Every finding on record at Shadelands Post Acute

Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 74) to prevent falls and injuries when Resident 74 with history of unwitnessed falls was found sitting by the foot of her bed with gushing of blood from forehead and two open skin tears.This failure caused Resident 74 to continue to fall and had the potential to result in severe injuries. During a review of Resident 74's admission Record (AR), printed on 5/14/26, AR indicated Resident 74 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait and mobility (ability to move, walk or change position easily and freely), hemiplegia and hemiparesis affecting left side (stroke), lack of coordination, cognitive communication deficit.During a review of Resident 74's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/22/25, the MDS indicated Resident 74's ability to see in adequate light with glasses was severely impaired, no vision or sees only light, colors, or shapes; eyes do not appear to follow objects. MDS indicated Resident 74 was dependent on the assistance of two or more helpers to walk at least 10 feet in room, corridor, or similar space. MDS indicated Resident 74 used a walker and wheelchair for mobility. MDS indicated Resident 74 was dependent with toileting hygiene, helper does all the effort. MDS indicated Resident 74 had impairment on one side of the upper (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). MDS indicated Resident 74's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 03 which indicated severely impaired mental status. The BIMS score indicated Resident 74 was unable to recall the correct year, month, and day of the week. During a concurrent interview and record review on 5/13/26 at 9:32 a.m. with Assistant Director of Nursing (ADON), Resident 74's fall risk assessments and progress notes were reviewed. The fall risk assessments dated 11/23/25, 12/15/25 and 2/10/26 indicated a score of 20, 20 and 22, respectively indicating Resident 74 was at high risk for falls. Further review of Resident 74's progress notes indicated that Resident 74 had the following unwitnessed falls:On 12/20/25 at 14:30 (2:30 PM) Resident 74 had unwitnessed fall. Staff found her lying down on the floor. Resident 74 complained of pain left arm.On 1/14/26 at 23:57 (11:57 PM), Resident 74 had unwitnessed fall, she was found lying on the floor. Resident 74 complained of left hip pain.On 2/10/26 at 16:02 (4:02 PM), Resident 74 had a fall in her room, combative rolled herself over the bed onto fall matt and crawled towards bathroom.On 2/24/26 at 22:25 (10:25 PM), Floor nurse found Resident 74 on top of her floor mattress.On 3/8/26 at 01:35 (1:35 AM), Resident 74 was found sitting on top of the fall mattress by the foot of the bed. Resident 74 was noted with gushing of blood to her forehead and two open skin tears. Resident 74 was transferred to emergency department (ED) for further evaluation.During an interview on 5/14/2026 at 8:42 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1stated Resident 74 was at high risk for falls. LVN1 stated Resident 74 was placed in room opposite the nurses' station. LVN 1 stated when Resident 74's daughter was present at facility Resident 74 was cooperative with care. LVN 1 stated Resident 74 became agitated couple of time got out of bed wanting to go home, looking for her daughter, need to find her belongings. LVN 1 said sometimes nurses are attending to other residents, Certified Nursing Assistants (CNAs) are on the floor answering call lights in other residents' room as much as possible. LVN 1 stated it was hard to coordinate to have someone monitor permanently at all times. LVN 1 stated Resident 74's daughter asks if facility could provide one-one-sitter, so we explain that family provide sitters. LVN 1 stated that Resident 74's daughter was concern about finance.During an interview on 5/14/26 at 9:36 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated Resident 74 rolls off the side of bed. CNA1 said staff kept eye on Resident 74. CNA1 said sometimes there was no staff at the nurse's station to monitor and at that time Resident 74 will slide down. CNA1 stated sometimes CNAs are doing rounds, nurse doing wounds. supervisor care meeting with other residents and there may be no staff at the nurse's station to watch.During a concurrent interview and record review on 5/13/26 at 4:56 p.m. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) Resident 74's fall care plans dated 2/24/26 and 2/27/26 were reviewed. Resident 74's fall care plan indicated Resident 74's falls are related to impaired safety judgement, impulsive behavior, decreased mobility and failure to follow safety precautions. Resident 74's fall care plan interventions included frequent rounding added to fall rounds. DON stated Resident 74 was monitored hourly with rounds. DON stated Resident 74 was moved to a room closer to nurses' station and monitored with frequent rounding. DON could not provide documentation to support hourly and frequent rounding's to fall rounds was provided for Resident 74.During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, revised March 2018, the P&P indicated; Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based an observation, interview and record review, the facility failed to observe infection control practices when residents dirty clothing were not bagged properly when transported to the laundry.This failure had the potential for spread of infections among residents at the facility. During a concurrent observation and interview on 5/13/26 at 3:19 p.m. with Environmental Services Director (ES), three mesh bags of residents dirty clothing were observed on the floor in the laundry room. ES stated resident's dirty clothing should be covered with a plastic bag when transported to the laundry room to prevent spread of infection.During an interview on 5/14/26 at 9:18 a.m. with Certified Nursing Assistant (CNA3), CNA 3 stated that residents dirty clothing are place in a plastic bag then hamper when transported to the laundry. During an interview on 5/14/26 at 10:45 a.m. with CNA 2, CNA 2 stated she received training of how to transport resident's personal dirty clothing to the laundry. CNA 2 stated dirty personal clothing are placed in a plastic bag and then placed in a mesh laundry bag before transported to the laundry to prevent spread of infection. CNA 2 stated she cared for resident in room [ROOM NUMBER] and placed the dirty clothing in the laundry. CNA 2 stated it must have been an oversight on her part that the dirty personal clothing was not first placed in a plastic bag. CNA stated she was sorry about the incident.During an interview on 5/14/26 at 8:23 a.m. with Licensed Vocational Nurse/Infection Preventionist (IP), IP stated residents' dirty clothes need to be in a plastic bag and placed in meshed bags when transported to laundry to prevent spread of infection. During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated January 2026, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices fotr infection prevention and control

Based on interview and record review the facility failed to ensure the implementation of its antibiotic use protocols for one of nine sampled residents (Resident 25), that address unnecessary or inappropriate antibiotic use.This failure had the potential for residents to receive unnecessary antibiotics and risk of development of antibiotic-resistant organisms. During a review of Resident 25's Nurse's Note (NN), dated 4/11/26, The NN indicated Resident 25's daughter stated Resident 25's had frequent urination throughout the night. Resident 25's daughter called the facility and spoke with supervisor. MD was notified of Resident 25's symptoms and Urine test /Culture & Sensitivity (UA/C/S) was ordered.During a review of Resident 25's Lab Results Report (LR), dated 4/14/26 and 4/20/26, the LR indicated Resident 25 UA/CS, collected on 4/11/26 and 4/17/26, final result indicated urogenital flora was isolated. During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), facility's monthly antibiotic stewardship/surveillance log (ATB), April and May 2026 were reviewed. The April 2026's ATB log indicated Resident 25 was admitted to facility on 3/17/26. ATB log indicated that on 4/11/26, Resident 25 had urinary frequency and was prescribed Macrobid oral capsule 100mg twice a day for 5 days for urinary tract infection (UTI). Further review of ATB log indicated Resident 25's use of Macrobid for UTI did not meet McGeer's Criteria. (McGeer criteria are standardized, evidence-based definitions used to identify and track infections in nursing homes and long-term care facilities). ATB logs indicated a number of residents use of antibiotics did not meet Mcgreer's criteria. IP stated nurses' do not have or use criteria when receiving orders for antibiotics. IP stated she use McGreer criteria after residents are started on antibiotic medication. IP stated facility did not follow antibiotic stewardship program with Resident 25's use of antibiotics for UTI. IP stated Resident 25's order for antibiotics should have been discontinued when LR showed it was urogenital flora. IP stated there are a number of residents on April 2026's ATB logs use of antibiotics that did not meet McGeer's criteria for infection and not consistent with antibiotic stewardship.During an interview on 5/14/26 at 8:52 a.m. with Licensed Vocational Nurse (LVN1), LVN1 stated nurses do not use criteria when communicating residents suspected infection signs and symptoms or receiving antibiotic medication orders with physician. LVN 1 stated when order for antibiotics is received nurses' call and inform family. LVN 1 stated families want residents' to be address with antibiotics and families sometimes insist. LVN 1 stated she was aware of the criteria, but we do not have or use [NAME] to crosscheck. LVN 1 stated she notified IP when physician ordered antibiotic for residents for follow up. During an interview on 5/14/26 at 8:23 a.m. with IP, IP stated that she did not know if the nurses use [NAME] to communicate with physician when order for antibiotics is received. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated December 2016, the P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. When a nurse calls a physician / prescriber to communicate a suspected infection, he or she will have the following information available: a. Signs and symptoms.b. When symptoms were first observed.c. Resident's hydration status.d. Current medication list. e. Allergy information. f. Infection type.g. Any order for warfarin and result of last INR. h. Lat creatinine clearance or serum creatinine, if available [NAME]. Time of the last antibiotic dose.

Based on interview and record review, the facility failed to ensure four of nine sampled residents (Residents 3, 9, 24) were offered appropriate pneumococcal (PNA- a disease that can cause infection in the lung) vaccination series.This failure had the potential to place Residents 3, 9, 24 and 34 at risk to be infected and spread of pneumococcal infection.During a review of Resident 3's admission Record (AR), printed on 5/13/26, AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (memory loss). During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 3's Immunization Record (IR). was reviewed. IR indicated Resident 3 had pneumococcal PPSV23 vaccine in 10/28/16. IP stated she did not know the time interval of when to recommend pneumococcal vaccine after the last dose. IP stated she was not aware of Center for Disease Control and Prevention (CDC) recommendations for use of pneumococcal vaccine series.During a review of Resident 9's admission Record (AR), printed on 5/14/26, AR indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included anemia (blood condition where body does not have enough healthy blood cells to carry oxygen to the body tissue).During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 9's Immunization Record (IR). was reviewed. IR indicated Resident 9 refused pneumococcal PPSV23 vaccine. IR indicated Resident 9 had no history of other pneumococcal vaccine. IP stated she did not know of the CDC recommendations for use of pneumococcal vaccine series. During a review of Resident 24's admission Record (AR), printed on 5/13/26, AR indicated Resident 24 was admitted to the facility on [DATE], with diagnoses anemia (blood condition where body does not have enough healthy blood cells to carry oxygen to the body tissue).During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 24's Immunization Record (IR). was reviewed. IR indicated Resident 24 refused pneumococcal PPSV23 vaccine. IR indicated Resident 24 had no history of other pneumococcal vaccine. IP stated she did not know of the CDC recommendations for use of pneumococcal vaccine series.During a review of Resident 34's admission Record (AR), printed on 5/13/26, AR indicated Resident 34 was admitted to the facility on [DATE], with diagnoses sepsis (The body's extreme life-threatening response to an infection).During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 34's Immunization Record (IR). was reviewed. IR indicated Resident 34 refused pneumococcal PPSV23 vaccine. IR indicated Resident 34 had no history of other pneumococcal vaccine. IP stated she did not know of the CDC recommendations for use of pneumococcal vaccine series.According to CDC pneumococci vaccination recommendations for patient characteristics Age: 50 years, PPSV23: no prior doses, PCV13: no prior doses, risk factor not applicable. Give one dose of PCV15, PCV20, or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV231 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least 1 year. Footnotes: If PPSV23 was inadvertently given before PCV15, one dose of PCV15, PCV20, or PCV21 should be given at least 1 year after PPSV23.{Reference:https://www2a.cdc.gov/vaccines/m/pneumo/agegroup.html}A review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 2001, indicated, Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 74), was provided information necessary to obtain an informed consent prior to the administration of Trazodone ( an antidepressant medication used for treatment of major depressive disorder in adults), when the physician (MD1) did not inform Resident 74's responsible party (RP) in advance of the use, risks, and benefits of Trazodone. This failure had the potential to deny residents and surrogate decision maker information needed to make an informed decision. During a review of Resident 74's admission Record (AR), printed on 5/14/26, AR indicated Resident 74 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting left-dominant side (stroke), cognitive communication deficit, depression (mood disorder) and anxiety disorder ( fear or worry that interferes with daily life). AR indicated RP was Resident 74's responsible party.During a review of Resident 74's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/22/25, the MDS indicated Resident 74's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status), score was 03 and indicated severely impaired mental status. The BIMS score indicated Resident 74 was unable to recall the correct year, month, and day of the week. MDS indicated Resident 74 was unable to recall recent information with cueing. MDS indicated Resident 74 had clear speech, make self-understood and understand others. During a review of Resident 74's Order Summary Report (OSR), dated 12/19/25 OSR indicated MD1 prescribed Trazodone oral tablet 50 mg give one tablet by mouth at bedtime for depression manifested by inability to sleep.During a review of Resident 74's Medication Administration Record (MAR), dated 1/1/26 to 1/31/26, MAR indicated Resident 74 was administered Trazodone 50 mg one tablet by mouth at bedtime from 1/1/26 through 1/14/26.During a review of Resident 74's Interdisciplinary team note (IDT), dated 1/16/26, the IDT indicated that IDT met with Resident 74's RP to discuss care concerns. IDT indicated Trazodone medication was discussed. IDT indicated RP was not happy and stated that Resident 74 will never consent to a psychotropic medication like Trazadone and RP started to cry. IDT indicated MD 1 gave order to discontinue Trazodone. IDT (Interdisciplinary Team, a group of individuals representing different departments of the facility a professional discipline that work together to provide the greatest benefit to the resident which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically and appropriate and person - centered.During an interview on 5/14/26 at 11:25 a.m. with MD1, MD1 stated that he did not obtain informed consent for use of Trazodone from Resident #74's responsible party. MD 1 stated he did not speak with RP prior to prescribing Trazodone for Resident 74. MD1 stated Resident 74's RP did not want Resident 74 to be administered trazodone. MD1 stated that the facility process was that nurses communicate medication needs with residents and RPs and when there was need for clarification physician will talk to resident/family. During a concurrent interview and record review on 5/14/26 at 11:32 a.m. with Assistant Director of Nursing (ADON), Resident 74's Informed Consent-Psychoactive Medication (IC), dated 12/19/25 was reviewed. The IC indicated a licensed nurse has verified the resident or resident representative has given informed consent verbally or via phone. ADON stated she completed the informed consent form because she assumed MD1 had obtained informed consent from Resident 74's responsible party. ADON stated she did not remember whether it was Resident 74's RP or son that ADON called for verbal consent. During a concurrent interview and record review on 5/14/26 at 12:01 p.m. with Director of Nursing (DON), Resident 74 IDT documentation dated 1/16/26, physician order and MAR were reviewed. IDT indicated MD1 did not provide Resident 74's RP information necessary to obtain an informed consent prior to the prescribing and nursing administration of Trazodone. DON stated she was aware that informed consent was not obtained prior to administration and use of trazodone. DON stated facility had provided in-service training to the nurses and MD. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, dated 4/2025, the P&P indicated, The prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a psychotropic medication.

Based on observation, interview and record review, the facility failed to ensure appropriate pain assessment was performed for one of eight sampled residents (Resident 18) when Resident 18, who was able to communicate verbally, was assessed for pain by facility staff using the Pain Assessment in Advanced Dementia (PAINAD, is an observational tool used to assess pain in patients with severe cognitive impairment who cannot verbally communicate their pain).This failure resulted in Resident 18 to receive pain medication without appropriate pain assessment.During a review of Resident 18's admission Record, dated 5/14/26, the admission Record indicated Resident 18 was admitted in the facility on 5/4/26 with an admission diagnosis of metabolic encephalopathy (a change in how your brain works due to an underlying condition), chronic diastolic heart failure (a condition when the heart's left fluid-filled chamber becomes thick and stiff and does not fill with enough blood between beats) and pleural effusion (an abnormal buildup of excess fluid between the layers of the thin selective barrier that line the lungs and chest cavity).During a record review of Resident 18's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 4/29/26, the MDS indicated Resident 18 had the ability to make himself understood (express ideas and wants) and had the ability to understand (clear comprehension) of others' verbal content. The MDS also indicated, Resident 18's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 14 out of 15, indicating cognitively intact status. A score of 8-12 indicated moderate cognitive impaired status and a score of 0-7 indicated severe cognitive impaired status.During a review of Resident 18's Nursing-Daily Skilled Charting Form, dated 5/12/26, indicated Resident 18 was able to communicate well verbally and was responsive.During an observation on 5/12/26 at 4:30 p.m. outside Resident 18's room, Resident 18 was observed requesting pain medication from Licensed Vocational Nurse (LVN) 3. LVN 3 was observed asking Resident 18 where his pain was. Resident 1 was heard saying both knees. LVN 3 was not heard asking Resident 1 for his pain level.During medication administration observation on 5/12/26 at 4:31 p.m., LVN 3 was observed preparing and administering one medication to Resident 18. This medication included one tablet of tramadol 50 milligram (mg).During an observation on 5/12/26 at 4:32 p.m., LVN 3 observed documenting Resident 18's pain level using the Pain Assessment in Advanced Dementia (PAINAD, is an observational tool used to assess pain in patients with severe cognitive impairment who cannot verbally communicate their pain)During a review of Resident 18's Order Summary Report, dated 5/4/26, Resident 18 was prescribed with one tablet of tramadol 50 mg every six hours as needed for moderate-severe pain (4-10 pain).During a review of Resident 18's Medication Administration Note, dated 5/12/26 at 4:32 p.m., LVN 3 documented that Resident 18 had knee pain (both knees) without a pain level.During a concurrent interview and record review on 5/13/26 at 4:49 p.m. with LVN 3, Resident 18's Medication Administration Record (MAR), dated May 2026 was reviewed. The MAR indicated, on 5/12/26, for the 4:32 p.m. administration time of one tablet of tramadol 50 mg, the pain level of Resident 18 was zero. LVN 3 stated, she did not ask Resident 18 for his pain level. LVN 1 stated, she had based her pain assessment of Resident 18 on his reaction.During a review of facility's policy and procedure titled Pain Assessment Using Numeric and PAINAD Scale, dated 3/25, indicated, Purpose: To ensure pain is identified, evaluated, treated, monitored, documented. Pain Assessment Tool Selection: Use the Numeric Pain Scale when the resident can reliably self-report: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain. Use the PAINAD Scale when the resident cannot reliably self-report. PAINAD scores five observed category: breathing, negative vocalization, facial expression, body language, and consolability.

Based on observation, interview and record review, the facility failed to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted when random controlled medication use audit for one of three residents (Resident 1) did not reconcile. The controlled medication was signed out of the controlled drug record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate the medication was given to the resident.This failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications.During a review of Resident 1's admission Record, dated 5/13/26, the admission Record indicated Resident 1 was admitted in the facility on 5/6/26 with an admission diagnosis of osteomyelitis of cervical vertebra (rare infection of the bones of the neck), acute respiratory failure with hypoxia (a life-threatening medical emergency where the lungs cannot adequately transfer oxygen to the bloodstream) and pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus).During a review of Resident 1's Order Summary Report, dated 5/6/26, the Order Summary Report indicated Resident 1 had an order for oxycodone (a controlled medication) 10 milligram (mg) one tablet by mouth every four hours as needed for pain.During a review of Resident 1's CDR for oxycodone, dated 5/6/26, the CDR indicated one amount of oxycodone 10 mg was used at 3:55 p.m.During a concurrent interview and record review on 5/13/26 at 2:19 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR), dated May 2026 was reviewed. The MAR indicated, on 5/6/26, there was no licensed staff initials in the box for Resident 1's one tablet of oxycodone 10 mg to demonstrate the medication was given. The ADON stated, Resident 1's one tablet of oxycodone 10 mg was not documented as given in the MAR. The ADON stated, the expectation from staff was to document in the MAR after the medication was taken out of the packaging and was signed in the CDR to know that the medication was given.During a review of the facility's policy and procedure titled, Controlled Substances, dated 11/22, indicated, Dispensing and Reconciling Controlled Substances: 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up., 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. records of personnel access and usage; b. medication administration records .During a review of the facility's policy and procedure titled, Administering Medication, dated 12/22, indicated, 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication.

Based on observation, interview and record review, the facility had a 7.69% error rate when two medication errors out of 26 opportunities were observed during the medication administration for two of eight sampled residents (Residents 18 and 59) when:1. Resident 18 received tramadol (medication used to treat pain) with a pain level of zero (no pain).2. Resident 59 did not receive polyethylene glycol (an over-the-counter medication used to treat occasional constipation) as ordered.These failures resulted in Resident 18 and 59 receiving medication not in accordance with the prescriber's orders.1. During a review of Resident 18's admission Record, dated 5/14/26, the admission Record indicated Resident 18 was admitted in the facility on 5/4/26 with an admission diagnosis of metabolic encephalopathy (a change in how your brain works due to an underlying condition), chronic diastolic heart failure (a condition when the heart's left fluid-filled chamber becomes thick and stiff and does not fill with enough blood between beats) and pleural effusion (an abnormal buildup of excess fluid between the layers of the thin selective barrier that line the lungs and chest cavity).During a record review of Resident 18's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 4/29/26, the MDS indicated Resident 18 had the ability to make himself understood (express ideas and wants) and had the ability to understand (clear comprehension) of others' verbal content. The MDS also indicated, Resident 18's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 14 out of 15, indicating cognitively intact status. A score of 8-12 indicated moderate cognitive impaired status and a score of 0-7 indicated severe cognitive impaired status.During a review of Resident 18's Nursing-Daily Skilled Charting Form, dated 5/12/26, indicated Resident 18 was able to communicate well verbally and was responsive.During an observation on 5/12/26 at 4:30 p.m. outside Resident 18's room, Resident 18 was observed requesting pain medication from Licensed Vocational Nurse (LVN) 3. LVN 3 was observed asking Resident 18 where his pain was. Resident 1 was heard saying both knees. LVN 3 was not heard asking Resident 1 for his pain level.During medication administration observation on 5/12/26 at 4:31 p.m., LVN 3 was observed preparing and administering one medication to Resident 18. This medication included one tablet of tramadol 50 milligram (mg).During an observation on 5/12/26 at 4:32 p.m., LVN 3 was observed documenting Resident 18's pain level using the Pain Assessment in Advanced Dementia (PAINAD, is an observational tool used to assess pain in patients with severe cognitive impairment who cannot verbally communicate their pain)During a review of Resident 18's Order Summary Report, dated 5/4/26, Resident 18 was prescribed with one tablet of tramadol 50 mg every six hours as needed for moderate-severe pain (4-10 pain).During a review of Resident 18's Medication Administration Record (MAR), dated 5/12/26, Resident 18's pain level was zero at 4:32 p.m. when one tablet of tramadol 50 mg was administered.During a review of Resident 18's Medication Administration Note, dated 5/12/26 at 4:32 p.m., LVN 3 documented that Resident 18 had knee pain (both knees) without a pain level.During a concurrent interview and record review on 5/13/26 at 4:49 p.m. with LVN 3, Resident 18's Medication Administration Record (MAR), dated May 2026 was reviewed. The MAR indicated, on 5/12/26, for the 4:32 p.m. administration time of one tablet of tramadol 50 mg, the pain level of Resident 18 was zero. LVN 3 stated, she did not ask Resident 18 for his pain level. LVN 1 stated, she had based her pain assessment of Resident 18 on his reaction.2. During a review of Resident 59's admission Record, dated 5/12/26, the admission Record indicated Resident 59 was admitted in the facility on 4/18/26 with an admission diagnosis of displaced midcervical fracture of right femur (the thighbone is broken in the middle of the neck and the bone fragments are misaligned), acute post hemorrhagic anemia (a condition where a rapid, massive loss of blood quickly depletes the body's cells responsible for transporting oxygen from the lungs to the body's tissues) and essential hypertension (persistently high blood pressure without a single identifiable medical cause).During medication administration observation on 5/12/26 at 8:23 a.m., LVN 4 was observed preparing five of Resident 59's medications. These medications included half tablet of atenolol (medication used to treat high blood pressure) , one capsule of stool softener (medication used to treat constipation), one tablet of losartan (medication used to treat high blood pressure), 17 grams (gm) of polyethyleyne glycol (medication to treat constipation) and one enoxaparin (medication used to prevent and treat blood clot) injection. LVN 4 mixed 17 gm powder of polyethylene glycol into a clear plastic cup halfway filled with water.During an observation on 5/12/26 at 8:32 a.m. in Resident 59's room, LVN 4 gave Resident 59's five prepared medications. Resident 59 was then observed drinking approximately half of the water mixed with polyethylene glycol. Resident 59 was then heard saying he did not want to drink all of the water from the clear plastic cup. LVN 4 was then observed taking the clear plastic cup with water outside Resident 59's room.During a review of Resident 59's Order Summary Report, dated 4/17/26, Resident 59 was prescribed with 17 gm of polyethylene glycol one time a day for bowel management, hold for loose stool, dissolve 17 gm into 4-8 oz of water or juice.During a concurrent observation and interview on 5/12/26 at 2:09 p.m. with LVN 4, one clear plastic cup had 5 ounces (oz) mark at the bottom. LVN 4 stated mixing Resident 59's 17 gm of polyethylene glycol powder approximately with 2.5 oz of water and not 4-8 oz as order. LVN 4 stated Resident 59 approximately only drank 1.5 oz of water mixed with the medication.During a review of the facility's policy and procedure titled, Administering Medication, dated 12/22, indicated, 3. Medications must be administered in accordance with the orders.

Based on observation, interview and record review the facility failed to ensure proper medication storage and labeling practices when:1. An afrin nasal spray (an over-the-counter medication that provides relief for nasal and sinus congestion) was unlabeled with Resident 60's name during medication administration observation.2. Resident 60's alvesco inhaler (medication used for the maintenance treatment of asthma) was stored in the medication cart without prescriber's order during the inspection of one of two sampled medication cart.These failures had the potential to result in unsafe medication administration and storage practices.1. During a review of Resident 60's admission Record, dated 5/12/26, the admission Record indicated Resident 60 was admitted in the facility on 4/29/26 with an admission diagnosis of pulmonary embolism without acute cor pulmonale (blood clot that blocks and stops blood flow to a blood vessel in the lung without right-sided heart failure), bacteriuria (presence of bacteria in the urine) and hypothyroidism (common condition where the thyroid gland fails to produce enough hormones, causing the body's metabolism to slow down).During a concurrent medication administration observation and interview on 5/12/26 at 8:48 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed preparing and administering four medications to Resident 60. These medications included one capsule of stool softener (medication used to treat constipation) , one tablet of eliquis (medication used to treat and prevent blood clots), one lidocaine patch (medication used as relief from minor muscle, joint, and nerve pain) and two sprays of afrin nasal spray to both nostrils. The afrin nasal spray bottle and box container was observed without label of Resident 60's name. LVN 4 stated, there should be Resident 60's name on the nasal spray bottle and on the box container.During a review of Resident 60's Order Summary Report, dated 4/30/26, the Order Summary Report indicated Resident 60 had a prescribed order for afrin nasal spray solution two spray into both nostrils one time a day for nasal congestion.During a review of Resident 60's Medication Administration Record (MAR), dated May 2026, the MAR indicated, Resident 60 had a scheduled order to receive afrin nasal spray solution two spray in both nostril on 5/12/26 at 9:00 a.m.During a review of facility's policy and procedure titled, Nasal Spray Administration, dated 11/24, indicated, Purpose: To ensure safe, accurate, and effective administration of nasal spray medications to resident in accordance with physician orders, manufacturer recommendations, infection control standards, and applicable federal and state regulations. Policy: Nasal spray medications shall be handles, stored, administered, . to maintain resident safety and prevent contamination. 6.Storage: Nasal spray medications shall be stored:. Clearly labeled for individual resident use.2. During a concurrent observation and interview on 5/13/26 at 11:08 a.m. with LVN 4, an alvesco inhaler was stored in a zip lock bag inside the third left drawer of the medication cart 2. The zip lock bag had Resident 60's name written in black ink marker. LVN 4 stated, Resident 60's family member brought in the medication. LVN 4 stated, medications stored in the medication cart were for current resident use. During an interview on 5/13/26 at 12:51 p.m. with the Director of Nursing (DON), the DON stated, Resident 60's alvesco inhaler supply cannot be used because there was no active order. The DON stated, the family member will be called to pick up the inhaler. The DON stated, the inhaler was stored in the medication room.During a follow up interview on 5/13/26 at 1:33 p.m. with the DON, the DON stated, Resident 60's inhaler should have been kept in the medication room until the family member picked it up.During a review of Resident 60's Order Summary Report, dated 5/13/26, the Order Summary Report indicated Resident 60 had no active prescribed order for alvesco inhaler.

Based on interview and record review, the facility failed to employ a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position, when facility's dietary manager was also not qualified/certified. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services. During an interview on 5/11/26 at 2:46 p.m. with Dietary Manager (DM), DM stated that he was not a certified dietary manager. DM stated he was currently in school.During an interview on 5/11/26 at 3:06 p.m. with Registered Dietician (RD), RD stated that she was hired to work on part time. RD stated she worked 24 hours a week.During an interview on 5/13/2026 at 1:02 p.m. Administrator (Admin), Admin stated he was aware DM was in school and not certified.During a concurrent interview and record review on 5/14/26 at 8:04 a.m. with Admin, DM's Employee Record (ER), was reviewed. The ER indicated DM was hired 10/3/22 as a DM. Admin stated DM was currently in a training program.

Based on interview and record review, the facility failed to ensure a binding arbitration agreement (a contract in which parties agree to resolve disputes outside of court) was explained in a manner that was understandable to one of three sampled residents (Resident 25's) family representative (FR 1). This failure had the potential to prevent FR 1 from making an informed decision regarding whether to enter into a binding arbitration agreement.During a review of Resident 25's admission Record, printed 5/14/26, the Record indicated Resident 25 was admitted to the facility in March 2026 with a diagnosis of major depressive disorder. During an interview on 5/13/26, at10:45 a.m., with FR 1, FR 1 stated they completed Resident 25's admission paperwork and signed their binding arbitration agreement. FR 1 stated the facility gave Resident 25's admission paperwork, and the binding arbitration agreement, all together at one time and was told to sign. FR 1 stated the binding arbitration agreement was not explained to them and they did not understand it was optional. FR 1 stated they would not have signed it if they knew it was optional. During an interview on 5/13/26, at 12:37 p.m., with Resident Relations Liaison (RRL), RRL stated during admission, they gave residents the binding arbitration agreement with all the admission paperwork. RL stated it was important to tell residents the binding arbitration agreement was optional and was not a condition of admission because it was their right to choose. During an interview on 5/13/26, at 12:45 p.m., with Clinical Liaison (CL), CL stated it was important to make sure residents, and resident representatives understood they waived their right to a trial when they signed the binding arbitration agreement. CL stated it was important to tell residents the binding arbitration agreement was optional and was not a condition of admission because if they didn't understand they might have been at risk if there were any disputes between the facility and the resident or resident representative. During an interview on 5/13/26, at 4:18 p.m., with RRL, RRL stated when they gave the binding arbitration agreement to FR 1, they did not explain the document line by line. During a review of Resident 25's Binding Arbitration Agreement, dated 4/6/26, the Agreement indicated, FR 1 signed it on 4/6/26. During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, revised November 2023, the P&P indicated, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. The P&P, indicated, it is unambiguously communicated to residents (or representatives) that binding arbitration agreements are optional and not required as a condition of admission or to receive care at this facility. The P&P indicated, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e., litigation).

Based on observation, interview and record review, the facility failed to ensure the essential equipment were properly maintained when; Resident 34's bed made loud cranking noise when bed was moved up and down during care. This failure had the potential to cause residents distress or discomfort. During a concurrent observation and interview on 5/12/26 at 10:03 a.m. with Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN1), Resident 34's healed wound on buttock was observed. Resident 34's bed made loud cranking noise when remote was operated to bring the bed up and down. Resident 34 stated he can live with the noise. During an interview on 5/12/26 at 10:06 a.m. with CNA 1, CNA 1 stated Resident 34's bed makes loud noise from time to time. CNA 1 stated that the nursing staff are aware that Resident 34's bed made cranking noise and that maintenance department was notified. During an interview on 5/12/26 at 10:09 a.m. with Registered Nurse (RN1) stated that sometimes Resident 34's bed was lubricated. During an interview on 5/12/26 at 10:11 a.m. with Maintenance Supervisor (MS), MS stated he was aware of the cranking noise made by Resident 34's beds. MS stated about half of the resident beds at the facility made cranking noise. MS stated beds are oiled when residents are discharged . MS stated he waited for residents' discharge because he was concern about the smell of the lubricant. MS stated facility had a plan to replace beds that made loud noise when used. During an interview on 5/13/26 at 12:57 p.m. with Administrator (Admin), Admin stated facility was in the process of buying new beds. Admin stated facility plan to replace all residents' beds. During a review of the facility's policy and procedure (P&P) titled, Preventative Maintenance, dated April 2025, the P&P indicated, The facility shall maintain a preventative maintenance program designed to minimize equipment failure, maintain resident safety and comfort, reduce operational disruptions, and ensure compliance with regulatory requirements.

Based on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified staff for facilily with census of 59 residents.This failure resulted in all residents receiving social services from unqualified staff.During an interview on 3/16/26, at 3:36 p.m., with Social Services Director (SSD), SSD stated they had worked here since 2022.During a concurrent interview and record review on 3/17/26, at 12:17 p.m., with Human Resources (HR), SSD's two job descriptions titled Job Description: Social Services Director, dated 9/8/23 and 9/2/25, was reviewed. HR stated the newer job description was changed to have the entire qualifications section which included education, the ability to read and solve practical problem be preferred qualities. HR stated preferred qualifications indicated those weren't requirements for the job, but the facility would prefer a candidate to possess. After review of the revised job description, HR was unable to determine what were the minimum educational requirements of the social services director, but stated the ability to read and solve problem was a requirement.During a concurrent interview and record review on 3/17/26, at 12:43 p.m., with HR, SSD's employment application titled, Application for Employment, dated 9/6/2023, was reviewed. The application indicated SSD had completed high school education and was a licensed vocational nurse. HR stated they did not check if applicants were qualified for the position and the department managers were responsible for ensuring employees were qualified. HR stated the SSD was the only staff in the social services department and did not have any other supervisor.During an interview on 3/17/26, at 2:15 p.m., with Administrator (ADM), the ADM stated they were the overall supervisor for all staff including the SSD. The ADM stated there was no qualified social worker overseeing the social services department.During a review of facility policy and procedure (P&P) titled Social Services, dated 9/2024, the P&P indicated the facility provided medically-related social services.the director of social services is responsible for.program planning, policy development, and priority setting of social services.supervising social services personnel.not all medically-related social services are provided by a qualified social worker. However, the facility is responsible for ensuring all residents are provide these services by a staff member or through referrals to an outside agency.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72105, the state regulation indicated a Clinical Social Worker was person who is a licensed clinical social worker by the Board of Behavioral Sciences.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview and review, the facility failed to ensure, for Residents 1-5, the scheduled (controlled medication, narcotic) medication system was accurate (information matches between documents). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were inaccurate. These failures resulted in the potential for the undetected loss and diversion of scheduled medications. In addition, these failures resulted in the potential for avoidable medication errors (medication not given as ordered). During an interview, on 3/16/26 at 10:15 am, the Director of Nursing (DON) and Medical Record Director (MRD) were asked to describe the scheduled medication documentation process. Their description included: medication was delivered by pharmacy with a Shipping Manifest and CDR. The medication and CDR were placed in the medication cart (stores medication). The nurse removed the medication and documented the date, time, and remaining amount on the CDR. Administered medications were documented on the MAR. CDRs and Shipping Manifests were sent to medical records for retention. The facility was requested to provide all scheduled medication Shipping Manifests and CDRs from 9/1/23 - 3/31/24.During a concurrent observation and interview, on 3/16/26 at 2:30 pm at the nursing unit, Licensed Vocational Nurse (LVN 1) identified a medication cart. LVN 1 was requested to describe the schedule medication documentation process. Her description includedmedication was delivered by pharmacy with a Shipping Manifest and CDR. The medication and CDR were placed in the medication cart. The nurse removed the medication and documented the date, time, and remaining amount on the CDR. Administered medication was documented on the MAR.During a concurrent interview and record review, on 3/17/26 at 9:45 am, DON identified Resident 1's MAR. She compared the 6215169 Hydrocodone (narcotic pain reliever)/APAP (acetaminophen) 10/325 mg (milligram) tablet #56 date 11/19/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the date and times listed below.12/6/23 0700, 2045Continuing the concurrent interview and record review, on 3/17/26 at 9:45 am, DON identified Resident 2's MAR. She compared the 6271329 Hydrocodone/APAP 5/325 mg tablet #27 date 12/3/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.12/7/23 030012/18/23 050012/24/23 1310Continuing the concurrent interview and record review, on 3/17/26 at 9:45 am, DON identified Resident 3's MAR. She compared the 6427953 Hydrocodone/APAP 10/325 mg tablet #26 date 1/13/24 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.1/18/24 21411/21/24 07001/22/24 0540Continuing the concurrent interview and record review, on 3/17/26 at 9:45 am, DON identified Resident 4's MAR. She compared the 6543671 Hydrocodone/APAP 5/325 mg tablet #28 date 2/11/24 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.2/14/24 12102/17/24 10003/8/24 20543/10/24 1013Continuing the concurrent interview and EMR review, on 3/16/26 at 9:45 am, DON identified Resident 5's MAR. She compared the 6690791 Oxycodone (narcotic pain reliever)10 mg tablet #28 date 3/20/24 CDR against the MAR. DON acknowledged the CDR removals did not have corresponding MAR administration on the dates and times listed below.3/7/24 06304/4/24 19454/7/24 22154/20/24 0500During a concurrent interview and record review, on 3/17/26 at 10 am, DON identified the Pharmacist's Medication regimen review and Report. She reviewed the report and acknowledged it identified Each PRN (as needed) dose documented on the Controlled Drug Count (CDR) sheet should have a corresponding nurse initialed charted in EMAR (MAR). During a concurrent interview and record review, on 3/17/26 at 11:05 am, DON identified the Controlled Substances Policy. She reviewed the policy and acknowledged it required the documentation (CDR and corresponding MAR) to be accurate (monitored and reconciled). An administrative record review, of the Pharmacist's Medication Regimen Review & Report, Monthly Pharmacy Inspection Report, 11/8/23-11/10/23 showed, A. Med Administration & Orders: 7. Random audit of controlled drug charting in EMAR (computer medical record) in all med carts were completed. Each PRN dose documented on Controlled Drug Count sheet (CDR) should have a corresponding nurse initial charted in EMAR. They should correlate and be exact duplicate of each order. This audit found 10 out of 14 were not reconciled.An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records.

Based on observation, interview, and record review, the facility failed to ensure that licensed nurses followed proper infection control precautions to prevent spread of infection for five of eight sampled residents (Resident 166, Resident 158, Resident 15, Resident 43, and Resident 6) when the medication tray was not cleaned and sanitized after taking the tray was placed on Resident 158's bedside table in Resident 158's room, and then placed on the bedside tables of Resident 43, Resident 15, and Resident 166. These deficient practices had the potential to result in the spread of infection at the facility. Findings: 1. During an observation with Licensed Nurse 1 (LN 1), on 7/29/24, at 10:05 AM, LN 1 was observed in Resident 6's room passing medications using the medication tray. After LN 1 gave Resident 6's medication, LN 1 did not clean or sanitize the medication tray. During subsequent observation with LN 1, on 7/29/24, at 10:33 AM, LN 1 was observed preparing Resident 158's medication. LN 1 was observed placing Resident 158's medication inside the medication tray that was previously used for Resident 6's medication. LN 1 entered Resident 158's room and placed the medication tray on top of bedside tray for Resident 158. LN 1 did not clean or sanitize the medication tray after the medication pass for Resident 158. During subsequent observation with LN 1, on 7/29/24, at 10:37 AM, LN 1 was observed preparing Resident 43's medications. LN 1 did not clean or sanitize the medication tray previously used for Resident 6 and Resident 158's medications. LN 1 entered Resident 43's room and placed on the top of the bedside table. LN 1 did not clean or sanitize the medication tray after administering medications to Resident 43. During an observation with Licensed Nurse 2 (LN 2), on 7/29/24, at 4:37 PM, LN 2 was observed preparing Resident 15's medications and placed them on the medication tray. LN 2 entered Resident 15's room and placed the medication tray on Resident 15's bedside table. After the medication administration, LN 2 did not clean or sanitize the medication tray. During a subsequent observation with LN 2, on 7/29/24, at 4:59 PM, LN 2 prepared Resident 166's medications and placed them on the same medication tray used for Resident 15 without cleaning or sanitizing it. LN 2 entered Resident 166's room and placed the medication tray on Resident 166's bedside table. LN 2 returned to the medication cart and did not clean or sanitize the medication tray. During a record review of the facility's policy and procedure, titled, Administering Oral Medication, dated 2001, the policy indicated, the following equipment and supplies will be necessary when performing this procedure . 2. Medication cart or tray. The policy further included the steps in procedure for medication administration which indicated on step 23 Perform hand antisepsis. The policy did not include cleaning of shared equipment in between residents' use.

Based on observation, interview, and record review the facility failed to ensure safe and accountable pharmaceutical services based on standards of practice and regulatory requirements with census of 59 when: 1. The prescription medication delivery or shipping manifest and receipts (a document generated by pharmacy containing shipment information on drugs delivered to the facility), including narcotic opioid (drugs with risk of abuse) medications, were not consistently signed, and acknowledged by licensed staff upon delivery for accountability. 2. The non-narcotic prescription medication destruction and disposals were not co-signed by two licensed staff on all the documented records. 3. The Emergency Kits (or eKit, a limited supply of medication for urgent use in a sealed box) for IV (Intravenous or Inject into Vein) medication box were opened with no documentation on when, who and what medication was removed from the eKit in both medication rooms. 4. The hazardous medications (Drugs that pose short or long-term harm upon exposure to human via skin or inhalation) were stored in medication carts and used by nursing staff without protective measures during storage and administration. These failed practices could contribute to unsafe medication use, risk of drug diversion, and unsafe handling of hazardous medications which could pose health risk to staff and residents. Findings: 1. During a concurrent interview with Licensed Nurse 4 (LN 4) and record review of the facility's document binder, titled Shipping Manifest, dated for month of July 2024, at Station 2, on 7/29/24, at 12:06 PM, the documents listed pages of yellow color sheets, which listed the name and quantity of narcotic and non-narcotic medications delivered to the facility. The delivery sheets were not consistently signed by a licensed staff for accuracy and accountability. LN 4 stated the delivery person required a signature from a nurse for their records and the nurses should have had signed and checked in and confirmed the medications listed on the receipt. During an interview with Director of Nursing (DON) on 7/29/24, at 3:30 PM, the DON stated the licensed nurse who received the delivered narcotic and non-narcotic medications should have signed on the yellow colored sheets for facility's record keeping and accuracy of medications delivery. During a phone interview with Consultant Pharmacist (CP), on 8/1/24, at 12:59 PM, CP stated when pharmacy delivered the medications to the facility, the licensed nurse who received the medications, especially the narcotics, should have signed and checked in the delivery sheet upon receiving the medications. CP stated one copy of record is returned to the pharmacy and the other copy should stay with the facility. During a record review of the facility's policy and procedure (P&P), titled Pharmacy Services Overview, dated 2001, the record indicated Medications received, labeled, stored, administered and disposed of according to all applicable to state and federal laws and consistent with standards of practice. 2. During a concurrent interview with Registered Nursed Supervisor (RN-SUP) and record review of the facility's document binder, titled Medication Disposition Record, on 7/29/24 at 12:40 PM, at Station 2, the document for non-narcotic prescription medication disposition listed the names of medications destroyed by facility. The document did not have a witness signature for medication destruction and the name of the resident was not listed on the destruction sheet. RN-SUP stated the nursing supervisor for day and evening shift were responsible to document the destruction by popping the pills in the pharmaceutical waste bin and another nurse could co-sign with them. RN-SUP acknowledged the witness signature, and the name of the residents were missing from the destruction log. During an interview with the DON and concurrent record review of Medication Disposition Record, on 7/29/24, at 3:35 PM, the DON stated non-narcotics medication disposition records should be co-signed by two licensed nurses. The DON confirmed a lot of medication disposition records were not co-signed by two licensed staff. During a record review of the facility's policy and procedure (P&P), titled Discarding and Destroying Medications, dated 2001, the record indicated The medication disposition record will contain the resident's name; date medication disposed; the name and strength of the medication; the name of dispensing pharmacy; the quantity disposed; method of disposition; and signature of witnesses. 3. During a concurrent interview with RN-SUP and inspection of the facility's medication room at unit #1, on 7/29/24, at 11:29 AM, the eKit for IV medication was opened with a red seal (red seal indicated the original green seal was replaced with red seal after use). Further inspection of the kit did not show any documentation as when it was opened and what product was removed by which nurse. The RN-SUP stated there should have been a copy of duplicate slip inside the re-sealed box with information on what was taken out. During a concurrent interview with RN-SUP and inspection of the facility's medication room at unit #2, on 7/29/24, at 12:40 PM, the eKit for IV medication was opened with a red seal. Further inspection of kit content did not show any documentation as when it was opened and what product was removed by which nurse. A quick count of the IV items in the box indicated a one-liter bag of saline (sterile salt solution) was missing from the eKit. RN-SUP acknowledged the finding and stated she would call the pharmacy provider to replace the eKits. During an interview with the Director of Nursing (DON), on 7/31/24 at 4:14 PM, the DON stated when eKit was opened and a medication was taken out, the licensed nurse should have signed the record slip included in the eKit. The DON stated the eKit had duplicate sheets. The DON stated the white sheet should have been faxed to the pharmacy and the yellow sheet should have been placed inside the eKit for pharmacy copy. The DON stated the nurses were not consistent of how they were processing the record sheets. The DON was unable to provide the eKit record sheet for the missing item from the eKits. The DON stated the risk of not replacing the eKit in a timely manner could have delayed the medication administration to the resident who needed it. During a record review of the facility's policy and procedure, titled Emergency Medications, dated 2001, the record indicated Any medication that is removed from the emergency kit must be documented on the emergency medication administration log. 4. During a medication pass observation with Licensed Nurse 1 (LN 1), on 7/29/24, at 10:30 AM, at facility's unit 1, LN 1 administered a medication called spironolactone (or Aldactone, medication used for heart disease with hormonal effect) labeled by pharmacy with a red sticker Hazardous Drugs. LN 1 did not use gloves when removed the drug from bubble pack (a card that packaged doses of medication within a plastic bubbles or blisters) into a pill cup for administration to Resident 158. Further observation indicated the bubble pack was not stored in zip lock bag for safer handling by nursing staff. During an interview with LN 1, on 7/30/24, at 3:48 PM, at facility's unit 2, LN 1 stated she should have used precaution and gloves when handling the hazardous drug. During an interview with the DON, on 7/30/24, at 4:16 PM, in the DON's office, the DON stated the licensed staff were supposed to use a special gloves when handling hazardous drugs. During a telephone interview with facility's Consultant Pharmacist (CP), on 8/1/24, at 1:05 PM, CP stated earlier this year, she gave an educational in-service on how to handle hazardous drugs during medication administration and disposal. During a record review of the facility's policy and procedure, titled Hazardous Drug, dated 2001, the record indicated Any staff members who come in contact with hazardous drugs are trained and exhibit competency in handling these drugs according to current safety and practice standards . safety data sheets, and drug packet inserts. Review of drug information database called UpToDate LexiDrug for spironolactone, last accessed on 8/2/24, the drug information records indicated spironolactone was a hazardous drug and was categorized in group 2 hazard level (group 1 is antineoplastic drugs (cancer drugs) and group 2 and 3 were non-antineoplastic hazardous drugs). The record further referenced Hazardous Drugs Handling Considerations; Hazardous agent NIOSH -2016 (National Institute for Occupational Safety and Health conducts research and makes recommendations for the prevention of work-related injury and illness) . Use appropriate precautions for receiving, handling, administration, and disposal . Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. NIOSH suggested careful precautions and safeguards to protect workers, fetuses, and breastfed infants. Further review of the document indicated to use single glove for handling intact tablet form and double glove/other PPE for handling oral liquid form of the hazardous medications as directed.

Based on observation, interview, and record review the facility failed to ensure safe and secure order communication among providers when medication order was communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access) for one resident out of 15 sampled residents (Resident 166) based on regulatory requirements on Protected Health Information (or PHI, any information in the medical record that can be used to identify an individual in the course of providing a health care services) This failure could violate residents' health information privacy and confidentiality. Findings: During a concurrent medication pass observation and interview with Licensed Nurse 5 (LN 5), at station 2 hallway, on 7/30/24, at 9:45 AM, RN 1 administered the morning medications for Resident 166. During the medication administration process Resident 166 told LN 5 that her midodrine (drug used to helped prevent sudden fall in blood pressure that occurs when a person assumes a standing position) dose needed to be higher and asked the nurse to clarify with the doctor. LN 5 then went to her medication cart, looked at the computer, then started typing (texting) using a smart phone. LN 5 moments later looked at the smart phone screen and went to the Resident 166 and told her the doctor increased her midodrine dose starting with the next dose due. In an interview with LN 5, at the station 2 hallway, on 7/30/24, at 2:38 PM, LN 5 stated she used her personal smart phone to send text message to Resident 166's doctor (Medical Doctor 1 or MD 1). LN 5 stated the facility, and her coworkers used a facility approved group application called WhatsApp (a free cross-platform messaging service that lets users to call and exchange text, photo, audio, and video messages with others across the globe) to communicate with medical providers. LN 5 stated for urgent situations they were to make phone call to the providers. LN 5 shared the phone screen when she communicated (texted) the request for midodrine dose increase with MD 1. Review of the smart phone communication screenshot from LN 5 to MD 1, on 7/30/24, time stamped at 9:51 AM, the screenshot indicated a message from LN 5 as follow: Good am, DR (MD 1) regarding new pt (patient) Resident 166 [redacted]. Did you by any chance increase dosage of Midodrine to 5 mg? (mg is milligram, a unit of strength). I was not able to see a pepr (paper) order for it. Thank you. The document then had a response from MD 1, timed at 9:51 AM, indicating Yes, 5mg bid (twice daily). In an interview with Director of Nursing (DON), in her office, on 7/31/24, at 4:10 PM, the DON stated the facility was using WhatsApp for communication among staff and medical doctors for about two years. The DON stated they were told the method of communication was safe since it was encrypted (encryption means confidentiality of information transmitted over the internet). The DON stated the facility had about eight different group messaging that helped with communication among staff and providers. The DON stated the WhatsApp group messaging for communication with medical doctors were between the individual doctors and 27 nurses the facility employed. The DON stated the staff were using own smart phone and facility did not provide any phone to them. The DON stated the medication orders received from a doctor via smart phone was considered telephone orders. The DON stated the orders via text messages were transcribed in the computer by nursing staff. When asked if staff's personal phone were a safe place to store resident medical information and if there was a risk of the information being compromised via phone loss or other family member access, the DON states she did not know what to say. The DON stated the facility did not have a written policy and procedure for use of WhatsApp messaging service for medical communication among licensed staff and doctors. Review of the facility's policy, titled Confidentiality of Information and Personal Privacy, dated 2001, the policy indicated The facility will safeguard the personal privacy and confidentiality of all resident personnel and medical records . the facility will strive to protect the resident's privacy regarding his or her . medical treatment, written and telephone communications . Review of the facility's policy, titled Medication and Treatment Orders, dated 2001, the policy indicated Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of online article from HIPAA Journal (HIPAA stands for Health Insurance Portability and Accountability Act, a set federal rules requires appropriate safeguards to protect the privacy of protected health information), dated 9/2023, last accessed on 8/6/24 via https://www.hipaajournal.com/whatsapp-hipaa-compliant/ , the article indicated WhatsApp is not HIPAA compliant and should not be used for receiving, storing, or sending Protected Health Information (PHI) . the platform should not be used to communicate PHI because it lacks the capabilities to support compliance with the HIPAA Security Rule . there are no capabilities to terminate an individual's access to PHI stored on their device, monitor logins, or support emergency access to PHI if the account owner is unavailable. The article further indicated WhatsApp will not enter into an Agreement, and notes in its Business Terms We make no representations or warranties that our services meet the needs of entities regulated by laws and regulations with heightened confidentiality requirements for personal data, such as healthcare, financial, or legal services entities.

Based on interview and record review the facility failed to ensure psychotropic (mind altering drugs) medications were properly assessed for use with a documented diagnosis by the medical doctor in the medical record in one out of five residents reviewed for unnecessary medications (Resident 33). This failed practice could contribute to unsafe medication use, monitoring, and adverse consequences. Findings: During a record review of Resident 33's electronic medical record admission timeline and nursing notes, the record indicated Resident 33 was admitted from the acute care hospital after a heart surgery called CABG (Coronary Artery Bypass Graft, an extensive, high risk heart surgery). The record indicated the next day after admission, Resident 33 was sent to Emergency Department (ED, hospital's emergency care) with chest pain and was returned to the facility on 6/28/24. During a record review of Resident 33's electronic medical record, titled Medication Administration Record (MAR, a document listed medications ordered and administered by nursing staff), dated for July 2024, the record indicated two psychotropic orders as follow: 1. Seroquel Oral Tablet 25 MG (or quetiapine, mind altering drug used for mood disorder, MG is milligram, a unit of measure); Give 1 tablet by mouth at bedtime for aggression m/b (manifested by) shouting and combativeness with staff .; Start Date:7/2/24. 2. Sertraline Tablet 100 MG (or Zoloft; a drug used to treat depression); Give 1.5 tablet by mouth one time a day for depression m/b social isolation .; Start Date: 7/4/24. During a record review of Resident 33's electronic medical record, titled Physician History and Physical (or H&P; admission note by doctor explaining resident's current and past medical condition, diagnosis, and plan of care), dated 7/1/24, written by Medical Doctor 2 (MD 2), the record did not address if resident was at risk for behavior issues and/or had a history of depression or other behavioral issues. During a record review of Resident 33's electronic medical record, titled Change in Condition, dated 7/1/24, at 21:18 PM, documented by nursing staff, the record indicated Behavioral Status Evaluation: Verbal aggression Depression (e.g. crying, hopelessness, not eating, multiple somatic complaints) Pt (patient) verbalized depression, has sharp pain in her chest and has hard time breathing. pt verbalized she hasn't slept last night. Continues to cry and wants to go to the ED . Refuses to let me assess her. The record further indicated the medical doctor responded with ordering Seroquel 25 mg PO (orally) qhs (at bedtime every night). During a record review of Resident 33's electronic medical record, titled Physician Progress notes, with date range of 7/1/24 to 7/26/24, written by MD 2, the record did not address Resident 33's mental health diagnosis and justification for use of mind-altering drugs. The records indicated Resident 33's physical examination for psychiatric system were documented as normal mood and cooperative. During a record review of Resident 33's electronic medical record, titled Minimum Data Set (or MDS- a mandatory report to federal government on resident care and medical diagnosis), dated 7/2/24 at 1:59 PM, the record under Psychiatric/Mood Disorder (mental health diagnosis) was marked no for all the mental health diagnosis including depression, anxiety, or psychotic disorder (delusion). During an interview with Resident 33, on 7/31/24 at 3:10 PM, Resident 33 stated she was admitted to the facility after a major heart operation that almost killed her. Resident 33 stated she had previous bad experiences from another nursing facility. Resident 33 stated she was only verbally aggressive toward her daughter and not to the facility's staff when she first arrived in the facility. Resident 33 stated she had been taking Zoloft for a long time. Resident 33 stated she had always been emotional even when watching a sad movie. Resident 33 stated she did not know she was taking Seroquel at night and did not know what it was for. Resident 33 stated she could not recall if the facility had informed or explained it to her. During an interview with Certified Nurse Assistant 1 (CNA 1), on 7/31/24 at 3:41 PM, CNA 1 stated Resident 33 was independent with use of walker and Resident 33's behavior was calm. CNA 1 stated he had never seen Resident 33 being hostile, erratic or agitated. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 33's medical record including MAR, doctor's notes and H&P, nursing notes, and MDS records, on 7/31/24, at 4:25 PM, the DON confirmed no documented diagnosis for use of mind-altering drugs by medical doctor, and MDS accurately reflected the medical record documentation of no diagnosis for use of psychiatric or mind-altering medications. The DON stated Resident 33 was crying, arguing with daughter, and was trying to get out of bed on first day of re-admission from the ED on 7/1/24. The DON stated the nurses could not convince Resident 33 refusal to be assessed. The DON stated MD 2 ordered Resident 33 to start on Seroquel on 7/2/24 for aggression. The DON stated Resident 33 had only one episode of combativeness and refusal of care. During a telephone interview with MD 2, on 8/1/24, at 12:44 PM, MD 2 stated Resident 33's daughter requested the facility to increase Resident 33's Zoloft to 150 mg, as per recommended by Resident 33's outpatient MD. MD 2 stated she ordered Seroquel for Resident 33 when the facility contacted her that Resident 33 was crying, yelling, and was having a lot of behavioral issues. MD 2 stated when prescribing psychotropic medications, there should be a pattern of behavioral issues and not just one episode. MD 2 stated she did not document Resident 33's mental health diagnosis and justification for starting the Seroquel in her progress notes. During a phone interview with Consultant Pharmacist (CP), on 8/1/24, at 12:59 PM, CP stated psychotropic medications should have had an indication or diagnosis from the physicians prior to starting the residents with the mind-altering medications. During a record review of the facility's undated policy and procedure (P&P), titled Psychoactive/Psychotropic Medication Use, the P&P indicated Residents will only receive Psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record.

Based on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices with census of 59 when: 1. Unlabeled prescription medication was stored in medication room at Unit 1. 2. Non-refrigerated medication was stored in the medication refrigerator at Unit 1. 3. The inhalation medication with limited shelf life after opening was not dated for beyond use date in medication cart #3. 4. Treatment cart stored opened and used wound care supplies marked for single use in the active storage area. These failed practices could contribute to unsafe used of medication and supplies. Findings: 1. During a concurrent interview and observation, with Registered Nurse Supervisor (RN- SUP), in the facility's medication room at Unit 1, on 7/29/24, at 11:29 AM, a large number of IV (Intravenous; Into the Vein) fluid medication called Sodium Chloride 500 mL (Sterile Salt solution used as IV; mL is milliliter, a unit of volume) were stored inside a drawer with no marking or label who it belonged to. RN-SUP stated she was not sure who it belonged to and why it was stored in the medication room. RN-SUP acknowledged the finding. 2. During a concurrent interview and observation, with RN-SUP, in the facility's medication room at Unit 1, on 7/29/24, at 11:29 AM, the medication refrigerator stored three vials of unopened medication called acetylcysteine 200 mg/mL (a liquid medication in a sealed vial used to treat breathing problems; mg/mL is milligram per milliliter a unit of strength) in a box labeled to keep at controlled room temperature. The manufacturer label on the product noted to keep refrigerated after opening the vials and discard after 96 hours. RN-SUP confirmed the finding. 3. During a concurrent interview and observation with, Licensed Nurse 3 (LN 3), at nurse's Unit 2, on 7/29/24 at 11:41 AM, an opened and undated inhalation medication called Trelegy Ellipta (drug used to treat breathing problems) was stored in medication cart # 3. The pharmacy label indicated to discard 42 days after opening. The medication usage counter showed it had been used 12 times. The manufacturer label on the box indicated discard the inhaler 6 weeks after opening the moisture protected foil tray . LN 3 stated she did not know it was opened and the medication should have been dated with an open date to know when to discard it. 4. During a concurrent interview and observation with Licensed Nurse 4 (LN 4), at Unit 2, on 7/29/24 at 12:08 PM, multiple opened sterile wound care supplies were found in the treatment cart as followed: a. Petroleum Dressing Xeroform, Sterile (medicated wound care supply) b. Puracol Wound Dressing, Sterile (medicated wound healing supply) c. Calcium Alginate Dressing, Sterile (medicated wound supply used to treat pressure ulcers) The sterile wound care supplies packets were opened and cut into portion. The wound care supplies label indicated sterile and do not reuse. LN 4 acknowledged the findings. During an interview with Director of Nursing (DON), on 7/31/24, at 3:35 PM, the DON stated she did not know who the IV bags belonged to. The DON confirmed the IV bags should have had proper labeling. The DON stated the facility's pharmacy and nurse consultant performed random audits for all medication rooms, medication carts and treatment carts. During a record review of the facility's Policy and Procedures, titled, Medication Labeling and Storage, dated 2001, the record indicated For medications that are prepared or compounded for IV infusion, the label contains: name and volume of the solution; resident's name . The policy further indicated The nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner and Labeling of medications .dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

Based on interview and record review, for two of three sampled residents (Resident 1 and Resident 2), the facility: -Failed to provide Resident 1 and Resident 2 a notice of proposed discharge within the required timeframe of at least 30 days prior to the actual discharge day. - Failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. These failures had the potential to result in the lack of added protection to Resident 1 and Resident 2 from being inappropriately discharged , without access to an advocate who can inform them of their options and rights. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included fracture of the left femur (thigh), fracture of the left arm, urinary tract infection, muscle weakness, and need for assistance with personal care, and anxiety disorder (feeling of fear, dread and uneasiness that does not go away and can get worse over time). The Admission Record indicated Resident 1 was self-responsible. During a review of Resident 1's Internal Medicine Progress Notes dated 9/29/23, the Internal Medicine Progress Notes indicated Resident 1 was alert, oriented to person, time, place and situation and had good insight into disease process. During an interview on 10/19/23 at 11:21 a.m with Social Services Director (SSD), SSD stated Resident 1 was discharged home on 10/5/23, 67 days after being admitted to the facility. SSD stated Resident 1 was given a Notice of Medicare Non-Coverage (NOMNC) on 10/2/23 (72 hours before actual discharge date ) to notify Resident 1 that Medicare coverage for services would end on 10/4/23. SSD stated Resident 1 was discharged from the facility on 10/5/23. During a concurrent interview and record review with Assistant Director of Nursing/Case Manager (ADON/CM) on 10/19/23 @ 12:06 p.m., Resident 1's Notice of Transfer and Discharge was reviewed. ADON/CM stated, on the actual discharge day, Notice of Transfer/discharge date d 10/5/23 was given to Resident 1, a copy of which was sent to the State Long Term Care Ombudsman office the same day. The Notice of Transfer/Discharge, (first page) indicated Family Member (FM) 1 as the person who was notified of Resident 1's discharge. The notice indicated If you intend to file an appeal of this discharge, it is suggested you do so within 10 calendar days of being notified . ADON/CM stated the Notice of Transfer/Discharge was the only formal discharge notice that was given to Resident 1, in addition to the NOMNC dated 10/2/23. ADON/CM also stated there was no confirmation/proof that the notice was sent to the State Long Term Care Ombudsman office because the facility's fax machine did not print a confirmation page. During further review of the second page of Resident 1's Notice of Transfer/discharge date d 10/5/23, the discharge notice indicated signature of the facility representative but did not indicate Resident 1's signature. The notice indicated a copy of it was faxed to the State Long Term Care Ombudsman office, and proof that it was sent was filed in Resident 1's medical record. The notice also indicated it was Resident 1's right to appeal the discharge decision and it should be done within 10 working days of being formally notified, additional rights available to Resident 1 included .[To] be given the opportunity to examine, at the reasonable time before the date of the hearing and during the hearing the content of the medical records and all documents and records to be used by the State at the hearing .you should be prepared to discharge at the end of the thirty (30) days from the date you were formally notified. The Notice of Transfer/Discharge indicated Resident 1 did not have 30 days as the notice was given on the actual day of discharge. During a telephone interview on 10/26/23 at 12:12 p.m. with Resident 1, Resident 1 stated receiving the NOMNC on 10/2/23 (three days before actual discharge date ). Resident 1 stated she was frustrated hearing about upcoming discharge for the first time, on 10/2/23, while not being physically ready to go home. Resident 1 stated she filed an appeal to be allowed to stay at the facility for more days. Resident 1 stated the three days' notice from the facility was not enough time to file a second appeal. Resident 1 stated she had to arrange for a 24-hour caregiver and home health, all in one day. Resident 1 stated she was not given information about the State Long Term Care Ombudsman program. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease that alters brain function), unspecified asthma, malignant neoplasm (abnormal tissue growth as a characteristic of cancer) of the head and neck, morbid obesity and need for assistance with personal care. During a review of Resident 2's 72-hour Charting dated 9/25/23, the 72-hour charting indicated Resident 2 was alert and oriented to person, time, place, and situation. During a review of Resident 2's Notice of Transfer/discharge date d 10/1/23, the Notice of Transfer/Discharge indicated Resident 2 was to be discharged the same day, on 10/1/23. The notice indicated FM 2 was the individual who was notified of the discharge, and it did not indicate Resident 2's signature. The notice also indicated it was faxed to the State Long Term Care Ombudsman office on 10/12/23, 11 days after Resident 2 was discharged from the facility. During a telephone interview on 10/27/23 at 11:33 a.m. with Resident 2, Resident 2 stated she felt there was not enough time to appeal the discharge for the third time after losing the first two appeals to stay at the facility for few more days. Resident 2 stated she was discharged to home on 10/1/23. During a telephone interview on 10/20/23 at 2:15 p.m. with Ombudsman (OMB), OMB stated she did not receive Resident 1 and Resident 2's Notice of Transfer/Discharge until both residents were already discharged from the facility. OMB stated calling the facility on 10/12/23 to ask for the discharge notices that were issued by the facility but were not received by the State Long-Term Care Ombudsman office the last two months. OMB also stated the first page of the notices had the incorrect address for Ombudsman's office and the second page where residents were supposed to sign, were always missing. OMB stated she had to call the facility to ask for the second page to make sure the residents signed off the discharge notices.