (AD), the AD stated if residents selected I have not executed an Advance Directive, it meant the residents did not have it and may either choose to formulate one or decline. The AD further stated Social Services was responsible for completing the remainder of the process. During a concurrent interview and record review on 7/9/26 at 10:05 AM with the Social Services Assistant (SSA), Residents 2, 4, 6, 7, 10, 19, 26, 37, 42, 43, 47, 58, and 91's medical records and Advance Directive Acknowledgement forms were reviewed. When asked whether the facility documented Advance Directive offers, acceptances, or declinations in the medical record, the SSA stated the facility documented on paper or electronically. The SSA verified the above findings and acknowledged there was no documented evidence the residents reviewed were offered assistance to formulate an Advance Directive and whether such assistance was accepted or declined. The SSA also acknowledged that Resident 42 and 43 did not have completed Advance Directive Acknowledgment forms. A review of the facility's policy and procedure titled Advance Directives, revised September 2022, indicated .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents legal representative.If the Resident Does not have an Advance Directive.1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. k. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 8. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.15. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record.

Based on interview and record review, the facility failed to accurately assess one of nine sampled residents (Resident 19) when the Minimum Data Set (MDS - a standardized assessment tool) assessment indicated Resident 19 was using anticoagulants (medications that stop the blood from clotting too easily) but did not have any physician orders for anticoagulant medications. This had the potential for inappropriate plan of care for Resident 19.Findings:A review of Resident 19's admission Record, dated 7/9/26, indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 19's Order Summary Report, dated as of 7/9/26, indicated Resident 19 had no physician's order for anticoagulant medications. During a concurrent interview and record review on 7/9/26 at 1:13 PM with the MDS Coordinator (MDSC), Resident 19's MDS Section N - Medications, dated 6/9/26, was reviewed. The MDS Section N indicated Resident 19 was assessed as taking anticoagulant medications. The MDSC stated Resident 19 is not taking anticoagulant medications and should have not be assessed as using one. The MDSC stated that the assessment did not reflect Resident 19's high-risk medication use, further stating that all resident assessments should be accurate. A review of the facility's Policy and Procedure titled, Resident Assessments, revised March 2022, indicated .8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on interview and record review, the facility failed to notify the physician regarding one of three sampled resident's (Resident 10) chest X-ray (a quick, painless imaging test that uses a small dose of radiation to photograph the heart, lungs, airways, blood vessels, and chest bones) result.This failure had the potential to delay other related physician services that may benefit Resident 10's care.Findings:During a review of Resident 10's admission Record (AR - a document showing a summary of the resident's information), dated 7/9/26, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included interstitial pulmonary disease (a broad group of conditions causing progressive inflammation and scarring in the lung tissue), Parkinson's disease (a movement disorder of the nervous system that worsens over time), and unspecified dementia (a progressive state of decline in mental abilities). The AR indicated Resident 10 was under the services of Physician 1. During a review of Resident 10's Progress Notes (PN), dated 5/25/25, the PN indicated Resident 10 was noted with mild nonproductive cough, with a negative result for COVID (a respiratory disease) testing. Physician 1 was notified and provided an order for Resident 10 to receive cough medication as needed every six hours for 14 days. During a review of Resident 10's PN, dated 5/27/26, the PN indicated Resident 10 had an episode of vomiting and generalized weakness. Physician 1 was notified and provided an order for stat (medical term for immediately) chest X-ray. During a review of Resident 10's order summary, dated 5/27/26, the order summary indicated Physician 1 gave an order for stat chest X-ray for Resident 10. During a concurrent interview and record review on 7/9/26 at 12:43 PM with the Director of Nursing (DON), Resident 10's electronic medical record was reviewed. The DON confirmed there was no documentation in Resident 10's electronic medical record that indicated Physician 1 was notified of the chest X-ray result ordered on 5/27/26. The DON further stated Physician 1 should have been notified of the chest X-ray result. During an interview on 7/9/26 at 1:35 PM with Physician 1, Physician 1 stated he was not notified of Resident 10's chest X-ray result. Physician 1 stated the result of the chest X-ray was normal upon review on the day of the transfer to the hospital for further evaluation. Physician 1 stated Resident 10 would still have been transferred unrelated to the X-ray result but still expected to be notified of the result once received. A review of the facility's policy and procedure titled Test Results, revised April 2007, indicated, .The resident's attending physician will be notified of the results of diagnostic tests.1. Results of laboratory, radiological, and diagnostic test shall be reported in writing to the resident's attending physician or to the facility. 2. Should the test result be provided to the facility, the attending physician shall be promptly notified of the results.

Based on interview and record review, the facility failed to provide nutritional care and services for one of two sampled residents (Resident 12) when Resident 12 had a significant weight loss of 10.31% within three months. This had the potential for Resident 12's nutritional needs and goals to be unmet.Findings:During a review of Resident 12's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), dated 7/9/26, the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (medical term for cancer) of gallbladder (a small organ under the liver that stores bile [a thick, greenish-yellow fluid that breaks down fatty food] which aids in digestion) and nutritional anemia (a condition where the body lacks enough healthy red blood cells to effectively carry oxygen to the tissues).During a review of Resident 12's Weights and Vitals Summary, with the effective date range from 10/8/25 to 7/8/26, the summary indicated Resident 12 lost 13 lbs. (lbs - an abbreviation for pounds, a unit of weight), from 126 lbs. to 113 lbs. within three months (from 10/8/25 to 1/2/26).During an interview on 7/8/26 at 3:17 PM with the Registered Dietitian (RD), the RD stated one of her responsibilities is to monitor the residents' weights in the facility and address significant weight changes. RD stated significant weight changes included 7.5% or more weight loss in three months. RD stated that Resident 12 lost 13 lbs. from 10/8/25 to 1/2/26 which accounted for 10.31% weight loss in three months. RD confirmed the weight loss within those three months was not reviewed. RD further stated she should have looked into the weight loss for appropriate interventions.During an interview on 7/8/26 at 3:32 PM with the Director of Nursing (DON), the DON stated Resident 12 was diagnosed with cancer and was being treated with radiation therapy, both of which contributed to the weight loss. The DON stated Resident 12's 10.31% weight loss within three months should have been addressed even if it was an expected outcome. A review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, revised March 2022, indicated . Weight Assessment. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe.A review of the facility's P&P titled Nutritional Assessment, revised October 2017, indicated . As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission. and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.

Based on observation, interview and record review, the facility failed to provide grooming services to one of nine sampled dependent residents (Resident 84), when Resident 84 was observed with untrimmed and dirty fingernails on both hands. This had the potential for skin problems and infection around the nail bed.Findings:A review of Resident 84's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), dated 7/9/26, indicated Resident 84 was admitted on [DATE] with diagnoses that included unspecified symptoms and signs involving cognitive functions and awareness (a medical classification used when a patient exhibits unclassified cognitive, memory, or awareness deficits).A review of Resident 84's History and Physical (a medical document detailing a patient's current health status and medical background), dated 7/8/25, indicated Resident 84 did not have the capacity to understand and make decisions.A review of Resident 84's Minimum Data Set (MDS - a standardized assessment tool) Section E - Behavior assessment, dated 4/27/26, indicated Resident 84 refused Activities of Daily Living (ADL - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) assistance, but not on a daily occurrence.A review of Resident 84's MDS Section GG - Functional Abilities assessment, dated 4/27/26, indicated Resident 84 required partial or moderate assistance for personal hygiene (daily habits and practices to maintain cleanliness and overall health).During an observation on 7/6/26 at 10:52 AM, inside Resident 84's room, Resident 84 was observed with untrimmed and dirty fingernails on both hands.During an interview on 7/9/26 at 10:00 AM with the Director of Staff Development (DSD), the DSD stated the facility provided grooming services, including nail care to residents during the weekends. The DSD further stated that if any resident refused care, the licensed nurse would document the refusal.During a concurrent interview and record review on 7/9/26 at 12:03 PM with the Director of Nursing (DON), Resident 84's Progress Notes (PN) were reviewed. The DON confirmed there was no documentation indicating Resident 84 refused nail trimmings, nor was there any documentation that the service was regularly offered to the resident, as scheduled every weekend. The DON stated Resident 84 had the right to refuse, but the facility should continue to offer as necessary.A review of the facility's policy and procedure titled Fingernails/Toenails, Care of, revised February 2018, indicated .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming.Documentation.The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care.4. Any difficulties in cutting the resident's nails.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (CS - medications with a high potential for abuse and dependence) for one of six randomly selected residents (Resident 23) reviewed for CS accountability. The facility's Controlled Drug Record (CDR - inventory records used to document receipt, use, and count of controlled substances) did not correspond with the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This failure resulted in inaccurate accountability of a controlled substance and had the potential for diversion (controlled substances used by someone other than the resident for whom the medication was prescribed) or misuse of controlled substances and compromised residents' medication therapy and safety. Findings:During a concurrent record review and inspection of the Medication Cart at the North Wing Nursing Station on 7/7/26 at 10:13 AM with Licensed Vocational Nurse (LVN) 2, Resident 23's blister card (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles [blisters] and attached to a rigid card or foil backing) for hydrocodone-acetaminophen (generic for Norco, scheduled II CS used for pain) 5-325 mg (milligram - unit of measurement) and corresponding records were reviewed.A review of Resident 23's physician order, dated 6/21/26, indicated an order for hydrocodone-acetaminophen 5-325mg, give 1 tablet by mouth every 4 hours as needed for pain 7-10/10 (pain scale).A review of Resident 23's CDR, dated 6/30/26 through 7/7/26, indicated the nursing staff removed one Norco 5/325mg tablet from the blister card on 7/2/26 at 9:06 PM and documented the removal in the CDR.A review of Resident 23's July 2026 MAR indicated no corresponding record documenting the administration of the Norco dose removed from the blister card on 7/2/26 at 9:06 PM. The MAR also did not contain a corresponding pain assessment associated with that dose. During a concurrent interview and record review on 7/7/26 at 10:13 AM with LVN 2, LVN 2 confirmed the discrepancy and stated the nursing staff should document the removal of CS in the CDR when the medication is removed from the medication cart. The nursing staff should also document in the MAR after the medication is administered. During a concurrent interview and record review on 7/7/26 at 10:51 AM with the Director of Nursing (DON) in the DON's office, the DON confirmed the discrepancy between the CDR and MAR. The DON stated her expectation was for the nursing staff to document medication administration in the MAR after administering the medication.A review of the facility's policy and procedures titled, Documentation of Medication Administration, dated November 2022, indicated .A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) .

Based on observation, interview, and record review, the facility failed to follow Infection Prevention and Control Practices when:1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after picking up trash from the floor and before assisting with resident care activities, including adjusting the resident's overbed table and obtaining a clean towel. This had the potential to spread microorganisms that can cause healthcare-associated infections.2. Licensed Vocational Nurse (LVN) 3 touched the blood collection tip of a glucose test strip (a disposable plastic or paper strip coated with chemicals that react with the sugar in blood) before obtaining Resident 39's blood specimen and discarded the used blood-contaminated test strip into a regular trash receptable. These failures had the potential to affect the accuracy of the blood glucose measurement, increase the risk of cross-contamination (the accidental transfer of germs, chemicals, or allergens from one surface, object, or food to another), and result in improper handling of blood-contaminated waste.Findings:1. During an observation on 7/6/26 at 8:56 AM inside room [ROOM NUMBER], CNA 1 picked up trash on the floor with bare hands. CNA 1 then put the trash into the bin, adjusted the overbed table, and removed the meal tray from the resident in Bed B out of the room without performing hand hygiene. CNA 1 then went to get a towel from the clean linen storage without performing hand hygiene. During an interview on 7/6/26 at 9:02 AM with CNA 1, CNA 1 acknowledged she picked trash from the floor then proceeded to adjust the overbed table and remove the meal tray out of the room. CNA 1 also acknowledged she got a towel out from the clean linen storage. CNA 1 stated she did not perform hand hygiene in between any of the tasks she stated. CNA 1 stated she should have performed hand hygiene. During an interview on 7/8/26 at 12:13 PM with the Infection Preventionist (IP), the IP stated all staff are expected to perform hand hygiene in between tasks and further stated that CNA 1 should have put on gloves when picking up trash from the floor. The IP stated that it is an expectation to perform hand hygiene before and after exiting a resident's room. The IP stated CNA 1 should have performed hand hygiene before taking any linen or towel from the clean linen storage. During a review of the facility's Policy and Procedure (P&P) titled Handwashing/Hand Hygiene, revised August 2019, the P&P indicated .Policy Statement.This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . m. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. q. Before and after assisting a resident with meals. During a review of the facility P&P titled, Personal Protective Equipment- Using Gloves, revised September 2010, the P&P indicated . Objectives. 3. To prevent hands from potentially infectious materials. When to use gloves. 4. When cleaning potentially contaminated items; and 5. Whenever in doubt. 2. During a medication administration observation on 7/6/26 at 11:37 AM, LVN 3 prepared the equipment to monitor Resident 39's blood glucose, including an Assure Platinum Blood Glucose Meter (glucometer - a portable device used to measure blood glucose levels) and Assure Platinum Blood Glucose Test Strips (disposable strips inserted into the glucometer to collect a small blood sample to measure blood glucose levels). During a concurrent observation on 7/6/26 at 11:49 AM, immediately before obtaining Resident 39's blood specimen, LVN 3 touched the blood collection tip of the glucose test strip that was already inserted into the glucometer, with a gloved hand. LVN 3 then performed a fingerstick (process of pricking the tip or side of a finger to draw a small drop of blood for testing) on Resident 39's left index finger, wiped the first drop of blood with a tissue, obtained a second drop of blood, and collected the blood specimen onto the previously touched blood collection tip of the glucose test strip. After completing the blood glucose test, LVN 3 removed the used glucose test strip from the glucometer with a gloved hand. LVN 3 then discarded the used blood-contaminated glucose test strip, the blood-contaminated tissue used to wipe the first drop of blood, and the used gloves into the regular trash receptacle located in Resident 39's room. During a concurrent observation and interview on 7/6/26 at 12:34 PM with LVN 3, the used glucose test strip wrapped in tissue and gloves were observed inside the regular trash receptacle located in Resident 39's room. LVN 3 confirmed touching the blood collection tip of the glucose test strip and stated he did so to ensure it was securely inserted into the glucometer. When asked whether touching the blood collection tip was appropriate, LVN 3 stated he was unsure and would verify the proper procedure. When asked about the proper disposal of the used glucose test strip, LVN 3 pointed to the sharps container (a designated, puncture-resistant container used to safely dispose of contaminated needles and other medical waste) attached to the medication cart and stated either the sharps container or the regular trash receptacle could be used. LVN 3 stated he would verify the proper disposal procedure. During an interview on 7/7/26 at 8:12 AM, LVN 3 stated the blood collection tip of the test strip should not be touched because doing so could alter the integrity of the blood specimen. LVN 3 also stated the used glucose test strip should be discarded into a biohazard (a potentially infectious material) container, such as the sharps container. During an interview on 7/7/26 at 9:01 AM with the Director of Nursing (DON), the DON stated touching the blood collection tip of the glucose test strip could affect the accuracy of the blood glucose result and had the potential for cross-contamination, even while wearing gloves. The DON stated nursing staff should not touch the blood collection tip of the glucose test strip. The DON stated the used glucose test strip should be discarded in a biohazard container, such as the sharps container. During an interview on 7/7/26 at 11:55 AM with the IP, the IP stated the blood collection tip of the glucose test strip should not be touched because microorganisms on gloved hands could contaminate the blood collection surface, alter the accuracy of the blood glucose result, and introduce microorganisms into the resident's fingerstick site during blood specimen collection. The IP also stated blood was considered a biohazard. During a concurrent interview and record review on 7/7/26 at 12:08 PM with the Assistant Administrator (AA) and the IP, the manufacturer's instructions were reviewed. The AA stated the manufacturer's instructions indicated disposal of used glucose test strips should follow the facility's policies and procedures. The AA and IP confirmed the facility's policy directed staff to discard disposable supplies in the designated containers. The AA acknowledged blood was considered a biohazard. A review of the manufacturer's manual titled Assure Platinum Blood Glucose Monitoring System Quality Assurance/Quality Control Reference Manual, dated October 2024, indicated: .To reduce the chance of infection.Before performing a blood glucose test, observe the following safety precautions: All components that come into contact with blood samples should be considered to be biohazards capable of transmitting viral diseases between patients and healthcare professionals. .Remove the test strip by holding the meter so that the test strip points down. Push the test strip release button forward. Dispose of test strip. .Dispose of the used Assure Platinum Test Strip and lancet (a small, single-use needled used to prick the skin to obtain a blood sample for blood glucose testing) after the test is performed in the appropriately marked containers or follow your facility's printed policy of disposal for this type of matter. A review of the facility's P&P titled Obtaining a Fingerstick Glucose Level, dated October 2011, indicated .Discard disposable supplies in the designated containers . A review of the facility's P&P titled Blood or Body Fluids Exposure, dated July 2016, indicated: .All blood .should be considered potentially infectious at all times . A review of the facility's P&P titled Standard Precautions, dated September 2022, indicated .Standard precautions (infection prevention practice used for all residents to prevent the spread of infection) presume that all blood .may contain transmissible infectious agents .Resident-care equipment soiled with blood.are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments .Single use items are properly discarded . A review of the facility's P&P titled Biohazard Labeling, dated July 2016, indicated .Materials contaminated with blood or body fluids shall be labeled and discarded appropriately .All wastes containing blood or body fluids will be identified by a red bag, Biohazard (potentially infectious materials) tab, label, or sign .The primary purposes of identifying and labeling biohazardous waste are to warn about possible occupational exposure and to prevent accidental injury or illness to hazardous or potentially hazardous materials .All inquiries concerning the identification of biohazards should be referred to the infection preventionist (or designee) . A review of the facility's P&P titled Medical Waste, Categories of, dated May 2012, indicated .Medical wastes from this facility are categorized into the following classifications .human blood . A review of the facility's P&P titled Medical Waste - Preparing for Pickup, dated May 2012, indicated .Medical waste generated by this facility will be segregated from general waste .Medical waste may not be discarded with general trash .Designated individual will be responsible for separating (to the extent practical) medical waste generated by this facility into the following groups .Other regulated medical waste (e.g., blood-soaked bandages .) .Medical waste will be discarded into designated containers (e.g., red bag or container marked with the biohazard symbol) .

Based on observation, interview, and record review, the facility failed to ensure continuous oxygen therapy was administered as ordered for one of one sampled resident (Resident 91).This failure had the potential to place Resident 91 at risk for hypoxemia (low levels of oxygen in the blood) and respiratory compromise (a dangerous state where breathing or gas exchange is impaired) which could lead to other serious health complications.Findings:During an initial tour observation on 7/7/26 at 8:24 AM inside Resident 91's room, Resident 91 was in bed eating breakfast. The oxygen concentrator (a medical device that pulls in regular room air, removes nitrogen, and delivers purified oxygen) at Resident 91's bedside was powered on and set at three liters per minute, but the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not connected to the resident.During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 7/7/26 at 8:24 AM inside Resident 91's room, the ADON verified the nasal cannula was not applied to the resident. The ADON stated that Resident 91 had a physician's order to receive continuous oxygen at three to five liters per minute. The ADON explained that Resident 91 recently returned from the bathroom, and oxygen had not been reapplied. The ADON then checked Resident 91's oxygen level using a pulse oximeter (a device that measures the heart rate and oxygen level in the blood) which showed an oxygen saturation of 85%. The ADON acknowledged that Resident 91 should have been receiving oxygen and reapplied the nasal cannula. The ADON confirmed portable oxygens were available for residents when using the bathroom to ensure oxygen was administered continuously. However, the ADON confirmed there was no portable oxygen available in Resident 91's room.During a concurrent interview and record review on 7/8/26 at 8:28 AM with Director of Nursing (DON), Resident 91's physician's order dated 2/3/26 was reviewed. The DON acknowledged the physician's order required continuous oxygen administration at three to five liters per minute via nasal cannula and that staff were expected to ensure oxygen was administered as ordered.A review of Resident 91's admission Record (front page of the chart that contains a summary of basic information about the resident), dated 7/8/26, indicated the resident was admitted to the facility on [DATE] with diagnosis that included Chronic Respiratory Failure (a long-term condition where the lungs cannot properly oxygenate the blood or clear carbon dioxide).A review of Resident 91's Order Summary Report, dated as of 7/9/26, indicated Resident 91 had an order for continuous oxygen at three to five liters per minute via nasal cannula to keep the oxygen saturation above 92% every shift.A review of the facility's Policy and Procedure titled Administering Medications, revised April 2019, indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to maintain a vending machine, located in the resident dining room, in good repair and free from hazard.This facility failure had the potential to place residents at risk of injury.During a concurrent observation, and interview, on 7/29/25, beginning at 12:47 p.m., with the Maintenance Director (MTD 1) and a kitchen staff member (KS 1), the facility's dining room vending machine was inspected. The vending machine had a broken plastic window screen and a note from KS 1 which indicated Please Please Please you have problem's with the machine call me please don't broken window thanks. The MTD 1 verbalized not being aware that the vending machine was broken and verbalized it posed a safety risk to residents, as they could attempt to reach through the broken plastic window and get hurt. The KS 1 verbalized the vending machine had been in a state of disrepair for two weeks.During an interview on 7/29/25, at 1:47 p.m., with the Director of Nursing (DON 1), the DON 1 verbalized staff should have informed the maintenance department of the vending machine issue.During a review of the facility's policy titled Maintenance Service revised 12/09, indicated in part Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy further indicated Functions of the maintenance personnel include, but are not limited to.maintaining the building in good repair and free from hazards.

Based on record review and interview, the facility failed to create a comprehensive dental care plan for one of two sampled Residents (Resident 1).During a concurrent record review and interview, on 7/16/25, at 11:40 a.m., with the Director of Nursing (DON 1), Resident 1's initial dental exam dated 11/6/24, was reviewed. The initial exam form indicated Resident 1 had five missing teeth, and four broken teeth. The DON 1 confirmed Resident 1's dental exam form indicated Resident 1 had five missing teeth and four broken teeth. When asked if the facility had created a care plan to address Resident 1's dental status and concerns, the DON 1 verbalzied no and acknowledged there should have been one. During a review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/22, indicated in part 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.

Based on record review and interview, the facility failed to obtain physician orders in a timely manner to ensure proper indwelling catheter care was provided to one of two sampled Residents (Resident 1). This facility failure had the potential to place Resident 1 at a higher risk for infection, and lead to negative outcomes. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including a urinary tract infection (an infection in any part of the urinary system), obstructive and reflex uropathy (conditions in which the flow of urine is blocked), and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should, leading to a buildup of waste and fluid in the body).During an interview on 7/16/25, at 2:00 p.m., with Resident 1's doctor (MD 1), the MD 1 was asked about indwelling catheter (a flexible tube inserted into the bladder to drain urine, and it's held in place by a balloon) and catheter drainage bag changes, and the frequency in which they should occur. The MD 1 verbalized facility policy was to change the catheter bags and catheter drainage bags once a month.During a record review of Resident 1's Order Summary Report, undated, indicated Resident 1 had the following physician orders dated 5/13/25:1. Catheter-monitor indwelling catheter for S/S (signs and symptoms) of UTI: amber colored urine, foul urine odor, poor urine output, sediments.every shift.2. Catheter- change Q (every) month and PRN (as needed) for blockage or dislodge.3. Catheter - Change urinary drainage bag Q month and PRN.During an interview on 7/15/25, beginning at 3:55 p.m., with the Director of Nursing (DON 1), the DON 1 verbalized Resident 1 was admitted to the facility with an indwelling catheter on 4/7/25. When asked why the above physician orders for catheter care were not obtained upon or shortly after admission, and instead obtained on 5/13/25, the DON 1 could not provide an explanation. When asked if the facility could produce any documentation indicating Resident 1 was being monitored for signs and symptoms of a UTI, prior to 5/13/25, the DON 1 verbalized no.During an interview on 7/16/25, at 2:16 p.m., with the DON 1, the DON 1 verbalized and confirmed the facility could not produce documentation indicating Resident 1's indwelling catheter or drainage bag was changed from Resident 1's admission on [DATE] to discharge 6/1/25.

Based on observation, interview, and record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. The sanitizing solution used in the kitchen was not routinely tested for concentration when the solution gets replaced every two hours. 2. The ice machine cleaning and sanitization procedures were not done according to manufacturer guidelines. The facility's failure to implement proper sanitization practices placed vulnerable residents at increased risk of foodborne illnessFindings: 1. During a concurrent observation, interview, and record review on 4/14/25 at 9:50 a.m., inside the facility kitchen with the Interim Dietary Supervisor (IDS), IDS was observed performing a chemical concentration test of the kitchen sanitizing solution found in red containers. The chemical test measured 700 ppm (parts per million - a unit of measurement that describes the concentration of a substance in a solution or mixture). IDS mentioned the measurement should be at least 200 ppm as shown on the kitchen form Quaternary Ammonium (the chemical found in the sanitizing solution that is used to kill bacteria, viruses and molds) Log, dated April 2025. IDS also mentioned the sanitizing solution was replaced every two hours. When asked if staff performed chemical concentration testing every time the solution was replaced, IDS stated, We don't test it. During a review of the facility's policy and procedures (P&P) titled, Quaternary Ammonium Log Policy, dated 8/2023, the P&P indicated in part, POLICY: The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution . PROCEDURE . The replacement solution will be tested prior to usage 2. During a concurrent interview and record review on 4/14/25 at 2:40 p.m., with the facility's Maintenance Supervisor (MS), the Ice Machine Cleaning Log(s), from January 2025 - March 2025 were reviewed. The log indicated the following maintenance tasks performed on the ice machine: a) Clean fins of coil - use vacuum cleaner or cleaning solution, b) Lubricate all parts in accordance with manufacturer, c) Tighten all connections required, d) Check and clean lid gasket, e) Clean exterior of the machine. MS indicated he performed the cleaning tasks using Nickel Safe Ice Machine Cleaner (a food-grade product for removing scale deposits from ice makers) , and IMS-III Sanitizing Concentrate (chemical that prevents the growth of bacteria, mold and mildew within ice machines and dispensers) to sanitize the EXTERIOR of the ice machine ONLY. During a review of the ice machine manufacturer's ICE Machine Cleaning and Sanitizing Instructions, undated, the instructions indicated the following steps: . 4) Add recommended amount of approved nickel safe ice machine cleaner to the water trough according to label instructions on the container, 5) Initiate the wash cycle at the ICE/OFF/WASH switch by placing the switch in the WASH position. Allow the cleaner to circulate approximately 15 minutes to remove mineral deposits, 6) Depress the purge switch and hold until the ice machine cleaner has been flushed down the drain and diluted by incoming water ., 10) Use an EPA (Environmental Protection Agency) approved food equipment sanitizer at the solution mix recommended by the sanitizer manufacturer, 11) Add enough sanitizing solution to fill the water trough to overflowing and place the ICE/OFF/WASH switch to the WASH position and allow to circulate for 10 minutes and inspect all disassembled fittings for leaks ., 12) Depress the purge switch and hold until sanitizer has been flushed down the drain

Based on observation, interview, and record review, the facility failed to ensure privacy curtains were in good condition for one of four sampled residents (Resident 54). This facility failure had the potential for the patient's privacy to be compromised. Findings: During an initial tour of Resident 54's room on 4/14/25 at 11:00 am., the privacy curtain on the right side of the resident's bed was observed to have large tears on multiple areas. During an interview with the licensed nurse (LN) 2 on 4/14/25 at 12:34 pm, LN2 acknowledged the curtain needs to be replaced. During an interview with the maintenance supervisor (MS) on 4/14/25 at 2:40 pm, the MS indicated housekeeping is the one in charge of maintaining the curtains. During an interview with the housekeeping supervisor (HS) on 4/14/25 at 3:39 pm, the HS acknowledged the tears on the privacy curtain. The facility policy and procedure titled Maintenance Service dated December 2009 indicates Maintenance service shall be provided to all areas of building, grounds and equipment.

Based on interview and record review, the facility failed to ensure individual financial records were provided to residents on a quarterly basis. This failure had the potential to violate the residents' rights to be routinely informed of their personal funds account activity. Findings: During an interview on 4/14/25: at 11:26 a.m. with Resident 10 and Resident 13, Residents 10 and 13 verbalized that the facility held their personal funds for safekeeping. Residents 10 and 13 were informed that a facility usually deposited resident personal funds into a bank account specifically created for the resident. When asked if the facility had provided them with a copy of their account statements or any documentation of their account activities, both residents verbalized they have not. During an interview on 4/16/25 at 3:48 p.m. with business office staff (BOS), BOS verbalized only providing an account statement if a resident requested an update and does not provide resident account statements on a regular basis. BOS was informed of regulatory requirements that in addition to requests, resident account statements must be provided on a quarterly basis. BOS stated, We will start doing that. During an interview on 4/16/25 at 4:24 p.m., the Director of Nursing (DON), DON was informed of the finding and acknowledged that the facility will start providing individual account statements on a quarterly basis. During a review of the facility's policy and procedures (P&P) titled, Accounting and Records of Resident Funds, dated 4/2021, the P&P indicated in part, . 5) Individual accounting records are made available to the resident through quarterly statements and upon request

Based on observation, interview, and record review, the facility failed to ensure the most current survey results and the plan of correction was posted in a place readily accessible to residents and the public. This failure had the potential for the residents, family and their legal representatives to not be fully informed of the facility's deficient practices and how they were corrected. Findings: During a concurrent observation and interview on 4/15/25 at 3:58 p.m., with the Administrator Assistant (AA) the survey results binder was observed stored in a file organizer mounted high on the wall outside of the medical records office in the east wing hallway. AA acknowledged the survey results binder is not easily accessible to residents in wheelchairs, and it should be placed in a location where residents can review it without having to ask for help. During a concurrent interview and record review on 4/16/25 at 4:45 p.m., with the Director of Nursing (DON), the survey results binder was reviewed. The survey results binder included the results of complaints, and the last recertification survey conducted from 3/18/24 to 3/21/24. The DON was not able to find the plan of correction in the binder. DON stated the plan of correction is not in the binder for residents and visitors to review and acknowledged it should be. During a review of the facility's policy and procedure (P&P) titled Survey Results, Examination of, (undated), the P&P indicated, 2. A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc , along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.

Based on interview and record review, the facility failed to follow up on positive Level I Preadmission Screening and Resident Reviews (PASRR-mental disability assessment) for two of eight sampled residents (Residents 34 and 43). This failure had the potential to result in the residents not followed up for mental health screening post admission and not being adequately assessed to receive recommended care and treatment. Findings: 1. During a review of Resident 34's Admission Record (AR) indicated, the resident was admitted to the facility with a history of diagnoses that include unspecified psychosis (when someone has delusions or hallucinations), unspecified mood affective disorder (mood disturbances that cause significant distress or impairment), and schizophrenia (mental disorder characterized by hallucinations, delusions, and disorganized thinking, speech, and behavior). During a review of document titled, Department of Health Care Services (DHCS) letter, with the subject of Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screening Results dated 8/7/24 for Resident 34 indicated, Positive for SMI (serious mental illness). Further record review of document titled, DHCS letter, with the subject of Notice of Attempted Evaluation, dated 8/07/24, for Resident 34 indicated, Unable to complete Level II evaluation .Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening .The case is now closed. To reopen, the facility must resubmit a new Level I screening. A review of Resident 34's clinical records showed no new level I PASRR was done after the 8/7/24 recommendation by DHCS. During an interview with the Director of Nursing (DON) on 4/17/25 at 10:52 a.m., the DON acknowledged Resident 34 had a positive PASRR Level I and a PASRR Level II was not done. The DON stated Resident 34 was admitted directly to the facility from a hospital and was told by a representative at DHCS that the facility did not need to have Resident 34 complete a Level II PASRR. The DON could not procure any documentation from the State or DHCS indicating the Level II PASRR was not required. 51883 2. During a review of the medical record for Resident 43, on 4/16/25 the medical record indicated an admitted [DATE] with diagnoses including but not limited to 'Alzheimer's' (a progressive brain disorder that primarily was conducted. affects memory, thinking, and behavior), 'Dementia' (a decline in mental ability, particularly memory, thinking, and reasoning, that significantly impacts daily life), and 'unspecified psychosis' (a diagnosis assigned when someone experiences psychotic symptoms (delusions or hallucinations), but their symptoms don't fully meet the criteria for a specific psychotic disorder, or there's insufficient information to make a more specific diagnosis). During a record review of the pre-admission PASRR Level 1 Screening, dated 9/3/24 revealed Resident 43 was Positive (+) for Serious Mental Illness (SMI). Level II PASRR was not followed up on by facility. During a record review of a letter from The Department of Health Care Services (DHCS) dated 10/16/24, the letter stated, Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During an interview conducted with the DON on 4/16/25 at 9:01 a.m., the DON confirmed that facility's follow up was not made to DHCS because DON thought the case was closed, but acknowledged they should have followed up with DHCS. Further review of the medical record for Resident 43, it was noted that on 1/25/25, Resident 43 had a significant change in condition to Hospice (a type of specialized healthcare that focuses on providing comfort and support to individuals facing the end of life, particularly those with terminal illnesses), and a PASARR screening had not been initiated. During an interview with the DON on 4/15/25 at 1:41 p.m., the DON acknowledged that a PASRR Level I Screening should have been done earlier for Resident 43's significant change in condition. During a review of the facility's policy and procedure (P&P) titled, Admission Criteria (2001), the P&P indicated in part, . If the Level I screen indicates that the individual may meet the criteria for a MD (mental disorder), ID (intellectual disorder), or RD (related disorder), he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process .

Based on interview and record review the facility failed to ensure turning and repositioning intervention on the care plan (a document that summarizes how a patient's needs will be met, and their care will be managed) was implemented for one of four sampled residents (Resident 56). This facility failure had the potential for Resident 56 to develop a pressure sore (damage to the skin caused by constant pressure.) Findings: During a review of Resident 56's health record (HR), the HR indicated Resident 56 was admitted with a diagnosis of Parkinson's (movement disorder of the nervous system) disease and muscle weakness. Nursing summary dated 4/10/25 indicated Resident 56 is an extensive assist on physical functioning, bed mobility, transfer, eating, and toileting. Minimum Data Set (MDS) -a standardized assessment tool that measures health status in nursing home residents)) dated 2/28/25, Section GG Functional Abilities and Goals indicated, Resident 56 is a substantial/maximal assist for roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer. Care plan indicated risk and potential for skin breakdown with an intervention of turn and reposition every 2 hours. Turning and repositioning log indicate on these dates: 3/1925, 3/25/25, 3/28/25, 3/30/25. 4/1/25, 4/6/25, 4/8/25, 4/12/25 and 4/15/25 Resident 56 was not turned and repositioned every 2 hours. During a concurrent interview and record review with the director for staff development (DSD) on 4/16/25 at 12:18 pm, the DSD acknowledged Resident 56 was not turned every 2 hours. The facility policy and procedure titled Repositioning dated May 2013 indicates in part The purpose of this procedure is to provide for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown and provide pressure relief for residents . Residents who are in bed should be on at least an every 2 hour repositioning schedule . Resident who are in a chair should be on an every hour repositioning schedule.

Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of five sampled residents (Resident 13) when there was no justification from the physician for continued use beyond 14 days of the drug Ativan and/or Lorazepam (a medication used to help control anxiety). This failure had the potential for Resident 13 to receive an unnecessary medication and have adverse complications due to the medication. Findings: During a review of the order summary (OS) for Resident 13, the OS indicated Lorazepam 1 mg (milligram - unit of measure) tablet. Give 1 tablet by mouth every 8 hours as needed for anxiety for 30 Days m/b (manifested by) inability to relax. Starting 3/18/25 with STOP date of 4/17/25. During an interview on 4/16/25 at 3:37 p.m. with the Director of Nursing (DON), DON acknowledged the physician order for PRN (as needed) Lorazepam was for 30 days and there was no physician justification for continued use beyond 14 days. During a review of facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated July 2022, P&P indicated, 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. 1. For psychotropic medications that are NOT antipsychotics (medications for a mental health condition where it's difficult to tell what's real and what isn't): If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on observation, interview, and record review, the facility failed to ensure Resident 1 received adequate supervision when Resident 1 was left unsupervised in the designated smoking area and proceeded to wheel herself across a parking lot from the designated smoking area. This failure resulted in Resident 1's wheelchair being hit by a car, and Resident 1 being run over by the same car causing critical injuries that led to her death. Findings: During a review of Resident 1's face sheet dated 10/4/21, the face sheet indicated diagnoses including, unspecified mood disorder (a mental health problem that primarily affects a person's emotional state), other secondary Parkinsonism (symptoms similar to [CONDITION(S)] that are caused by certain medicines), unspecified Alzheimer's Disease (a progressive disease starting from mild memory loss and possibly leading to a loss of the ability to carry on a conversation and respond to the environment), unspecified generalized muscle weakness, Dementia in other diseases classified elsewhere with behavioral disturbance (a general term for memory loss and cognitive abilities serious enough to interfere with daily life), nicotine (a stimulant that is the main ingredient in tobacco products) dependence, cigarettes, uncomplicated, personal history of other mental and behavioral disorders, and unspecified [CONDITION(S)] (clouding of the lens of the eye). During a review of Resident 1's History and Physical (H&P), dated 10/6/20, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions per physician assessment. During a review of Resident 1's Minimum Data Set (MDS - resident assessment of healthcare functional needs and abilities), dated 7/31/21, the MDS indicated, Resident 1's cognitive skills were moderately impaired, with a Brief Interview for Mental Status score of 9 (BIMS - a test used to get a quick snapshot of how well a resident functions cognitively at the moment: 13-15 cognitively intact, 8-12 moderately impaired, and 0-7 severe impairment). Resident 1's functional status included, extensive assistance during bed mobility and transfers, requiring a one-person physical assist, supervision during locomotion off the unit, and total dependence during bathing, also requiring a one-person physical assist. During a review of Resident 1's Psychiatric Evaluations, dated 5/7/21, 6/8/21, and 9/9/21, the evaluations indicated, Resident 1 was assessed as unpredictable and confused, delusional (beliefs that are contradicted by reality or rational argument, and a typical symptom of mental disorder), had impaired/no judgment and insight, and had intermittent irritability around smoking time. During a review of Resident 1's Smoking Assessment, dated 7/31/21, the smoking assessment indicated, Resident 1 had cognitive loss, smokes six to ten times per day (morning, afternoon, and evening), refuses use of a smoking apron. The assessment also indicated; facility staff will continue to monitor resident's whereabouts especially during smoking time to ensure safety of the resident. During a review of Resident 1's Smoking Care Plan, initiated 6/2/14, last updated, 7/25/21, the care plan indicated, Resident was at risk for safety hazard, injury to self and/or others related to smoking and/or lighting materials. Resident does not use a smoking apron and goes out to smoke when she wants to. Care plan interventions included, Monitor for safe smoking habits and compliance with smoking schedule. Encourage resident to follow safe smoking policy and procedures; smoke only in designated areas . During a concurrent observation and interview on 10/4/21, at 9:50 a.m., with the Assistant Administrator (AADM), and Infection Preventionist (IP), in the parking lot next to the original designated smoking area, a visual inspection was completed, pictures were taken, and drawings were depicted of the area where the accident happened. The AADM and IP interchangeably explained the sequence of events that transpired on 10/1/21. The AADM and IP stated, Resident 1 had finished her smoke break and started to go to the door located on the side of the facility leading to the parking lot and smoking area in her wheelchair, when suddenly, she veered to her right. The Receptionist (RECPT) overseeing Resident 1 was at the entrance getting ready to open the door when another resident with a tab alarm wanted to go out. This triggered the alarm to go off and the RECPT was trying to turn the alarm off. During this time, Certified Nursing Assistant (CNA) 1 was driving around the parking lot to park after coming back from lunch. CNA 1 made a slow turn and hit Resident 1 in her wheelchair. This ejected Resident 1 from the wheelchair. CNA 1's car went over the wheelchair, tilting the car upward. CNA 1 thought it was a flat tire, stopped for a moment, and then proceeded to drive again. When CNA 1 was about to go over the resident, CNA 1 accelerated to make sure to go past that obstacle, not knowing that Resident 1 was the obstacle. The car dragged Resident 1's body towards the first available parking space, where CNA 1 parked the car. Around the same time, another CNA, (CNA 2), witnessed part of the accident. CNA 2 got out of her car to try to help but it was too late. At this point, CNA 1's car had already hit Resident 1 and ran over her body. CNA 2 then alerted CNA 1 as to what had just happened. CNA 1 got out of the car and only then realized she ran over Resident 1. CNA 2 ran inside the facility to get help. Staff came out to help until the ambulance and fire department came along with the police. While being transported to the hospital, Resident 1 passed away. During a review of Resident 1's hospital records, dated 10/1/21, the emergency room (ER) physician notes indicated, Resident 1's diagnosis to be Traumatic [CONDITION(S)] (is a condition in which the heart has ceased to beat due to [MEDICATION(S)] or penetrating trauma). Further review indicated, Resident 1 was transported by paramedics with agonal respirations (someone who is not getting enough oxygen and is gasping for air), on the way to the hospital, Resident 1 suffered a [CONDITION(S)] and was dead upon arrival. Time of death was recorded at 8:22 p.m. During an interview on 10/4/21, at 3:23 p.m., with Resident 2, Resident 2 stated, he was outside by the parking lot talking to a friend on the phone when he saw Resident 1 in her wheelchair moving down towards the parking lot. Resident 2 stated, he saw a car turning and hit Resident 1 in her wheelchair. The car then continued forward to park. Resident 2 stated he heard a clunk, clunk, CNA 1 got out of her car and CNA 2 was going towards the accident. Resident 1 just kept going even though the car was coming. The sun had already set and was dark. There is good lighting over the parking area, but the smoking area is dark. During an interview on 10/4/21, at 4:14 p.m., with the RECPT, the RECPT stated, Resident 1 Prefers to be left alone to do her business and supervised the resident from inside the entrance door most times and could usually see the resident, and never had issues because it was always just routine. The RECPT stated, she was trained by another RECPT when it was her first time to take Resident 1 out for a smoke. The training to supervise a resident while they were smoking was, to keep an eye watch on them, and be aware as to where they are going and not to leave the lighter with the resident. The RECPT stated, it was around 7:35 p.m. and Resident 1 wanted to go to smoke and asked for a cigarette. The RECPT stated, she took the resident outside, lit her cigarette with a lighter, and took the lighter back inside, as she never leaves it with the resident. The RECPT stated, Resident 1 was supervised from inside the entrance door at the time of the incident, I supervised from a distance .from the entryway. After smoking, she stated, Resident 1 gestured with her hand to let her know she was done. She opened the door, then another resident set off the alarm at the door. I had to redirect the other resident and when I turned around, I saw Resident 1 on the ground with CNA 1 out of her car and CNA 2 came inside saying, call 911. The RECPT stated, she doesn't have to be standing directly with or have proximity to the resident to supervise but checks in on her frequently. During an interview on 10/4/21, at 5 p.m., with CNA 3, CNA 3 stated, the light over the parking area is bright but the light over the smoking area is not as bright and would be difficult to see at night from the doorway. You stay next to them the entire time. If they do not like for me to be next to them, I stay at most 10 feet away, in case of an emergency. During an interview on 10/4/21, at 6 p.m., with CNA 4, CNA 4 stated, while supervising a resident smoking, you stay close to them, don't leave them by themselves .not more than five to six feet. During an observation on 10/5/21, at 9:10 a.m., within the area of the accident, measurements of the surrounding area were taken. The edge of the doorway to the table in the smoking area was 60 feet. From the tree at the end of the smoking area, behind the table to the doorway was 70 feet. During an interview on 10/5/21, at 10 a.m., with CNA 2, CNA 2 stated, she was going to lunch and was about to leave the driveway when she saw the accident happen. CNA 2 stated, When I saw what was happening, I immediately stopped the car and parked and I ran to CNA 1's car, but it was too late. I saw Resident 1 being run over by the car. I ran inside to ask for help. During an interview on 10/5/21, at 3:50 p.m., with CNA 1, CNA 1 stated, on the night of the accident, she was coming back from lunch. She was driving in the parking lot and started to make a turn to park when, It felt like a flat tire and I kept going and it felt weird, but I kept driving and got into the first space. Then someone came to me and kept telling me it's (Resident 1 . it's (Resident 1). I stopped the car and parked, ran out and I saw the patient. I did not see anything, and it felt like a flat tire or something was under the car. During an interview on 10/5/21, at 4:30 p.m., with Registered Nurse Supervisor (RNS), RNS stated that when the accident happened, she called 911. RNS stated, Supervision is when you sit with them. A safe distance would be one to two feet. I think someone should sit with them. During an observation on 10/5/21, at 7:30 p.m., at the accident location by the parking lot, a visual inspection was conducted during nighttime. General lighting in the area was observed. There were three sets of lights, two were focused on the parking lot, these lights were bright and illuminated certain areas of the parking lot, and were activated by movement, and one sensor light was focused on the previous smoking area, where Resident 1 smoked. The light by the smoking area was not bright, and when it was off, the area became dark. Observation from a view from the doorway (outside), there was a tree preventing a direct view of the smoking area. Observation inside the doorway, looking through the glass the view of the smoking area was obstructed. Observation of the smoking area by the doorway, a person could not be visualized. During an interview on 10/6/21, at 3:15 p.m., with Licensed Vocational Nurse (LVN), LVN 1 stated, Supervision means having eyes on the patients all the time. You stand next to them. During an interview on 10/6/21, at 5:25 p.m., with the Director of Nursing (DON) and AADM, the DON stated, Supervision can be direct, visual, full supervision, case by case basis, depending on the needs of the resident. For example, wandering is one to one supervision. Resident 1 was one to one supervision. The AADM stated, Supervision is visual and audio supervision at any distance and is case by case basis. The AADM and DON were made aware of the distance of 60 to 70 feet between Resident A and the doorway, where RECPT stated she was standing observing the resident. The DON stated, you can't supervise a resident from a distance of 60-70 feet. During a review of facility's P&P, titled, Smoking Policy - Residents, dated December 2007, the P&P indicated in part, 1. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences .7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. 8. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 13c. Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment was maintained when live and dead cockroaches were found in the kitchen. This deficient practice had the potential to cause foodborne illness to all of the 83 highly susceptible residents currently residing in the facility. According to the FDA (Food and Drug Administration) Food Code (YEAR), A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; . or older adults; and (2) Obtaining food at a facility that provides services such as .health care . Findings: During an observation and concurrent interview on 10/06/19 at 4:04 PM, by the sink and dishwasher area, Dietary Aide (DA) confirmed observing cockroach running around on the floor by our feet. During further observation an Orkin trap was noted under the dishwasher next to the floor drain. DA indicated it was for small ants due to the summer heat. When asked to look in the trap, a live cockroach was observed trapped in the gel. DA confirmed it was a cockroach and indicated she had no knowledge of cockroaches in the kitchen prior to today. During an observation and concurrent interview with DA in the kitchen on 10/6/19, at 04:10 p.m., there were large two more bait traps found in the kitchen. One bait trap was located under the sink where the vegetables were being washed, the second bait trap was located under the rack where the dry storage food items are kept. On 10/06/19 at 4:40 PM the survey team notified the Director of Nursing (DON) of the IJ due to the cockroach infestation around the sink and dishwasher area, this resulted in an immediate jeopardy (IJ) situation that could cause foodborne illness to all residents residing in the facility. During an interview on 10/6/19, at 4:41 p.m., the director of nursing (DON), indicated she was unaware of cockroaches in the kitchen. During an observation and concurrent interview with the dietary supervisor (DS), on 10/6/19, at 5:22 p.m., the bait trap under the kitchen sink contained five large dead insects. DS indicated he was not aware there was a Roach problem in the kitchen. During an interview on 10/6/19, at 6:15 p.m., the assistant administrator (AA), acknowledged she was unaware of the pest control issue in the kitchen. During an interview with the registered dietician (RD) on 10/6/19, at 6:45 p.m., RD indicated she did not know the kitchen had issues with cockroaches. RD verbalized that DS did not inform her of the issue. On 10/06/19 at 7:23 PM the IJ was abated in the presence of the Assistant Administrator (AA) and DON after an acceptable plan of action was provided by the AA which included the following; closed the kitchen and removed the food service equipment for a thorough pest control service, obtained meals for the residents from outside restaurants that had passed their County inspection, use of disposable products, and kitchen was deep cleaned and sanitized. In addition, the plan included routine monitoring of dietary staff cleaning schedule and the outside pest control service was increased to monthly. Record review of the facility's pest control service titled Inspection Reports dated 10/2/19, indicated the service had found a Few live bugs around the dishwasher and they are seeing them. Conditions listed were food debris, moist temperature, cracks and crevices in the back for them to hide them. On 10/2/19, the report further indicated gel bait and three monitoring glue boards were placed around the dishwashing area and kitchen areas target pest German Roaches in the Dishwashing areas and Kitchen areas, recommendations to service the kitchen area after staff is gone. During an interview with DS on 10/8/19, at 1:30 PM acknowledged he did not read the pest control report written on 10/2/19. During an interview on 10/8/19, at 2:30 p.m., the director of nursing (DON), acknowledged she did not see or read the pest control report written on 10/2/19 and verbalized each department is responsible for reviewing their reports. During an interview on 10/8/19, at 2:35 p.m., the assistant administrator (AA), acknowledged she did not read the pest control report written on 10/2/19, AA further acknowledged that normally each department is responsible for reading and taking action for their department. The facility policy and procedure titled Sanitization dated 12/8, indicated The food service area shall be maintained in a clean and sanitary manner. The policy further indicated 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. According to the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health-Care Facilities dated 7/19, indicated Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector.

Based on interview and record review, the facility failed to provide supervision and assistance devices when a pressure alarm and low bed recommended by the physical therapist to minimize fall risk was not evaluated and implemented for one of three sampled residents (Resident 2). As a result, Resident 2 fell during an unassisted transfer and fractured her hip. Findings: Review of Resident 2's comprehensive assessment dated [DATE] revealed, impaired cognition (mental process of understanding), required extensive assistance with transfers and bed mobility, and balance problems during transitions and walking. Review of fall risk assessment dated [DATE] revealed, Resident 2 was a fall risk related to intermittent confusion and use of antihypertensive (drugs for high blood pressure control) and psychotropics (mood-altering drugs) medications. Review of care plan created on 5/6/15 revealed, Resident 2 was a fall risk due to balance problem, weakness, memory problem, and severe cognitive impairment. The goal was to minimize the risk of falls/injury daily. One of the interventions included the use of High-low bed (beds that can be adjusted to high or low position). Review of physician's orders [REDACTED]. Review of physical therapist's (PT 2) initial evaluation and plan of treatment dated 4/24/15 revealed, Resident 2 has poor balance and impaired gross motor coordination (harmonious functioning of body parts during movement). PT 2 recommended the use of pressure alarm (alarms when a resident changes pressure on the bed or chair) and keep bed in low position as fall precaution measures. Review of physical therapists' treatment notes signed by several physical therapists, dated 5/1, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/12, 5/13, 5/14, 5/15, 5/16, 5/18, and 5/19/15, revealed, fall precaution recommendations to use pressure alarm and keep the bed low. Review of PT 1's summary of status report dated 5/20/15 revealed, Resident 2 was ambulating with the use of front wheel walker with contact guard assist (direct contact with patient for safety but no physical assistance) but was unpredictable and loses her balance at times. PT 1 again, recommended the use of pressure alarm and to keep bed low. Review of PT 1's discharge summary dated 5/20/15 revealed, Resident 2 continued to have balance/coordination deficits affecting safety and all functional mobility. Review of facility's report dated 6/17/15 revealed, on 6/15/15, at 1 p.m., Resident 2 fell on the bathroom floor in her room when she went to the bathroom by herself. Resident 2 sustained a hip fracture was transferred to the hospital. Review of care plan conference summary dated 5/21/15 revealed, there was no evidence of the PT's recommendations for the use of pressure alarm and bed in low position was reviewed and followed up for implementation. The care plan was not updated to reflect the recommendations. Interview on 6/18/15 at 2:30 p.m., with licensed nurse (LN 1), who was responsible for initiating and updating Resident 2's fall risk care plan dated 5/6/15, confirmed, the high-low bed intervention was just a piece of equipment and not really an intervention. LN 1 was unaware of the PT's recommendations for the use of pressure alarm and to keep the bed lowered and these were not reflected in Resident 2's plan of care. LN 1 revealed, there was a daily interdisciplinary team (IDT) meeting to communicate resident specific recommendations but the PT's recommendation for Resident 2's fall precaution measures were not communicated and discussed. During an interview on 6/18/15, at 3:10 p.m. revealed, PT 1 was unable to recall if her recommendations for the use of pressure alarm and low bed for Resident 2 was communicated to nursing. Interview with PT 2 on 7/2/15, at 12:40 p.m. revealed, PT communicates recommendations during the daily stand-up/IDT meeting. PT 1 was unable to recall if the recommendations for the use of pressure alarm and low bed for Resident 2 was communicated to the team. During an interview with the LN 1 on 7/2/15, at 1:30 p.m., revealed, Resident 2 had no pressure alarm during her fall on 6/15/15. Review of facility policy titled, Alarms-Use of Personal, dated 6/15/15, states in part, Purpose 1. To alert staff of unassisted transfers. 2. To provide the highest degree of resident independence as possible. 3. To minimize risk of falls associated with unsafe transfer attempts 7. Use of an alarm will be included in the care plan and regularly reviewed by the IDT.

Based on record review and interview, the facility failed to ensure adequate supervision was provided for two of four sampled residents (Residents 1 and 2) to prevent accidents. As a result Residents 1 and 2 sustained second degree burns (a second-degree involves the first two layers of skin and may appear as reddening of the skin with pain and blisters). Findings: 1. Record review on 5/18/12, revealed Resident 1 was admitted with [DIAGNOSES REDACTED]. Resident 1 was assessed to have short and long term memory problems and moderately impaired cognitive skills for daily decision making. Resident 1 had unsteadiness in his hands and required direct supervision and encouragement for eating and drinking. Review of a nursing notes dated 2/6/12 at 12:30 p.m., revealed a certified nursing assistant (CNA), while toileting Resident 1, discovered an "18 x 12 cm (centimeter) pink skin discoloration irregular with 8 x 5 x 1 cm blister" to Resident 1's right thigh. During an interview on 6/13/12 at 9:15 a.m., the director of dinning services explained a CNA gave Resident 1 a cup of coffee while he was in bed during lunch and then left Resident 1 alone. It was later discovered that Resident 1 had sustained a burn. During an interview on 6/14/12 at 4:15 p.m., a licensed nurse (LN 2) explained the best practice would have been for the staff giving the cup of coffee to Resident 1 to make sure that the coffee was not scalding hot and that Resident 1 could safely hold and drink the cup of hot coffee. 2. Record review on 5/18/12, revealed Resident 2 was admitted with [DIAGNOSES REDACTED]. Review of the comprehensive assessment, dated 4/2/12, indicated Resident 2 had short and long term memory problems and moderately impaired cognitive skills for daily decision making. Resident 2 required limited assistance of one person for ambulation and extensive assistance of one person for transfer between surfaces including to or from the bed, chair, wheelchair, and standing position. Resident 2 was independent with eating. Review of a behavior care plan dated 4/3/12, indicated Resident 2 needed behavior management related to taking food and drinks from other resident meal trays. The goal was that Resident 2 would have "less episodes of taking food." There were no specific interventions identified as to how the facility would assist Resident 2 in achieving this goal such as keeping other residents food outside the reach of Resident 2. Review of nursing notes dated 4/11/12 at 7:15 p.m. revealed a CNA and Resident 2's family reported to the licensed nurse that Resident 2 had "blisters on right thigh." The note indicated Resident 2 stated "I spilled coffee." During an interview on 5/18/12 at 3 p.m., the facility administration explained Resident 2 was attending a facility coffee social with a CNA and the activities director present. Resident 2 was seated near another resident and grabbed this resident's cup of coffee spilling it on himself. During an interview on 6/14/12 at 4:15 p.m., administrative staff explained that staff are inserviced on the importance of providing supervision to prevent accidents when a resident is assessed to have impulsive behaviors (grabbing food and drinks from other residents). Administrative staff was unable to elaborate on any precautions taken during the coffee social to prevent Resident 2 from grabbing another resident's cup and being burned by the hot coffee. Review of the facility policy titled "Food Serving Temperatures" dated 9/2008 revealed resident safety is a critical concern and takes precedence over food temperatures to avoid accidental burns. Individual residents should also be evaluated and supervised for safety when using coffee mugs or utensils to prevent burns.