Every finding on record at Smith Ranch Skilled Nursing & Rehabilitation Cente

Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was timely reported to the Department or was investigated for one of three sampled residents (Resident 1).This failure delayed state agency awareness and oversight of an alleged abuse incident and caused Resident 1 unnecessary anxiety. Cross reference F610. A review of Resident 1's admission Record (a facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (hemiparesis is weakness on one side of the body, while hemiplegia is complete paralysis or loss of movement on one side), memory deficit following cerebral infarction (occurs when an artery supplying oxygen to the brain is blocked, causing tissue damage critical for memory), schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as seeing or hearing things that are not there, and mood disorder symptoms, such as depression), and bipolar disorder (a lifelong mental health condition characterized by dramatic shifts in mood, energy, and activity levels).A review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) indicated Resident 1's cognitive ability (the mental processes involved in acquiring, processing, storing, and retrieving information) was moderately impaired.During a record review of facility Progress Notes dated 4/13/26 at 2:27 p.m., it indicated Resident 1 entrance to the facility on 4/09/26 followed an unwitnessed fall with a loss of consciousness. This accident was reportedly due to Resident 1's family member administering twice the amount of insulin (a vital hormone medication that regulates blood sugar levels; insulin overdose is a medical emergency that causes dangerously low blood sugar) Resident 1 was prescribed.A review of an online communication to the Department dated 6/01/26 from an external entity indicated Resident 1 had received a verbal death threat from her family member.During an interview on 6/09/26 at 10 a.m., Resident 1 stated she had been scheduled for discharge on [DATE] but had decided to remain in the facility longer. Resident 1 further stated her family member was angry about this and threatened to kill her. Resident 1 added her family member was serious about the threat. Additionally, Resident 1 mentioned her family member, whom she resided with prior to admission to the facility, had verbally and physically abused her in the past. Resident 1 stated the thought of discharging her to the care of her family member made her anxious.During an interview on 6/09/26 at 10:30 a.m. with the facility Nurse Case Manager (NCM), she stated she learned of the death threat to Resident 1 from the facility Social Worker (SW), but stated because the situation was not internal, she believed it did not have to be reported to any outside agencies.During an interview on 6/09/26 at 10:48 a.m. with the facility SW, she stated Resident 1's caregiver had told her that Resident 1 had received a death threat from her family member, but SW had not reported the threat to local law enforcement, the Ombudsman, or to the Department. During an interview on 6/09/26 at 11 a.m. with the facility Administrator (ADM), he stated no SOC-341 (the official form used by those required to report crimes against vulnerable adults) was prepared or sent to any outside agencies or the Department , and no internal investigation was conducted related to the death threat made to Resident 1.A review of facility Policy and Procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 3/2022, indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state/licensing/certification agency .b. The local/state ombudsman.d. Adult Protective Services e. Law enforcement officials.all allegations are thoroughly investigated.within five business days of the incident, the administrator will provide a follow-up investigation report.

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered nursing care plans for one of three sampled residents (Resident 1), after Resident 1 received verbal threats of violence/death from a family member.This failure had the potential to result in Resident 1's physical harm and/or continued psychological distress. A review of Resident 1's admission Record (a facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (hemiparesis is weakness on one side of the body, while hemiplegia is characterized by complete paralysis or loss of movement on one side), memory deficit following cerebral infarction (when an artery supplying oxygen to the brain is blocked, depriving the it of oxygen and causing tissue damage critical for memory), and bipolar disorder (a lifelong mental health condition characterized by dramatic shifts in mood, energy, and activity levels).A review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool used in Medicare and Medicaid-certified nursing facilities) indicated Resident 1's cognitive ability (the mental processes involved in acquiring, processing, storing, and retrieving information) was moderately impaired.A review of an online communication to the Department dated 6/01/26 from an external agency indicated Resident 1 had received a verbal death threat from her family member.During an interview on 6/09/26 at 10 a.m., Resident 1 stated she had been scheduled for discharge on [DATE] but had decided to remain in the facility longer. Resident 1 further stated her family member was angry about this and threatened to kill her. Resident 1 added her family member was serious about the threat. Additionally, Resident 1 mentioned her family member, whom she resided with prior to admission to the facility, had verbally and physically abused her in the past. Resident 1 stated the thought of discharging her to the care of her family member made her anxious.During a record review on 6/09/26 of Resident 1's nursing care plans, no updated content to address safety or psychosocial concerns was found following death threats made to Resident 1.During an interview on 6/09/26 at 10:30 a.m. with the facility Nurse Case Manager (NCM), she stated she learned of the death threat to Resident 1 from the facility Social Worker (SW). The NCM stated she was not sure if care plans for the protection and/or psychosocial needs of Resident 1 had been created or updated.During an interview on 6/09/26 at 10:48 a.m. with the facility SW, she stated no care plan had been initiated to ensure Resident 1's physical or psychological safety while in the facility or upon discharge, and that the facility was, working on this with the Ombudsman [assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences] on it.A review of facility Policy and Procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, 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.assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on interview and record review, the facility failed to develop and implement a care plan for three of five sampled residents (Resident 2, Resident 3, and Resident 5) when:1. Resident 2's care plan for intravenous (IV) therapy (a medical process that administers fluids, medications and nutrients directly into a person's vein) was initiated seven days after the start of his IV therapy, and;2. Resident 3 and Resident 5's IV therapy was not care planned. These failures placed Resident 2, Resident 3, and Resident 5 at risk for unmet care needs and inadequate care planning. Cross reference F684.1. A review of Resident 2's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included muscle wasting and atrophy (wasting or loss of muscle tissue), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/20/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 10, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 2's order summary report indicated the following order with a start date of 3/24/25, Normal saline [NS (sodium chloride)- a saltwater solution] flush intravenous [into the vein] solution 0.9% (Sodium Chloride flush). Use two (2) liter [L- a unit measure of capacity] intravenously one time a day for 40cc/hr [cubic centimeters per hour- a unit used in medical settings to measure the rate of IV fluid infusion]. Resident 2's order summary report also indicated the following order with a start date of 3/24/25, Peripheral IV [PIV- a short, flexible catheter inserted into a small peripheral vein] site location: R [right] arm, for hydration. [Which indicated Resident 2 had an IV.] A review of Resident 2 's Medication Administration Record (MAR) dated March 2026 indicated the order for NS was administered on 3/24/26, and 3/27-3/28/26. A review of Resident 2's care plan report indicated, IV therapy. At risk for IV therapy complication(s): Phlebitis [inflammation of a vein, often causing pain], Extravasation [leakage of IV medications into surrounding tissue rather than the vein, causing pain], Air Embolism [a life-threatening medical emergency occurring when air bubbles enter veins or arteries]. At risk for adverse drug reaction. This care plan was not initiated until 3/30/26. 2. A review of Resident 3's admission record indicated she was admitted to the facility in February 2026 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness) of left lower limb and asthma (inflammatory disease of the airway causing breathing difficulties). A review of Resident 3's MDS dated [DATE] indicated her BIMS score was 15, which indicated her cognition was intact. A review of Resident 3's order summary report indicated the following order with a start date of 3/13/26, please place a peripheral IV ASAP [as soon as possible] one time only for IV antibiotics [a medication used to treat or prevent bacterial infections] for one (1) day. A review of Resident 3's progress note type, Health Status Note, dated 3/14/26 at 8:07 a.m. indicated, Patient had a new PIV [peripheral IV] line to right wrist.for Ceftriaxone [IV antibiotic]. A review of Resident 3's care plan report with a print date of 4/2/26, indicated no evidence that an IV therapy care plan was initiated. A review of Resident 5's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included sepsis (a life-threatening blood infection) and acute pyelonephritis (a serious bacterial infection of the kidneys [organs that filters blood to remove waste, excess fluid and toxins from the body]). A review of Resident 5's MDS dated [DATE] indicated his BIMS score was eight, which indicated his cognition was moderately impaired. A review of Resident 5's order summary report indicated the following order with a start date of 3/25/26 and 3/31/26, Dextrose-Sodium Chloride IV Solution 5-0.9% [Dextrose with Sodium Chloride: D5NS- a fluid that contains 5% dextrose (sugar) and 0.9% NS]. Use two (2) liter intravenously one time only for dehydration for two (2) days 75 cc/hr. A review of Resident 5's progress note type, Health Status Note, dated 3/26/26 at 3:03 p.m. indicated, Pt [patient] IV started on their right upper forearm. A review of Resident 5's care plan report with a print date of 4/15/26, indicated no evidence that an IV therapy care plan was initiated. During an interview on 4/2/26 at 2:12 p.m., Licensed Nurse 1 (LN 1) confirmed residents that received IV therapy should have the IV therapy care planned. LN 1 stated care plans were important because they provided continuity of care. LN 1 further stated, It gives a lay out of who we are working with and how to adjust their plans of care if needed. During an interview and concurrent record review on 4/2/26 at 4:08 p.m., the Director of Nursing (DON) stated a resident's care plan determined the plan of care. The DON further stated the care plans identified active diagnosis and what the nursing goals and interventions were for it. The DON stated a resident on IV therapy required a care plan because it identified the indication, the risk and how to minimize the risks through the interventions. The DON reviewed Resident 2's care plan report and confirmed she expected his care plan for IV therapy to be initiated on 3/23/26, when his IV therapy started. The DON reviewed Resident 3's care plan report and confirmed no care plan was initiated for IV therapy. During an interview on 4/15/26 at 2:19 p.m., the DON stated she reviewed Resident 5's care plan and she confirmed that no care plan was initiated for his IV therapy. A review of the facility's policy and procedures (P&P) titled, Care Plans, revised 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished.reflects currently recognized standards of practice for problem areas and conditions.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. A review of the facility's P&P titled, Resident Quality of Care and Quality of Life, revised 2025, indicated, Resident Care Plans.Individualized, resident-centered care plans are based on comprehensive and ongoing assessments.Care plans are appropriate for the resident and include reasonable objectives and timetables. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Review care plans daily to ensure that appropriate care is being rendered.Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

Based on interview and record review, the facility failed to provide services in accordance with professional standards of practice for a census of 71 residents when: 1.A Licensed Vocational Nurse (a licensed nurse responsible for rendering basic nursing care) provided nursing services outside of her scope of practice (a defined range of responsibilities and procedures that a licensed professional is legally permitted to perform) when she provided IV therapy to facility residents without IV certification, and; 2. The facility did not maintain accurate training documentation. These failures posed a potential risk to resident health and safety by compromising adherence to professional nursing standards and by impairing the facility's ability to ensure staff competence through accurate training documentation. Cross reference F684 and F842.1. A review of Resident 2's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included muscle wasting and atrophy (wasting or loss of muscle tissue), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/20/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 10, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 2's order summary report dated 4/2/26 indicated:Start date 3/24/26: Peripheral IV (PIV - a short, flexible catheter inserted into a small peripheral vein) intravenous (IV- into the vein) flush (positive pressure technique) with normal saline (NS- a saltwater solution) 5 ML (milliliter, a unit of volume) before and after medications. Two times a day. Start date 3/24/26: PIV site location: R [right] arm, for hydration. [Which indicated Resident 2 had an IV.]A review of Resident 2's IV Administration Record dated 3/1/26 - 3/31/26 indicated the physician order to flush the PIV with NS 5 ML before and after medications two times a day was documented as completed by Licensed Nurse 3 (LN 3, a Licensed Vocational Nurse) on 3/24/26, 3/29/26, and 3/31/26, evening shift (3 - 11:30 p.m.) at 9 p.m. A review of a facility provided document titled, Nursing Staffing Assignment and Sign-In Sheet, dated 3/24/26, indicated the evening shift Registered Nurse (RN) had called off. [Which indicated there was no RN on duty to cover the evening shift for residents that required IV therapy (a medical process that administers fluids, medications and nutrients directly into a person's vein)]. A review of Resident 3's admission record indicated she was admitted to the facility in February 2026 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness) of left lower limb and asthma (inflammatory disease of the airway causing breathing difficulties). A review of Resident 3's MDS dated [DATE] indicated her BIMS score was 15, which indicated her cognition was intact. A review of Resident 3's order summary report dated 4/2/26 indicated: Start date 3/17/26: Change primary intermittent IV tubing (a tubing administration set to deliver IV fluids [IVF]) every 24 hours. Every evening shift. Start date 3/17/26: PIV cap change after each use. Every evening shift. Start date 3/17/26: PIV flush (positive pressure technique] with NS 5 ML before and after medications. Every day and evening shift.A review of Resident 3's IV Administration Record dated 3/1/26 - 3/31/26 indicated the physician order to change the primary intermittent IV tubing every evening shift; change PIV cap every evening shift; and to flush the PIV with NS 5 ML before and after medication two times a day was documented as completed by LN 3 on 3/20/26, evening shift. During an interview on 4/1/26 at 1:15 p.m., Resident 3 stated LN 3 administered her IV antibiotics (a medication used to treat or prevent bacterial infections). Resident 3 further stated LN 3 changed the IV tubing and flushed the IV line when IV care was provided. During an interview on 4/2/26 at 3:10 p.m., LN 2 stated, As a [Licensed Vocational Nurse], if you do not have an IV certification, you should not be managing anything with the IV. During an interview on 4/2/26 at 4:08 p.m., the Director of Nursing (DON) stated [Licensed Vocational Nurses] should not provide IV therapy if they were not IV certified. The DON further stated in doing so, the [Licensed Vocational Nurses] practiced outside of their scope of practice. The DON stated if nursing staff (Licensed Vocational Nurse and/or RN) practiced outside of their scope of practice, it could compromise resident safety. The DON further stated nursing staff that practiced outside of their scope were not in compliance with the Board (Board of Nursing), the State, or CMS (Center for Medicare and Medicaid Services) regulations. During a phone interview on 4/15/26 at 12:24 p.m., LN 3 confirmed she was a Licensed Vocational Nurse and was not IV certified. LN 3 stated she could not provide IV therapy because it was outside of her scope of practice. LN 3 stated she was not allowed to change the IV tubing, the caps, or flush the IV line. LN 3 further verified she was not allowed to start IVF or antibiotics. During an interview and concurrent record review on 4/15/26 at 2:19 p.m., the DON stated that when a Licensed Vocational Nurse was assigned to a resident that required IV therapy, the IV requirements were expected to be handed off to the RN on duty. The DON stated she expected the RN to assume responsibility for the administration, documentation and monitoring of the IV therapy. The DON confirmed LN 3 was not IV certified and did not meet training requirements to perform IV therapy. The DON reviewed the facility provided document titled, Nursing Staffing Assignment and Sign-In Sheet, dated 3/24/26, and confirmed there was no RN that worked the evening shift. The DON stated, I could have stayed later to assist with the IV, but I don't recall being asked to stay and assist. The DON reviewed LN 3's documentation on Resident 2's IV administration record dated 3/24/26, 3/29/26, and 3/31/26 and confirmed based on LN 3's documentation, she completed the tasks. The DON reviewed LN 3's documentation on Resident 3's IV administration record dated 3/20/26 and confirmed based on LN 3's documentation, she completed the tasks. Subsequently, the Administrator (ADM) joined the interview and confirmed that if a Licensed Vocational Nurse performed skills outside of his/her scope of practice, it was an issue of concern. The ADM further stated he did not believe that to be the case, but that the documentation would show otherwise. 2. A review of a facility provided document titled, ON DUTY: In-Service Compliance Class Attendance Record, dated 1/7/26, indicated the class covered standards of safe medical administration. The document indicated the in-service was conducted by DON 2. The document indicated the topics covered included: best practices for safe medication administration, error reduction and timely and accurate documentation. The document was signed by 16 nurse staff and included their wet signatures (a physical signature made by hand using pen or pencil on paper). The document was signed by the instructor [DON 2]. A review of a facility provided document titled, ON DUTY: In-Service Compliance Class Attendance Record, dated 2/25/26, indicated the class covered the prevention of medication errors. The document indicated the in-service was conducted the DON. The document indicated the topics covered included: covering all routes- PO (by mouth), SQ (subcutaneous- applied under the skin), IM (intramuscular- applied in the muscle), IV, enteral (administering nutrients or medications directly into the gastrointestinal tract [esophagus, stomach, and intestines]), intranasal (applied into the nose), optic (applied into the eye) and otic (applied into the ear). The document had the same exact 16 nurse staff wet signatures, and the signatures were documented in the same staff order as the in-service compliance class attendance record conducted on 1/7/26. Visually, this document was an exact copy of the, ON DUTY: In-Service Compliance Class Attendance Record, dated 1/07/26, except with different trainings listed. The document was signed by the instructor [DON]. During a phone interview on 4/16/26 at 1:02 p.m., the DON and Administrator (ADM) stated they could not explain the duplicate in-service compliance class attendance records dated 1/7/26 and 2/25/26. The DON and ADM confirmed the in-service classes were conducted on different dates, by different instructors, and included different topics. The DON and ADM confirmed that the attendance record sign-in sheet from 2/25/26 had the same wet signatures of staff and was in the same order as signed on the attendance record sign-in sheet from 1/07/26. A review of the facility's policy and procedures titled, Staffing, Sufficient and Competent Nursing, revised 2025, indicated, The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.Licensed staff must demonstrate the skills and techniques necessary to care for residents needs including.Nursing skills consistent with scope of practice.Competency requirements and training for nursing staff are established and monitored by nursing leadership. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure. A review of the facility's document titled, Preventing Medication Errors: Mastering the Rights of Medication Administration Across All Routes, no date, indicated, Stay within scope of practice- know what your license and facility policy allow (e.g. [example], IV pushes is RN-only).

Based on interview and record review, the facility failed to provide quality of care for three of five sampled residents (Resident 2, Resident 3, and Resident 5) when: 1. A peripheral venous catheter (PIVC- a short, flexible catheter inserted into a small peripheral vein, also known as, peripheral intravenous [PIV] line) was inserted into Resident 2 and Resident 5 without a physician's order, 2. No order was obtained for the removal of the PIVC and the removal of the PIVC was not documented for Resident 2, Resident 3 and Resident 5, and;3. Resident 2, Resident 3, and Resident 5's physician orders were not followed. These failures increased Resident 2, Resident 3, and Resident 5's risk for complications related to intravenous (IV) therapy (a medical process that administers fluids, medications and nutrients directly into a person's vein), infection, and compromised quality of care. Cross reference F657 and F842.1. A review of Resident 2's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included muscle wasting and atrophy (wasting or loss of muscle tissue), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/20/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 10, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 2's order summary report dated 4/2/26 indicated:Start date 3/24/26: Normal saline (NS [sodium chloride]- a saltwater solution) flush intravenous (into the vein) solution 0.9% (Sodium Chloride flush). Use two (2) liter (L- a unit measure of capacity) IV one time a day for 40 cc/hr (cubic centimeters per hour- a unit used in medical settings to measure the rate of IV fluid infusion). [End date not indicated.],Start date 3/30/26: Dextrose-Sodium Chloride IV Solution 5-0.9% (Dextrose with Sodium Chloride: D5NS- a fluid that contains 5% dextrose [sugar] and 0.9% NS). Use two (2) liter intravenously one time only for dehydration for three (3) days 40 cc/hr. End date dated 4/2/26, Start date 3/24/26: Monitor IV site every shift for signs and symptoms (s/s) of complications- Infiltration (when medications or fluids leak into the soft tissue instead of the vein), Phlebitis (inflammation of the vein, often causing pain), Hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel), Infection. Every shift. [End date not indicated.],Start date 3/24/26: PIV flush (positive pressure technique) with NS 5 ML (milliliter, a unit of volume) before and after medications. Two times a day. [End date not indicated.],Start date 3/24/26: PIV site location: R [right] arm, for hydration. [Which indicated Resident 2 had an IV. End date not indicated.],No evidence of a physician's order to insert a PIVC, and;No evidence of a physician's order to remove the PIVC after the completion of IV therapy.A review of Resident 5's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included sepsis (a life-threatening blood infection) and acute pyelonephritis (a serious bacterial infection of the kidneys [organs that filters blood to remove waste, excess fluid and toxins from the body]). A review of Resident 5's MDS dated [DATE] indicated his BIMS score was eight, which indicated his cognition was moderately impaired. A review of Resident 5's order summary report dated 4/16/26 indicated: Start date 3/25/26: D5NS. Use two (2) liters IV one time only for hydration for two (2) days 75 cc/hr. End date dated 3/27/25,Start date 3/31/26: D5NS. Use two (2) liters IV one time only for hydration for two (2) days 75 cc/hr. End date dated 4/2/26,Start date 3/26/26 and 4/1/26: PIV flush (positive pressure technique) with NS 5 ML before and after medications. Every shift. [End date not indicated.],Start date 3/26/26: PIV cap change after each use. Every shift. [End date not indicated.],Start date 3/26/26 and 4/1/26: Monitor IV site every shift for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. [End date not indicated.],Start date 4/1/26: PIV site location: R [right] arm, for hydration. [Which indicated Resident 5 had an IV. End date not indicated.],No evidence of a physician's order to insert a PIVC, and;No evidence of a physician's order to remove the PIVC after the completion of IV therapy.A review of Resident 5's progress notes titled, Health Status Note, dated 3/26/26 at 3:03 p.m., indicated, Pt [patient] IV started on their right upper forearm. 2. A review of Resident 3's admission record indicated she was admitted to the facility in February 2026 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness) of left lower limb and asthma (inflammatory disease of the airway causing breathing difficulties). A review of Resident 3's MDS dated [DATE] indicated her BIMS score was 15, which indicated her cognition was intact. A review of Resident 3's order summary report dated 4/2/26 indicated: Start date 3/15/26: Ceftriaxone (an antibiotic used to treat bacterial infections) sodium solution reconstituted (NS is added to the antibiotic to form a solution) 1 GM (gram- a unit of mass). Use one (1) gram IV every 24 hours for acute exacerbation of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) for six (six) days. End date dated 3/21/26,Start date 3/13/26: Please place a PIV ASAP (as soon as possible) one time only for IV antibiotics for one (1) day. End date dated 3/14/26,Start date 3/16/26: Monitor IV site for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. [End date not indicated.],Start date 3/17/26: Change primary intermittent IV tubing (a tubing administration set to deliver IV fluids [IVF]) every 24 hours. Every evening shift. [End date not indicated.],Start date 3/17/26: PIV cap change after each use. Every evening shift. [End date not indicated.],Start date 3/17/26: PIV flush (positive pressure technique] with NS 5 ML before and after medications. Every day and evening shift. [End date not indicated.], and; No evidence of a physician's order to remove the PIV after the completion of IV therapy.A review of Resident 3's progress notes titled, Health Status Note, dated 3/14/26 at 8:07 a.m., indicated, Patient had a new PIV line to right wrist. A review of Resident 3's Medication Administration Record (MAR) dated 3/1/26 - 3/31/26, indicated ceftriaxone sodium solution reconstituted 1 GM was started on 3/15/26 and ended on 3/20/26. [Which indicated the order was completed.] A review of Resident 3's progress notes dated 3/1/26 - 3/31/26 indicated no evidence of when the PIVC was removed. During an interview on 4/1/26 at 1:15 p.m., Resident 3 stated her IV was removed when her antibiotic treatment was completed.A review of Resident 5's MAR dated 3/1/26 - 3/31/26, indicated IVF D5NS was started on 3/26/26 and again on 3/31/26. A review of Resident 5's progress notes dated 3/25/26 - 4/3/26 indicated no evidence of when the PIVC was removed. The progress notes also did not indicate instructions to leave the PIVC site inserted. A review of Resident 2's MAR dated 3/1/26 - 3/31/25 indicated IVF NS was started on 3/24/26 and ended on 3/28/26, and that IVF D5NS was started on 3/30/26. A review of Resident 2's progress notes titled, Health Status Note, dated 3/28/26 at 2:59 p.m., indicated, .informed to leave the IV site in. A review of Resident 2's progress notes titled, Health Status Note, dated 4/2/26 at 11 p.m., indicated, IV hydration will be discontinued. A review of Resident 2's progress notes dated 4/1/26 - 4/16/26 indicated no evidence of when the PIVC was removed. 3. A review of Resident 2's IV Administration Record dated 3/1/26 - 3/31/26 indicated the following physician orders were not followed: PIV flush (positive pressure technique) with NS 5 ML before and after medications. Two times a day. The order was not completed on the day shift 3/25/26 and 3/26/26, and;Monitor IV site for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. The order was not completed on the night shift 3/24/26, the day and night shift 3/25/26, the day shift 3/26/26, and the night shift 3/30/26 and 3/31/26. A review of Resident 3's IV Administration Record dated 3/1/26 - 3/31/26 indicated the following physician orders were not followed:PIV flush (positive pressure technique] with NS 5 ML before and after medications. Every day and evening shift. The order was not completed on the day shift on 3/21/26, and;Monitor IV site for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. The order was not completed on the night shift on 3/19/26 and 3/20/26, and the day shift 3/21/26. A review of Resident 5's MAR dated 3/1/26 - 3/31/26 and 4/1/26 - 4/30/26 indicated the following physician orders were not followed: D5NS. Use two (2) liters IV one time only for hydration for two (2) days 75 cc/hr was not completed on 3/28/26, and; D5NS. Use two (2) liters intravenously one time only for hydration for two (2) days 75 cc/hr was not completed on 4/1/26 and 4/2/26. A review of Resident 5's IV Administration dated 3/1/26 - 3/31/26 and 4/1/26 - 4/30/26 indicated the following physician orders were not followed: Monitor IV site for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. The order was not completed on the evening and night shift on 3/26/26, the day, evening and night shift on 3/27/26, the night shift on 3/28/26, the day and night shift 3/29/26 and 3/30/26, and the night shift on 3/31/26,PIV flush (positive pressure technique] with NS 5 ML before and after medications. Every shift. The order was not completed on the evening and night shift on 3/26/26, the day, evening and night shift on 3/27/26, the night shift on 3/28/26, the day and night shift 3/29/26 and 3/30/26, and the night shift on 3/31/26, PIV flush (positive pressure technique] with NS 5 ML before and after medications. Two times a day. The order was not completed the evening shift 4/2/26, and the day shift 4/3/26, and;Monitor IV site for s/s of complications- Infiltration, Phlebitis, Hematoma, Infection. Every shift. The order was not completed on the night shift 4/1/26 and 4/2/26, and the day shift 4/3/26. During an interview on 4/1/26 at 2:40 p.m., the Director of Nursing (DON) stated Resident 2's IVF order for NS 2 L at 40 cc/hr would take approximately two days to complete. The DON confirmed the end date would be two days after the order was started. The DON stated, At this rate [the rate of infusion], it's [the IVF] causing no harm as long as the IV site is being monitored. The DON further stated that she expected the nursing staff (Licensed Nurses [LN] and Registered Nurses [RN]) to monitor the IV site for redness, infiltration and for signs of infection. During an interview on 4/2/26 at 3:10 p.m., Licensed Nurse 2 (LN 2) stated a physician order was required to start or discontinue a PIV. LN 2 further stated the start or discontinuation of an PIV was expected to be documented as a progress note in the resident's medical record. During an interview and concurrent record review on 4/2/26 at 4:08 p.m., the DON reviewed Resident 2's order summary report and confirmed there was no order to start a PIV. The DON stated she expected that a physician order be obtained before the IV is started. The DON further expected the physician to be notified when IV therapy is completed to inquire if the physician wanted to order lab work, or to obtain an order to remove the IV. The DON stated communication with the physician was expected to be documented in the residents' progress notes. The DON further stated she expected the removal of the IV to be documented and to include when it was removed, by who, and the condition of the IV site to ensure no complications. The DON stated complications of IV therapy were increased risk for infection, phlebitis, and infiltration. The DON further stated the longer the IV was inserted, the risks of complications were increased. The DON reviewed Resident 2's March 2026 IV administration record and confirmed the physician order to flush the IV was not documented on 3/25/26 or 3/26/26. The DON further stated, There is no way to know if the order was followed. You can't confirm if the order was followed if it's not documented. The DON confirmed Resident 2's physician order to monitor the IV site was not completed on the night shift 3/24/26, the day and night shift 3/25/26, the day shift 3/26/26, and the night shift 3/30/26 and 3/31/26. Subsequently, the DON reviewed Resident 3's March 2026 IV administration record and confirmed the physician's order to flush the PIV was not completed on the day shift on 3/21/26. The DON further confirmed Resident 3's physician order to monitor the IV site was not completed on the night shift on 3/19/26, 3/20/26, and the day shift 3/21/26. During a phone interview on 4/15/26 at 1:15 p.m., RN 1 stated a physician order to insert an IV is required. RN 1 further stated, Because the IV is considered a medication and it is invasive [the body is entered by a needle, tube, device, or scope]. RN 1 stated an order was required before an IV was removed, and the removal was expected to be documented under a progress note in the resident's medical record. During an interview on 4/15/26 at 2:19 p.m., the DON stated, Everything you do for the patient [resident], has to have a corresponding order from the doctor so it's clear what is being provided and what needs to be done. The DON confirmed a physician order was required to insert or remove a PIVC. The DON stated she expected the PIVC insert or removal to be documented in a progress note in the resident's medical record. The DON stated she reviewed Resident 2, Resident 3, and Resident 5's order summary reports and confirmed there were no orders to remove the resident's PIV catheters. The DON further stated that without an order and corresponding progress notes, you would not know when the PIV catheter was removed and if the PIV catheter was intact upon removal. The DON stated she reviewed Resident 5's medical records and confirmed that the physician orders to monitor and flush the IV were not followed during multiple shifts. Subsequently, the DON stated the facility document titled, Charge Nurse, covered the responsibilities expected by LN staff. A review of the facility's policy and procedures (P&P) titled, Resident Quality of Care and Quality of Life, revised 2025, indicated, The following quality of care/quality of life standards are recognized as high-risk areas and therefore are carefully monitored.Sufficient Staffing: Staffing is provided.with staff who have.expertise to meet the needs of residents.Medication Management: Procedures are in place to ensure accuracy and safety of administering.of medications.Resident safety: Nursing staff have the appropriate training and levels of competency to ensure resident safety. A review of the facility's P&P titled, Documentation of Medication Administration, revised 2022, indicated, Documentation of medication administration included.the condition of the venipuncture [process of puncturing the vein] or vascular access device site before and after medication administration [if administered intravenously]. A review of the facility's P&P titled, Intravenous Administration of Fluids and Electrolytes [electrically charge minerals], revised 2025, indicated, The purpose of this procedure is to provide guidelines for the safe and aseptic [free from contamination] administration of intravenous fluids and electrolytes for hydration.When continuous fluids are infusing, resident is monitored for s/s of.catheter patency [unobstructed].insertion site complications.the resident's tolerance to the procedure.Review providers order.When infusion is complete.flush catheter per protocol.Document procedure in the resident's medical record. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, The primary purpose of your job position is to provide direct nursing care to the residents.to ensure that the highest degree of quality care is maintained at all times.Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.Review MAR's for completeness of information, accuracy in the transcription of the physician's order.

Based on interview and record review the facility failed to ensure accurate documentation for three out of five sampled residents (Resident 2, Resident 3, and Resident 5) when medications administered and tasked physician orders were not documented by the nurse who completed the order. This failure had the potential to compromise resident safety, monitoring, and the facility's ability to communicate essential clinical information. Cross reference F658. A review of Resident 2's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included muscle wasting and atrophy (wasting or loss of muscle tissue), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/20/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 10, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 2's order summary report dated 4/2/26 indicated:Start date 3/24/26: Normal saline (NS [sodium chloride]- a saltwater solution) flush intravenous (into the vein) solution 0.9% (Sodium Chloride flush). Use two (2) liter [L- a unit measure of capacity] IV one time a day for 40 cc/hr [cubic centimeters per hour- a unit used in medical settings to measure the rate of IV fluid infusion), Start date 3/30/26: Dextrose-sodium chloride IV solution 5-0.9% (dextrose with sodium chloride: D5NS- a fluid that contains 5% dextrose [sugar] and 0.9% NS). Use two (2) liter intravenously one time only for dehydration for three (3) days 40 cc/hr, and;Start date 3/24/26: PIV flush (positive pressure technique) with NS 5 ML (milliliter, a unit of volume) before and after medications. Two times a day. A review of Resident 2's Medication Administration Record (MAR) dated 3/1/26 - 3/31/26 indicated the physician order to administer D5NS two (2) liter IV was documented as administered by Licensed Nurse 3 (LN 3) on 3/30/36 at 10:55 p.m.A review of Resident 2's IV Administration Record dated 3/1/26 - 3/31/26 indicated the physician orders to flush the PIV with NS 5 ML was documented as administered by LN 3 on 3/24/26 - 3/26/26 and 3/29/26 - 3/31/26. A review of Resident 2's progress notes indicated the following: Type, Health Status Note, dated 3/30/26 at 11:44 p.m., indicated, Pt [patient] on IV hydration 5% D5 NS 0.9% to run 40 cc/hr. on R forearm. First bag initiated @22:39 pm [at 11:39 p.m.]. IV line is flushed. was documented by Registered Nurse 3 (RN 3),Type, eMAR [electronic medication administration record]- Medication Administration Note, dated 3/30/26 at 11:55 p.m., indicated the physician order to administer D5NS, done by RN 3, was documented by LN 3,Type, eMAR- Medication Administration Note, dated 3/26/26 at 3:36 p.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 1, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 3/25/26 at 5:41 p.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 3, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 3/25/26 at 4:41 p.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 1, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 4/1/26 at 11:55 p.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 1, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 4/2/26 at 10:37 a.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 3, was documented by LN 3, and;Type, eMAR- Medication Administration Note, dated 4/2/26 at 10:38 a.m., indicated the physician order to flush PIV with NS 5 ML, done by RN 1, was documented by LN 3.A review of Resident 3's admission record indicated she was admitted to the facility in February 2026 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness) of left lower limb and asthma (inflammatory disease of the airway causing breathing difficulties). A review of Resident 3's MDS dated [DATE] indicated her BIMS score was 15, which indicated her cognition was intact. A review of Resident 3's order summary report dated 4/2/26 indicated: Start date 3/15/26: ceftriaxone (an antibiotic used to treat bacterial infections) sodium solution reconstituted (NS is added to the antibiotic to form a solution) 1 GM (gram- a unit of mass). Use one (1) gram IV every 24 hours for acute exacerbation of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) for six (six) days,Start date 3/17/26: Change primary intermittent IV tubing (a tubing administration set to deliver IV fluids [IVF]) every 24 hours. Every evening shift,Start date 3/17/26: PIV cap change after each use. Every evening shift, and;Start date 3/17/26: PIV flush (positive pressure technique] with NS 5 ML before and after medications. Every day and evening shift. A review of Resident 3's MAR dated 3/1/26 - 3/31/26 indicated the physician order to administer ceftriaxone 1 GM was documented as administered by LN 3 on 3/18/26 at 4 p.m. A review of Resident 3's IV Administration Record dated 3/1/26 - 3/31/26 indicated the physician orders to change the primary intermittent IV tubing every evening shift; change PIV cap every evening shift; and to flush the PIV with NS 5 ML before and after medication two times a day was documented as administered by LN 3 on 3/17/26 - 3/20/26. A review of Resident 3's progress notes indicated the following: Type, eMAR- Medication Administration Note, dated 3/17/26 at 11:32 p.m., indicated the physician orders to change the primary intermittent IV tubing every evening shift; change PIV cap every evening shift; and to flush the PIV with NS 5 ML before and after medication two times a day, done by RN 3, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 3/18/26 at 4 p.m., indicated the physician order to administer ceftriaxone 1 GM, done by RN 3, was documented by LN 3, Type, eMAR- Medication Administration Note, dated 3/18/26 at 10:01 p.m., indicated the physician orders to change the primary intermittent IV tubing every evening shift; change PIV cap every evening shift; and to flush the PIV with NS 5 ML before and after medication two times a day, done by RN 3, was documented by LN 3, and;Type, eMAR- Medication Administration Note, dated 3/19/26 at 10:17 p.m., indicated the physician orders to change the primary intermittent IV tubing every evening shift; change PIV cap every evening shift; and to flush the PIV with NS 5 ML before and after medication two times a day, done by RN 1, was documented by LN 3.A review of Resident 5's admission record indicated he was admitted to the facility in March 2026 with medical diagnosis which included sepsis (a life-threatening blood infection) and acute pyelonephritis (a serious bacterial infection of the kidneys [organs that filters blood to remove waste, excess fluid and toxins from the body]). A review of Resident 5's MDS dated [DATE] indicated his BIMS score was eight, which indicated his cognition was moderately impaired. A review of Resident 5's order summary report dated 4/16/26 indicated: Start date 3/26/26 and 4/1/26: PIV flush (positive pressure technique) with NS 5 ML before and after medications. Every shift. A review of Resident 5's IV administration record dated 3/1/26 - 3/31/26 indicated the physician order to flush the PIV with NS 5 ML was documented as administered by LN 4 on 3/31/26. A review of Resident 5's progress note type, eMAR- Medication Administration Note, dated 3/31/26 at 2:15 p.m., indicated the physician order to flush PIV with NS 5 ML, done by Nurse Practitioner (NP), was documented by LN 4.During an interview on 4/1/26 at 1:15 p.m., Resident 3 stated LN 3 administered her IV antibiotics. Resident 3 further stated LN 3 changed the IV tubing and flushed the IV line when IV care was provided. During a phone interview on 4/13/26 at 3:27 p.m., the Director of Staff Development Consultant (DSD C) stated LN 3 was not IV certified. When asked if it was acceptable for LN 3 to document Resident 3's IV antibiotics as administered, as well as the associated IV tasks as completed in the resident's MAR, the DSD C did not directly provide an answer. The DSD C stated, I believe it was documented in error.During a phone interview on 4/15/26 at 12:24 p.m., LN 3 confirmed she was an Licensed Vocational Nurse and was not IV certified. LN 3 stated she could not provide IV therapy because it was outside of her scope of practice (a defined range of responsibilities and procedures that a licensed professional is legally permitted to perform). LN 3 stated she was not allowed to change the IV tubing, the caps, or flush the IV line. LN 3 further verified she was not allowed to start IVF or antibiotics. LN 3 confirmed it was not acceptable to document a medication as administered or a physician order as completed if it was administered and/or completed by someone else. LN 3 stated, I didn't do it, and I should have not done that, when referenced to the IV therapy provided and documentation of administration. LN 3 further stated the documentation was inaccurate. During an interview on 4/15/26 at 12:45 p.m., LN 5 confirmed it was not acceptable to document a medication as administered or a physician order as completed if it was administered and/or completed by someone else. LN 5 stated, The next person [nurse staff] wouldn't know if they [the resident] really got it [the medication]. LN 5 stated the documentation would be inaccurate. LN 5 further stated, Whoever provided the IV therapy should be the one documenting. During a phone interview on 4/15/26 at 1:02 p.m., LN 4 confirmed she was a Licensed Vocational Nurse and was not IV certified. LN 4 stated, It's never ok to document that you did something that you didn't actually do. It would be inaccurate or false documentation. During a phone interview on 4/15/26 at 1:15 p.m., RN 1 stated that if she provided the IV therapy, it was her responsibility as the RN to document what was completed. RN 1 further stated, The best practice is for the performing nurse to document under their own log-in, because it shows and ensures accuracy of medication administration. During an interview and concurrent record review on 4/15/26 at 2:19 p.m., the DON stated that when an LN was assigned to a resident that required IV therapy, the IV requirements were expected to be handed off to the RN on duty. The DON stated she expected the RN to assume responsibility for the administration, documentation and monitoring of the IV therapy. The DON stated, I expect the performing RN to document because they are the one's who did it. They need to take ownership and accountability to document it. The DON stated when nurse staff documented a medication as administered or a physician order as completed if it was administered and/or completed by someone else, It makes it confusing as to what actually happened and the accuracy of the documentation is in question. The DON reviewed Resident 2's MAR and eMAR progress notes dated March 2026 and confirmed the physician's order to flush the PIV with NS 5 ML was cross charted in the eMAR by LN 3 as done by RN multiple times. The DON stated, This kind of charting is not acceptable. A review of the facility's policy and procedures (P&P) titled, Documentation of Medication Administration, revised 2022, indicated, The medication administration record [MAR] is used to document all medications administered.Documentation of medication administration includes.initials, signature and title of the person administering the medication. A review of the facility's P&P titled, Medication Administration, revised 2019, indicated, The individual administering the medication documents/initials the resident's MAR.the individual administering the medication records in the resident's medical record.the signature and title of the person administering the drug. A review of the facility's P&P titled, Resident Quality of Care and Quality of Life, revised 2025, indicated, Medication Management.procedures are in place to ensure accuracy and safety of administering.medications. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. A review of the facility's document titled, Preventing Medication Errors: Mastering the Rights of Medication Administration Across All Routes, no date, indicated, Preventing Medication Errors.Common causes: poor communication.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) were free from significant medication errors when her breathing treatments and intravenous (IV- into the vein) antibiotics (a medication used to treat or prevent bacterial infections) were not administered in accordance with the physician's order. These failures decreased the facility's potential to safely administer medications and increased Resident 3's risk for compromised respiratory status and infection. A review of Resident 3's admission record indicated she was admitted to the facility in February 2026 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness) of left lower limb and asthma (inflammatory disease of the airway causing breathing difficulties). A review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 2/26/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 15, which indicated her cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 3's order summary report dated 4/2/26 indicated: Initial start date 3/13/25: ceftriaxone (an antibiotic used to treat bacterial infections) sodium solution reconstituted (NS is added to the antibiotic to form a solution) 1 GM (gram- a unit of mass). Use one (1) gram IV every 24 hours for acute exacerbation of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) for seven (7) days. (The order summary report is with multiple start dates, discontinuations, and re-orders.), and;Initial start date 2/20/26: ipratropium-albuterol inhalation solution 0.5-2.5 (a combination inhalation solution used to treat wheezing and breathlessness caused by COPD) (3) MG/3ML (milligram [mg] measures weight, and milliliters [mL] measures volume). 3 ml inhale orally (by mouth) via nebulizer (a medical device that converts liquid medication into a fine mist) every 12 hours for asthma (a chronic respiratory disease that causes breathing difficulties). (The order summary report is with multiple start dates, discontinuations, and re-orders). A review of Resident 3's Medication Administration Record (MAR) dated 3/1/26 - 3/31/26 indicated ceftriaxone sodium solution reconstituted 1 GM initial start date and time was 3/13/26 at 9 p.m. The MAR indicated on 3/13/26, the ceftriaxone medication administration was documented as a '2' (2= No med required-Outside Parameter). Subsequently, the MAR indicated the new start date and time was 3/15/26 at 3 p.m. Resident 3's MAR indicated the ceftriaxone was administered at 7:15 p.m. on 3/15/26. A review of Resident 3's progress notes dated 3/1/26 - 3/31/26, indicated the following: Type, eMAR [medication administration record]- Medication Administration Note, dated 3/13/26 at 11:50 p.m., indicated, Ceftriaxone Sodium Solution Reconstituted 1 GM.RN [Registered Nurse] will start tomorrow 03/13 AM [morning], and; No documented evidence of why the physician's order for ceftriaxone was administered late on 3/15/26.A review of Resident 3's Respiratory MAR dated 3/1/26 - 3/31/26 indicated ipratropium-albuterol inhalation solution 0.5-2.5 (3) MG/3ML:Start date with time 2/20/26 at 8 a.m. and 8 p.m. According to the MAR, this order was discontinued on 3/5/26, Start date with time 3/5/26 at 7 a.m. and 7 p.m. Subsequently, this order was discontinued 3/11/26, and; Start date with time 3/11/26 at 7 a.m. and 7 p.m.A review of Resident 3's Medication Admin (Administration) Audit Report dated 3/1/26 - 3/31/26, indicated, based on the administration times scheduled on the respiratory MAR, the physician's order for ipratropium-albuterol inhalation solution 3 mL every 12 hours was administered late by more than one hour on 17 out of 60 opportunities. A review of Resident 3's progress notes dated 3/1/26 - 3/31/26, indicated no documented evidence why the physician's order for ipratropium-albuterol inhalation solution 3 mL every 12 hours was administered late. A review of Resident 3's care plan initiated on 2/20/26 indicated, Shortness of breath.[staff were expected to] Administer/monitor effectiveness of medications and breathing treatments as ordered by the physician, and [Resident 3] has asthma.[staff were expected to] Administer medications as ordered.A review of Resident 3's care plan initiated on 3/16/26 indicated, Antibiotic therapy r/t [related to] medical diagnosis: COPD exacerbation.Medication: Ceftriaxone Sodium Solution 1 GM.[staff were expected to] Administer antibiotic & treatment as ordered by physician.During an interview on 4/1/26 at 1:15 p.m., Resident 3 stated she was receiving IV antibiotics to treat a lung infection. Resident 3 stated she recalled receiving her IV antibiotics late one time and she did not know why. During an interview on 4/2/26 at 2:12 p.m., Licensed Nurse 1 (LN 1) stated medication could be administered one hour before and one hour after it was ordered. LN 1 further stated if the resident did not want the medication at the ordered time, it should be documented in the resident's MAR as a progress note. LN 1 stated if the ordered medication was a maintenance medication (medication taken regularly to manage chronic, long-term conditions like asthma) it was important to give as ordered. LN 1 confirmed that a breathing treatment to treat asthma was a maintenance medication. LN 1 stated it was important that breathing treatments were administered as ordered to avoid respiratory distress (a critical condition indicating severe difficulty breathing). LN 1 stated that antibiotics had to be administered on time. LN 1 further stated if antibiotic therapy was not completed as ordered, the infection could not be treated. LN 1 stated if antibiotics were administered late, the reason for the late administration was expected to be documented in the resident's medical record, along with the physician's notification. LN 1 further stated the scheduling administration times might need to be changed. During an interview on 4/2/26 at 3:10 p.m., LN 2 stated medications could be administered one hour before and one hour after it was ordered. LN 2 stated the same applied to breathing treatments. LN 2 stated if antibiotics were administered too early or too late, the antibiotic would not act as it should to fight the infection. LN 2 further stated if an antibiotic was administered late, it was considered a delay in care because the antibiotic needed to be maintained at a certain concentration in the resident's body for the antibiotic to be effective. During an interview and concurrent record review on 4/2/26 at 4:08 p.m., the Director of Nursing (DON) stated the expectation for medication administration was that medications could be administered one hour before and one hour after the ordered administration time. The DON reviewed Resident 3's March 2026 MAR and March progress notes and stated the IV antibiotics were not administered as ordered on 3/13/26. The DON stated she expected staff to notify the physician to let them know if the facility did not have the medication. The DON further stated it was expected that the notification be documented in the resident's medical record and to include any change to the order. The DON confirmed that there was no evidence that the physician was notified about Resident 3's delay in care. The DON further stated that an antibiotic was given to prevent or treat an infection. The DON stated, It's important to give as ordered so that the antibiotic can reach the maximum therapeutic effect [the desired outcome of a medical treatment]. The DON stated she reviewed Resident 3's March medication administration audit report and confirmed the ipratropium-albuterol inhalation breathing treatment was administered late on multiple occasions. The DON stated Resident 3's scheduled breathing treatments helped with bronchodilation (a medication that opens the airways) so that she could breathe better. A review of the facility's policy and procedures (P&P) titled, Medication Administration, revised 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber's orders, including any required time frame.Medication administration times are determined by resident need and benefit. Factors that are considered include.enhancing optimal therapeutic effect of the medication.Medications are administered within one (1) hour of their prescribed time.A review of the facility's P&P titled, Intravenous Administration of Fluids and Electrolytes, revised 2025, indicated, Documentation.The following information should be recorded in the resident's medical record.Notification of the provider if there are any complications.A review of the facility's P&P titled, Administering Medications through a Small Volume [Handheld] Nebulizer, revised 2010, indicated, General Guideline.Follow the medication administration guidelines in the policy entitled Administering Medications.A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Prepare and administer medications as ordered by the physician. A review of the facility's document titled, Preventing Medication Errors: Mastering the Rights of Medication Administration Across All Routes, no date, indicated, The Rights of Medication Administration.Right time [usually within 30-60 minutes of the scheduled time. A review of the facility's document titled, Medication Safety Essentials: Proper Storage, Labeling, and Adhering to Physician Orders, no date, indicated, Following MD [medical doctor] Orders in Medication Administration.Timely administration: Adhere to scheduled times [usually within 30-60 minutes before/after); document exact time given.

Based on observation, interview, and record review, the facility did not provide a safe, hazard free environment for five of eight sampled residents (Resident 3, Resident 23, Resident 61, Resident 81, and Resident 93), when four rooms had damaged wall trims with exposed sharp edges, and Resident 23's wall trim was detached.These failures had the potential to cause harm and injury to the residents, especially those with cognitive impairments who might not recognize the hazards. A review of Resident 3's admission record indicated he was admitted to the facility in December 2025 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and narcolepsy (a chronic sleep disorder). A review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/02/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 15 which indicated his cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 23's admission record indicated she was admitted to the facility in January 2026 with medical diagnosis which included muscle wasting and atrophy (weakening of muscle mass), and lack of coordination. A review of Resident 23's MDS dated [DATE], indicated her BIMS score was 15 which indicated her cognition was intact. A review of Resident 61's admission record indicated he was admitted to the facility in July 2024 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (stroke). A review of Resident 61's MDS dated [DATE], indicated his BIMS score was 15 which indicated his cognition was intact. A review of Resident 81's admission record indicated she was admitted to the facility in December 2025 with medical diagnosis which included nondisplaced fracture of the sacrum (a crack in the tailbone area) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). A review of Resident 81's MDS dated [DATE], indicated her BIMS score was 15 which indicated her cognition was intact. A review of Resident 93's admission record indicated he was admitted to the facility in February 2026 with medical diagnosis which included hemangioma of intracranial structures (vascular malformations) and history of falling. A review of Resident 93's MDS dated [DATE], indicated his BIMS score was 15 which indicated his cognition was intact. During an observation and concurrent interview on 2/09/26 at 10:52 a.m., in Resident 3's room, approximately six inches (in.- a unit of measure) above the head of his bed, the top layer of the wooden wall trim was observed damaged. The wood was broken and created a sharp, [NAME]-like pointed tip. Resident 3 stated the condition of the wall trim bothered him. Resident 3 further stated he could hurt himself if he came into contact with the sharp edge. Resident 3 stated he informed facility staff and no one had been in to repair it. During an observation on 2/09/26 at 11:07 a.m., in Resident 81's room, approximately five in. above the head of her bed and to the left of the headboard, the top layer of the wooden wall trim was observed damaged. The wood was broken and created a rough-edged pointed tip with a blunt cut edge below it. During an observation on 2/09/26 at 12 p.m. in Resident 23's room, approximately three in. above the head of her bed and to the left of the headboard, the top layer of the wooden wall trim was observed damaged. The wood was broken and created a sharp, splintered pointed tip that protruded approximately one in. from the base layer of wall trim. The base layer of wall trim appeared to be detached down the entire length of the wall with approximately half an inch gap between the base layer of the wall trim and the wall. Resident 23 confirmed the broken wall trim had a very sharp edge. During an observation on 2/09/26 at 2:28 p.m. located in the middle of the room between Resident 61's and 93's designated spaces, the top layer of the wooden wall trim was observed damaged along the wall. Approximately two in. below the damaged area, a walker and wheelchair was stored. The wood was broken and created a rough edge along the underside of the trim and was pointed on top. Resident 61 and Resident 93 confirmed the wall trim was damaged. During a concurrent observation and interview on 2/11/26 at 1:51 p.m., with the Maintenance Director (MTD) in Resident 3's room, the damaged top layer of the wall trim was cut to a blunt, flat edge. The MTD stated he repaired the broken wall trim on 2/09/26. The MTD further stated he did not know how long it had been damaged for. The MTD confirmed the damaged wall trim was located behind Resident 3's head of bed and was sharp prior to the repair. Subsequently, in Resident 61 and Resident 93's room, the MTD verified the top layer of the wall trim was broken and exposed a rough edge. The MTD stated he was unaware of the damage because it was not reported to him. Following, in Resident 23's room, the MTD confirmed the top layer of the wall trim was broken and located near Resident 23's head of bed. The MTD verified the edge was very sharp. Resident 23 stated the entire wall border was coming off the wall. Observed, along the length of the wall, the base layer of the wall border was observed detached from the wall by approximately two to three in. and exposed nails on the opposite side of the wall border that attached to the wall. The MTD was observed to quickly push the detached wall border back into the wall. The MTD confirmed the entire wall border was loose and coming off the wall. Lastly, in Resident 81's room, the MTD confirmed the top layer of the wall trim was broken and located by Resident 81's head of bed. The MTD stated the damaged trim required maintenance right away. The MTD further stated, Anything could happen, when asked if the broken wall trims were a safety concern. During a concurrent observation and interview on 2/11/26 at 2:30 p.m., in Resident 23's room with the Director of Nursing (DON), she confirmed the top layer of the damaged wall trim was sharp. The DON further stated, The resident [Resident 23] could cut themselves- it's near the patient. The DON verified that the entire wall border was loose from the wall and was a safety issue. The DON stated, It [the wall border] could fall from the wall, and there should be nothing loose from the wall. A review of the facility's document titled, Maintenance Log, dated 11/02/25 thru 12/31/25, and 1/26/26 thru 2/10/26 showed no evidence that the damaged wall trims was reported to maintenance. A review of the facility's document titled, Certified Nursing Assistant, dated 2003, indicated, Report all hazardous conditions and equipment to the Nurse Supervisor/Charge Nurse immediately. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Ensure that your unit's resident care rooms.are maintained in a clean, safe, and sanitary manner.Report hazardous conditions or equipment. A review of the facility's policy and procedures (P&P) titled, Maintenance Service, dated 2001, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe.manner.maintaining the building in good repair and free from hazards. A review of the facility's P&P titled, Free from Accident Hazards, dated 2001, indicated, Our facility strives to make the environment as free from accident hazards as possible.

Based on interview, and record review, the facility failed to provide services according to professional standards of practice for three of eight sampled residents (Resident 15, Resident 59, and Resident 80) when 72-hour monitoring was not completed following a change of condition (COC).These failures had the potential for Resident 15, Resident 59, and Resident 80 to experience further complications after a COC. A review of Resident 15's admission record indicated she was admitted to the facility in February 2025 with medical diagnosis which included displaced intertrochanteric fracture of the left femur (a serious hip fracture involving the pelvis and thigh bone), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebrovascular disease (conditions that affect blood flow to the brain).A review of Resident 15's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/16/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 11 which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 15's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a COC among the residents) form, dated 1/31/26 at 12 p.m., indicated, [Resident 15] was noted with wound on R [right] medial [closer to midline of the body] middle finger . A review of Resident 15 ' s care plan initiated on 1/31/26 indicated, Resident [Resident 15] noted with R(right) medial middle finger wound. At risk of complications/infection. A review of Resident 15's progress notes, type, Change in Condition Note X 72 Hours, indicated the COC type s/p [status post] wound to R medial finger, was monitored. However, the progress notes indicated the following:There was no evidence that 72-hour (hr.) monitoring was completed on 1/31/25 for evening shift (PM) and night shift (NOC),There was documented monitoring on 2/01/26 at 10:27 p.m. (PM) but no evidence indicating 72-hr. monitoring was completed day (AM) and NOC shift on 2/01/26,There was documented monitoring on 2/02/26 at 4:17 p.m. (PM), and 10:09 p.m. (PM) but no evidence that 72-hr. monitoring was completed AM and NOC shift on 2/02/26, and;There was no evidence that 72-hr. monitoring was completed on 2/03/26 for AM, PM and NOC shift.A review of Resident 59's admission record indicated he was admitted to the facility in November 2023 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities).A review of Resident 59's MDS dated [DATE], indicated his BIMS score was three which indicated his cognition was severely impaired. A review of Resident 59's SBAR form, dated 12/10/25 at 9 a.m., indicated, Patient [Resident 59] had witnessed fall at 0840 [8:40 a.m.]. Assigned CNA [Certified Nurse Assistant] was doing frequent rounds when they observed patient trying to transfer himself from the bed to his wheelchair. CNA stated patient fell backward onto the floor, hitting his head on the suction machine next the bed. Patient assessed with small lacerations measuring about a cm [centimeter- a unit of measure] each on his forehead, R side of face, and behind ear. A review of Resident 59's progress notes, type Change in Condition Note X 72 Hours, indicated the COC type s/p witnessed fall 12/10, was monitored. However, the progress notes indicated the following:There was no evidence that 72 hr monitoring was completed 12/10/25 for PM and NOC shift,There was monitoring documented on 12/11/25 at 12:31 a.m. (NOC) and 10:57 p.m. (PM) but no evidence that 72 hr. monitoring was completed for AM shift,There was monitoring documented on 12/12/25 at 9:30 p.m., (PM) but no evidence that 72-hr. monitoring was completed for AM and NOC shift, and;There was monitoring documented on 12/13/25 at 1:59 p.m. (AM) and 7:57 p.m., (PM) but no evidence that 72-hr. monitoring was completed for NOC shift.A review of Resident 59's progress notes, type eINTERACT SBAR Summary for Providers, dated 11/29/25 at 5:27 p.m., indicated, Pt [Patient-Resident 59] observed on the floor with wife in the room. Wife states that pt was trying to transfer from the bed to the wheelchair and ended up falling down. A review of Resident 59's progress notes, type Change in Condition Note X 72 Hours, indicated the COC type unwitnessed fall, was monitored. However, the progress notes indicated the following:On 11/29/25, the only documented monitoring was at 11/29/25 at 6:51 p.m.,There was monitoring documented on 11/30/25 at 2:20 p.m. (NOC) and 6:08 p.m. (PM) but there was no evidence that 72-hr. monitoring was completed for AM shift,There was monitoring documented on 12/1/25 at 6:24 a.m. (NOC) and 4:51 p.m. (PM) but there was no evidence that 72-hr. monitoring was completed AM shift,There was monitoring documented on 12/02/25 at 2:35 a.m. (NOC) but there was no evidence that 72-hr. monitoring was completed for AM and PM shift, and;There was no evidence that 72-hr. monitoring was completed 12/03/26 for AM, PM and NOC shift.A review of Resident 59's progress notes, type eINTERACT SBAR Summary for Providers, dated 10/9/25 at 5:30 p.m., indicated, Falls. A review of Resident 59's progress notes indicated no evidence that 72-hr. monitoring was completed status post fall on 10/9/25.A review of Resident 80's admission record indicated he was admitted to the facility in October 2025 with medical diagnosis which included encounter for surgical aftercare following surgery on the skin and subcutaneous (under the skin) tissue and cerebral palsy (a neurological [related to the nervous system] disorder that affects movement and posture).A review of Resident 80's MDS dated [DATE], indicated his BIMS score was 15 which indicated his cognition was intact. A review of Resident 80's SBAR form, dated 1/3/26 at 12:28 p.m., indicated, TX [Treatment] nurse reported patient's [Resident 80] right buttock surgical site noted to be re-opened. Measurement of 2.5 cm x 1 cm. A review of Resident 80's progress notes, type Change in Condition Note X 72 Hours, indicated the COC type right buttock re-opened, was monitored. However, the progress notes indicated the following:There was monitoring documented on 1/03/26 at 11:52 p.m. (NOC), but there was no evidence that 72-hr. monitoring was completed for PM shift,There was no evidence that 72-hr. monitoring was completed on 1/04/26 for AM, PM and NOC shift,There was monitoring documented on 1/05/26 at 6:22 a.m. (NOC) but there was no evidence that 72-hr. monitoring was completed for AM and PM shift, and;There was no evidence that 72-hr. monitoring was completed on 1/06/26 for AM, PM and NOC shift.During an interview on 2/11/26 at 11:08 a.m., Licensed Nurse 2 (LN 2) stated that after a COC was initiated for a resident, 72-hour monitoring was required every shift (AM, PM, and NOC). LN 2 confirmed that documentation for this monitoring was in residents' progress notes and emphasized its importance. LN 2 explained the purpose of the 72-hr. monitoring, To make sure something is improving and if it is not improving, what are we supposed to do next. LN 2 stated that any significant changes in a resident typically occurred within the first three days of the COC, and added, The first three days are crucial-we keep a closer eye on them.During an interview and concurrent record review on 2/12/26 at 1:44 p.m., the Director of Nursing (DON) stated she expected 72-hr. monitoring to be completed after a COC. The DON further stated she expected 72-hr. monitoring to be documented every AM, PM and NOC shifts. The DON stated the purpose of 72-hr. monitoring was to assess if the current orders and interventions were effective. The DON stated 72-hr. monitoring followed the progress or decline of the resident. The DON reviewed multiple SBAR reports that pertained to Resident 59. The DON confirmed Resident 59's SBARs reported multiple falls and that 72-hr. monitoring status post COCs were inconsistent. The DON reviewed Resident 15's SBAR dated 1/31/26. The DON confirmed 72-hr. monitoring status post COC was not completed on 1/31/26 for PM and NOC shifts, and on 2/01/26 for AM and PM shifts. The DON also confirmed that no 72-hr. monitoring was documented on 2/03/26. The DON reviewed Resident 80's SBAR dated 1/03/26. The DON confirmed 72-hr. monitoring status post COC was not completed on 1/03/26 for PM shift, on 1/04/26 for PM and NOC shifts, on 1/05/26 for AM and PM shifts, and on 1/06/26 for AM, PM and NOC shifts. A review of the facility's document titled, Nursing Staffing Assignment and Sign-in Sheet, dated 2/2026, indicated AM shift was 7 a.m. to 3:30 p.m., PM shift was 3 p.m. to 11:30 p.m., and NOC shift was 11 p.m. to 7:30 a.m. A review of the facility's document titled, Charge Nurse, dated 2003, indicated, Perform routine charting duties as required. A review of the facility's policy and procedures (P&P) titled, Acute Condition Changes- Clinical Protocol, revised 3/2018, indicated, The staff will monitor and document the resident/patient's progress and responses to treatment. A review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 3/2018, indicated, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the facility's P&P titled, Pressure Injuries/Skin Breakdown-Clinical Protocol, revised 4/2018, indicated, To ensure skin issues are identified promptly, properly classified, treated and monitored appropriately.

Based on observation, interview, and record review, the facility failed to safely obtain, prepare and serve food to a census of 70 residents receiving food from the kitchen when dietary staff:Used damaged/worn food preparation equipment;Stored frozen meats improperly;Served unpasteurized, uncooked eggs to four residents (Residents 25, 34, 53 and 81);Did not practice appropriate hand hygiene and wore unapproved jewelry during food preparation, and;Used cracked and worn implements to transport and serve resident food.These failures could have led to foodborne illnesses in residents. Additionally, those with weakened immune systems or health conditions faced a higher risk of serious complications.During a concurrent observation and interview on 2/09/26 at 8:58 a.m. with the Dietary Manager (DM), an initial tour of the kitchen was conducted. Several brightly colored plastic cutting boards were observed to have deep scratches and cuts. The colored material coating on the boards was excoriated, showing approximately a ten-inch round area of white material underneath. The DM stated all the cutting boards should have been changed out, since the plastic material that became dislodged could have contaminated resident food during preparation. The DM also stated cutting boards in this condition might be more difficult to clean.During a review of 2022 Food Code section 4-501.12, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.During a concurrent observation and interview on 2/09/26 at 9:15 a.m. with the DM, a box containing chicken cutlets was seen in the kitchen walk-in freezer; with the meat stored in a plastic bag that was open to air. Additionally, in the walk-in freezer, a large frozen beef roast was stored directly on top and touching loose boxed breadsticks. The DM stated the chicken should have been stored in closed bags to prevent freezer burn, and cross-contamination from beef drippings or particles could have fallen on other foods directly below. The DM removed the chicken cutlets and the breadsticks from the freezer to discard.A review of the undated facility policy and procedure (P & P) titled, Food Preparation and Service, indicated, food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.appropriate measures are used to prevent cross-contamination. These include: storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods.During a concurrent observation and interview on 2/10/25 at 10:30 a.m., with DM in the kitchen, a box containing trays of eggs was observed in the walk-in refrigerator. Upon inspection of the outside box and of the unstamped eggshells themselves (pasteurized eggs are commonly stamped p), it was discovered that the eggs were not pasteurized, and approximately half of the eggs were already used. The DM stated the facility did not serve sunny-side up eggs (eggs cooked on one side, not flipped over), but did serve over-easy (eggs flipped to cook the tops lightly, usually preserving a liquid, uncooked yoke). The DM stated there were residents that regularly requested their eggs cooked over-easy, and the unpasteurized eggs were used for that purpose.During an interview on 12/12/26 at 12:30 p.m., Resident 25, Resident 34, Resident 53, and Resident 81 were asked if they had received fried eggs in the last week with uncooked or runny yokes. All four residents replied they had recently received eggs cooked this way, as that was their preference.During a concurrent interview and record review with the Registered Dietitian (RD) on 12/12/26 at 12:45 p.m., the RD presented documentation showing the facility usually ordered pasteurized eggs from their food supplier. The RD confirmed the facility had been out of pasteurized eggs for several days but would be able to resume serving them in two days. The DM stated until pasteurized eggs were again available, residents would receive fried eggs with the yokes completely cooked to avoid salmonella infections.A review of the undated facility P & P titled, Food Preparation and Service, indicated, only pasteurized shell eggs are cooked and served when: residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked.unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm.During a concurrent observation and interview on 2/11/25 at 12 p.m. with DM, and the Dietary Aide (DA) in the kitchen, tray-line food service was taking place. The DA was placing food items on trays and dropped her pen on the ground. With gloved hands, DA picked up the pen and placed it in her pocket. The DA did not wash her hands and/or put on clean gloves but resumed touching resident food items to be served at lunch. The DA was also seen to be wearing gold hoop earrings that were not covered or secured by a hairnet. The DM stated he would have expected the DA to have removed her gloves, wash her hands and put on a new pair of clean gloves after picking up anything from the floor, to avoid any germs or dirt from coming into contact with resident food. During an interview on 2/11/26 at 3:20 p.m., the Infection Prevention Nurse (IPN) stated that failure to wash hands and change dirty gloves when handling resident food could lead to food-borne illnesses for this vulnerable population.A review of facility P & P titled, Dress Code and Personal Hygiene, dated 5/2019, indicated, all personnel are trained and in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Jewelry should be limited to watches and wedding rings.During a concurrent observation and interview on 2/11/25 at 12:15 p.m., with the DM in the kitchen, tray-line process continued and staff were observed placing hot food on plates, then into purple heat insulating containers for transport to the dining room. Several of the insulating lids were observed to be worn and crumbling around the edges, and one lid had a thin one-inch crack along the edge. The DM stated plate insulators in this condition should have been replaced, and he removed them from the ready-for-use rack for disposal. The DM stated if pieces of the plastic broke off, they could land in resident foods and be ingested accidentally.A review of 2022 Food Code, Annex 4, Table 3., indicated, Illness and injury can result from foreign objects in food. These physical hazards can result from contamination or poor procedures at many points in the food chain.A review of facility P & P titled, Sanitation, dated 11/2022, indicated, plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded.

Based on observation and interview, the facility failed to ensure laundry equipment was safely maintained for a census of 71 residents when the inside of one of two laundry dryers was visibly contaminated with debris (pieces of waste). This failure had the potential to expose resident's linens and laundry to unsanitary conditions and damage. During a concurrent observation and interview on 2/11/26 at 12:20 p.m., the Housekeeping Supervisor (HS) removed dry linens from one of two operated laundry dryers. The inside of the dryer cylinder was observed with debris that was melted, hardened, and adhered throughout the inside of the cylinder that was in direct contact with laundry. The HS stated the inside of the dryer cylinder did not get cleaned. The HS further stated the items inside the dryer cylinder appeared to be melted plastic bags and bandages. The HS stated he could not ensure that laundry that came out of the dryer was clean.During an interview on 2/11/26 at 1:51 p.m., the Maintenance Director (MTD) stated it was hard to know what the debris inside the dryer cylinder was. The MTD described the inside of the dryer cylinder with sticky parts. The MTD confirmed that he would not put his clothes inside that dryer cylinder. During an interview on 2/11/26 at 3 p.m., the Infection Preventionist (IPN) was shown photographs that were taken of the inside of the dryer cylinder. The IPN stated the dryer cylinder required to be thoroughly cleaned. The IPN confirmed debris was inside the dryer cylinder. The IPN further stated she would not put her clothes in the dryer cylinder.A review of the facility's document titled, Tumble Dryers, dated 2017, indicated, Daily.Check cylinder for foreign objects to avoid damage to clothing and equipment. A review of the undated facility document titled, JOB DESCRIPTION: Laundry Worker, indicated, Responsibilities include.cleaning and sanitizing the work area including; machines.Reports observations concerning structural and equipment wear.Ensures that established sanitation and safety standards are maintained.A review of the facility policy and procedure titled, Laundry and Linen Services, revised 1/2014, indicated, Follow manufacturer's instructions for all laundry processing materials (equipment).Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination.

Based on interview and record review, the facility failed to submit Level I Preadmission Screening and Resident Reviews (PASRR) by the 31st day after admission for two of four sampled residents (Residents 4 and 5), who stayed longer than 30 days.This failure had the potential to result in Resident 4 and Resident 5 losing their eligibility for specialized medical services if diagnosed with a serious mental illness, intellectual disability, developmental disability, or related condition(s). A review of Resident 4's admission record indicated she was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] from a general acute care hospital (GACH), with medical diagnoses which included anxiety disorder (mental health condition marked by intense, persistent, and excessive worry or fear about everyday situations, leading to significant distress and impairment in daily life); obsessive compulsive disorder (a mental health condition where a person gets caught in a cycle of unwanted, intrusive, and upsetting thoughts [obsessions] that create intense anxiety); depression (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life); and bipolar disorder (a mental illness causing extreme shifts in mood, energy, and activity). A review of Resident 4's GACH Discharge summary dated [DATE], indicated she was hospitalized from [DATE] to 4/09/25 for the treatment of sepsis (the body's extreme, life threatening response to an infection), stercoral colitis (severe, dangerous form of inflammation in the large intestine caused by long term, extreme constipation), and hyperkalemia (a medical condition where there is too much potassium in the blood). This document indicated Resident 4 was transferred back to the nursing facility on 4/09/25. A review of a letter from the California Department of Health Care Services (CDHS) dated 4/01/25 indicated that a Level I PASRR was completed for Resident 4, and no Level II Mental Health Evaluation was required. This letter also indicated that if Resident 4 stayed in the nursing facility for more than 30 days after GACH discharge, a new Level I PASRR screening was required to be submitted on the 31st day. A review of Resident 4's nursing care plan, initiated on 4/09/25, indicated a risk for altered psychosocial well-being due to facility placement, fear, sadness, isolation, and non-adherence. The care plan noted Resident 4 was admitted with antipsychotic medication (Abilify, an atypical antipsychotic medication used to treat serious mental health conditions) for bipolar disorder, posing a risk of adverse drug reactions. On 4/22/25, the care plan recorded suicidal ideation. The interdisciplinary team (IDT) recommended plastic utensils. The care plan also recorded an increase of Buspirone (an anti-anxiety medication) to 10 milligrams (MG) twice a day for Resident 4. During an interview on 2/12/26 at 8:51 a.m., the admission Director (LN 1) stated she processed the residents' PASRR Level I and II screenings. LN 1 confirmed that Resident 4's PASRR Level I screening letter from CDHS, dated 4/01/25, was obtained for readmission on [DATE]. LN 1 mentioned that at that time, the facility lacked a system to catch the 30-day PASRR screenings requiring resubmission on the 31st day after admission, however, the facility now had a system to ensure timely resubmissions for Resident Review PASRR screenings. LN 1 acknowledged the facility should have resubmitted Resident 4's PASRR Level I screening on the 31st day after admission, as instructed by the CDHS letter dated 4/01/25. During an interview on 2/12/26 at 3:37 p.m., the Director of Nursing (DON) stated that PASRR screenings were required to be performed before residents were admitted to the facility and when residents already in the facility experienced a change in condition. The DON acknowledged that Resident 4 had a change in condition that required hospitalization on 3/28/25 and was readmitted to the facility on [DATE]. The DON stated that the purpose of PASRR screenings was to assess every resident for severe mental illness, intellectual disability, developmental disability, or related conditions. The DON stated she began her role at the facility on 1/21/26 and was unsure why Resident 4's Level I screening had not been resubmitted the previous year, even though Resident 4 remained in the facility for more than 30 days after her readmission on [DATE]. The DON acknowledged that the facility should have submitted a new Level I PASRR screening on the 31st day following Resident 4's readmission on [DATE], as instructed by the letter from CDHS dated 4/01/25. 2. A review of Resident 5's admission Record, dated 2/12/26, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational suspicion, persecutory delusions, and auditory hallucinations), lack of expected normal physiological development in childhood, and adult failure to thrive. A review of Resident 5's Minimum Data Set (MDS, a federally mandated, standardized clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate resident health, functional capabilities, and care needs) dated 11/08/25, indicated Resident 5 had severe cognitive impairment. The MDS also indicated Resident 5's active diagnoses included schizophrenia. A review of Resident 5's PASRR Level I Screening, dated 4/30/24 [completed by a GACH], indicated Resident 5's screening was, negative, and did not require a PASRR Level II screening due to, 30-Day Exempted Hospital Discharge. A review of Resident 5's Physician's Progress Notes, dated 1/28/26, indicated Resident 5 had displayed alertness, but was unaware of the time, date, or of her current location. According to these notes, Resident 5 described that she was lonely. During an observation on 2/09/26 at 10:48 a.m., outside of the nurse's station, Resident 5 was seen sitting in a wheelchair, periodically yelling out and crying for approximately ten minutes, after which time staff were able to calm her. A review of correspondence to the facility from DHCS, dated 2/10/26, with the subject, Notice of PASRR Level I Screening Results, indicated Resident 5 required a Level II PASRR screening due to, Required for SMI [serious mental illness]. During an interview on 2/12/26 at 3:45 p.m., the DON acknowledged a PASRR Level I was not initiated when Resident 5 remained in the facility for longer than 30 days, and this process should have been re-started to confirm Resident 5's appropriate placement and the need for specialized services. The DON further confirmed that the Level I PASRR screening was not re-started until 2/10/26, although the resident had been in the facility since 4/30/24. A review of the facility policy and procedure titled, California Preadmission Screening and Resident Review (PASRR), dated 7/01/20, indicated, Resident Review (RR) (Status Change) . is selected if the resident has already been admitted to the facility and the facility is updating the existing PASRR on file for either of the following reasons: a. The resident has exceeded the 30-day exempted hospital discharge. A level I screening should be conducted on the individual's 31st day in the facility. b. There is a significant change in the resident's physical or mental condition.

Based on interview and record review, the facility failed to initiate a chance in condition process, and appropriately monitor and document a resident's response to treatment for one of eight sampled residents (Resident 71) after he suffered a hypertensive crisis (a medical emergency characterized by rapid, severe increase in blood pressure above 180/120 millimeters of mercury [mmHg, unit of measurement for blood pressure]).As a result, Resident 71 experienced another acute hypertension episode one week later, which could have been prevented with close supervision. This posed risks of severe harm, such as a heart attack, stroke, or organ damage to Resident 71.A review of Resident 71's admission record, dated 2/12/26, indicated he was originally admitted to the facility on [DATE], with diagnoses including hypertensive heart disease (heart damage caused by chronic, long-term high blood pressure), heart failure (a chronic condition where the heart cannot pump enough oxygen-rich blood to meet the body's needs), atrial fibrillation (an irregular and usually rapid heart rate where the upper chambers quiver instead of beating effectively), and generalized anxiety disorder (chronic, excessive, and uncontrollable worry about everyday events, lasting for at least six months). A review of Resident 71's Minimum Data Set (MDS, an assessment tool), dated 1/20/26, indicated Resident 71 was severely cognitively impaired.A review of Resident 71's progress notes dated 1/12/26 at 10:23 p.m., indicated Resident 71's blood pressure was 190/152, with a heart rate of 114 beats per minute (a normal blood pressure is no greater than120/80, and a normal heart rate is 60 to 100 beats per minute) on 1/12/26 at 7:02 p.m. The progress note further indicated, Writer provided PRN [as needed] hydralazine [a medication to treat high blood pressure] at 19:02 [7:02 p.m.].blood pressure taken three times, all showing BP [blood pressure] of 196/152 HR [heart rate] 102.[Physician] was texted and informed. New orders by Dr [doctor] was placed-new orders for metoprolol tartrate [used to treat high blood pressure, heart failure, and to improve survival after heart attacks] 12.5 mg [milligram-a unit of measure] PO [by mouth] for one time. New vitals were assessed one hour later, BP 151/65, HR 67.A review of Resident 71's medical records did not indicate a change of condition was initiated following this episode of hypertension and new medication orders on 1/12/26, even after Resident 71's blood pressure remained elevated.A review of Resident 71's nursing progress notes dated 1/19/26 at 12:19 a.m., indicated Resident 71's blood pressure was 158/70 at 6:40 p.m., and rechecked, with no time noted, for a reading of 163/88. According to this progress note, Resident 71's physician was notified and PRN hypertensive medications were administered. No further notes were documented of treatment results, and no change of condition documentation or ongoing monitoring was initiated.During an interview on 2/12/26 at 3:45 p.m., the Director of Nursing (DON) stated licensed nursing staff should have initiated a change of condition in Resident 70's medical record, periodically monitored his blood pressure and heart rate, and documented his response to medications. The DON stated change of condition documentation involved closely monitoring a resident's new or abnormal medical issues, such as changes in vital signs, consciousness, and symptoms related to cardiovascular or respiratory problems. The DON further stated she would expect licensed nursing staff to closely monitor Resident 71's change of condition because new medications were ordered and hypertension did not completely resolve.A review of facility policy and procedure titled, Acute Condition Changes - Clinical Protocol, dated 3/2018, indicated, the staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.the physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized.

Based on observation, interview and record review, the facility failed to ensure safe medication storage and administration for one of eight sampled residents (Resident 53) when nursing staff left a medication at Resident 53's bedside, without an assessment, and physician order for self-administration of medications.This failure had the potential to result in serious medication errors, overdoses and theft. In addition, leaving medication unattended risked consumption by other residents, accidental ingestion, or misuse. A review of Resident 53's admission record (facility demographic), dated 2/12/26, indicated Resident 53 was admitted to the facility on [DATE], with medical diagnoses which included psoriatic arthritis mutilans (a rare, severe, and destructive condition causing painful, stiff, and swollen joints, often accompanied by scaly skin patches), generalized anxiety disorder (a chronic, excessive, and uncontrollable worry about everyday events), and venous insufficiency (a condition in which leg vein valves are damaged or weak, causing blood pooling).A review of Resident 53's Minimum Data Set, (MDS, an assessment tool), dated 12/26/25, indicated Resident 53's mental acuity was intact, with little or no cognitive impairment.A review of Resident 53's physician order summary report dated 2/12/26, indicated Resident 53 was ordered, hydrocortisone cream [a steroid ointment used to relieve skin irritation, inflammation, redness, and itching] 2.5%, apply to affected area topically as needed for rashes, use only for visible redness.During a concurrent interview and observation on 2/09/26 at 11:01 a.m., in Resident 53's bedroom, Resident 53 was observed lying in bed, with his bedside table positioned over him. The bedside table contained several personal items on it, including a small white medicine cup containing white cream. Resident 53 stated the cream was hydrocortisone for his rash, left by the nurse for self-application. During a concurrent interview and record review on 2/10/26 at 12:50 p.m., with the Director of Nursing (DON), clinical documentation was reviewed after a resident medication self-administration assessment for Resident 53 was requested. During a concurrent interview and record review with the Director of Nursing (DON) on 2/10/26 at 12:50 p.m., the clinical documentation for Resident 53 was reviewed, following a request for an assessment for self-administration of medications. The DON stated there was no assessment of this kind in Resident 53's medical record, but provided a facility document titled, Patient Clinical Evaluation, dated 8/02/20, which indicated Resident 53 did not wish to self-administer his own medications. The DON stated that after asking Resident 53 if he wanted to administer his own medications, he still preferred the nursing staff to do it. The DON stated that residents wanting to take medicine unsupervised were required to undergo a thorough assessment. The DON added that if medications were left at the bedside, residents without cognitive ability or proper instructions might take or apply medications late, incorrectly, or not at all.A review of facility policy and procedure titled, Self-Administration of Medications, dated 2/2021, indicated if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.if the team determines that a resident cannot safely self-administer medications, the nursing staff administers the resident's medications.any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.

Based on observation, interview and record review, the facility failed to ensure a medication was labeled and stored safely when it was found in an unlocked area accessible by four residents (Resident 21, Resident 31, Resident 55 and Resident 71). This violated professional standards of nursing practice and state and federal regulations.This failure had the potential to result in medication errors potentially requiring medical intervention, theft, diversion and/or accidental ingestion by residents.During an observation on 2/09/26 at 10:30 a.m., in the common bathroom shared by the residents in room [ROOM NUMBER] and the residents in room [ROOM NUMBER], a bottle of medicine was found inside an unlocked, plastic chest of drawers containing various personal care items. The manufacturer's label in the medication bottle indicated, Senakot [Senna Docusate, a stimulant laxative and a stool softener to treat occasional constipation], 17.2 milligrams(mg, a unit of measurement), extra strength, 36 tablets. This information was on the bottle, but did not have a label affixed identifying the specific resident the medication belonged to, an opened date, or a use-by date. During a concurrent interview and observation on 2/10/26 at 9:30 a.m. with the Director of Nursing (DON), the medication bottle was found in the same location as the day prior, in the bathroom shared by four residents (Resident 21, Resident 31, Resident 55, and Resident 71). The DON stated she thought the Senakot medication belonged to Resident 21 but could not be certain as there was no label on the bottle. The DON stated the bottle should be stored securely and separately from personal care items accessible to other residents who used the shared, unlocked bathroom.A review of the undated facility policy and procedure titled, Medication Labeling and Storage, indicated, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use.

Based on observation, interview, and record review, the facility failed to ensure infection prevention measures were provided for one of eight sampled residents (Resident 59) when: 1: Resident 59's portable oxygen concentrator (an oxygen delivery device) filter cabinet was dusty,2: Resident 59's nasal cannula (a tube that delivers oxygen directly into the nostrils) was not labeled, and;3: Resident 59's suctioning machine (a medical device used to remove fluids from the airway) was stored close to the floor and the yankauer (a suctioning tool that goes inside the mouth) was not covered during storage.These failures increased Resident 59's risk of infection. A review of Resident 59's admission record indicated he was admitted to the facility in November, 2023, with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). A review of Resident 59's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/01/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was three which indicated his cognition was severely impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 59's order summary report indicated the following active orders as of 2/12/2026, Oxygen: Change oxygen tubing to include NC (nasal cannula).every week and PRN (as needed).Date tubing. A review of Resident 59's order listing report indicated the order for, Trach [a surgically created opening in the neck]: Suction trach for increased secretions as needed, was discontinued on 1/15/26. During an observation on 2/09/26 at 9:52 a.m., in Resident 59's room, Resident 59 was observed with an oxygen concentrator and NC in use. Resident 59's NC was observed without a label [to indicate the date it was changed]. The oxygen concentrator that delivered oxygen to Resident 59 was observed with light gray, dusty debris covering approximately 80% of the filter cabinet's internal surfaces and what appeared to be the filter. A label on the oxygen concentrator labeled, Concentrator Data, indicated the last date of service was 8/26/25. Subsequently, a suctioning device was observed to the left of Resident 59's bed and along the wall, approximately 12 inches (in.- a unit of measure) from the floor and set on top of a styrofoam box. A canister attached to the suctioning machine that collected suctioned fluids was approximately 700 ml (milliliter- a unit of volume) full of cloudy, yellow fluid. The yankauer was observed attached to the suctioning device, uncovered, and approximately eight in. from the floor. During an interview on 2/09/26 at 10:32 a.m., Licensed Nurse 2 (LN 2) confirmed Resident 59's oxygen concentrator and NC were currently in use. LN 2 further confirmed Resident 59's NC was not labeled, and stated the label indicated when the NC was last changed. LN 2 stated the filter cabinet of the oxygen concentrator was dirty, and described it as, dusty. LN 2 stated the oxygen concentrator was an issue for infection control reasons. LN 2 further stated, It [oxygen concentrator] converts the room air into oxygen for the resident. If it's dusty, it's not filtering the air well enough and could be an infection control concern. LN 2 verified Resident 59's suctioning machine was in use and stored close to the floor. LN 2 confirmed the canister was approximately 700 ml full of yellow fluid. LN 2 confirmed the yankauer was not covered and was close to the floor. LN 2 stated the yankauer was required to be changed weekly and covered when not in use because it went inside Resident 59's mouth. LN 2 further stated the uncovered yankauer was an infection control concern. During an interview on 2/11/26 at 1:51 p.m., the Maintenance Director (MTD) stated a rental company managed the oxygen concentrators provided to the facility. The MTD was shown a photo of Resident 59's oxygen concentrator and stated the date on the Compressor Data label indicated the last date of service. The MTD stated it was nursing staff's responsibility to assess the oxygen concentrators and report to him if the filters were dirty. The MTD stated he did not recall the dirty oxygen concentrator being reported to him. The MTD confirmed Resident 59's oxygen concentrator filter cabinet had debris. During an interview on 2/11/26 at 3 p.m., the Infection Preventionist (IPN) stated if an oxygen concentrator was dirty, it could cause a bacterial infection in the lungs of the resident. The IPN further stated, It is really a cause for concern, when shown a photo of Resident 59's oxygen concentrator. The IPN confirmed the filter cabinet was dirty. The IPN stated she expected a resident's NC to be changed on a weekly basis and the NC to be labeled and dated when changed. The IPN further stated a NC could harbor debris and any type of infection. Subsequently, the IPN reviewed the photo's taken of Resident 59's suctioning machine and yankauer and confirmed the machine should had been stored on Resident 59's bedside table. The IPN confirmed Resident 59's yankauer should have been stored in a place bag. The IPN further stated if the yankauer was uncovered it could fall on the floor and, it has the potential to harbor bacteria and cause an infection- it goes in someone's mouth. During an interview on 2/12/26 at 1:44 p.m., the Director of Nursing (DON) stated respiratory devices should be changed weekly or as needed. The DON stated she expected the NC to be labeled and dated when changed. The DON further stated, The purpose is for infection control. The DON stated she expected nursing staff to monitor the oxygen concentrator to ensure it was clean and free from dust, debris, or any fluids. The DON confirmed that a yankauer needed to be covered for infection control purposes. The DON further stated that she expected a suctioning machine to be stored at the resident's bedside, preferably on a flat clean surface and far from an area where is would contact debris. The DON stated, It [suctioning machine] is not appropriate to be close to the floor. A review of the facility's document titled, User Manual: Perfecto2 Series, dated 2009, indicated, NEVER block the air openings.Keep the openings free from lint, hair and the like.Remove the filter and clean at least once a week.A review of the facility's undated policy and procedure (P&P) titled, [Name of facility] Oxygen Concentrator Filters Policy, indicated, Proper maintenance of filters prevents dust accumulation, reduces infection risk.Disposable/internal filters: Must be replaced.if visibly dirty.Any visibly contaminated or damaged filter must be replaced immediately.Failure to follow this policy may result in.increased infection risk. A review of the facility's P&P titled, Oxygen Administration, revised 10/2010, indicated, Oxygen tubing.will be changed and labeled every seven days and as needed.A review of the facility's P&P titled, Suctioning, revised 8/2014, indicated, The purpose of this procedure is to help prevent nosocomial [an infection acquired in a healthcare facility] infections.Use fresh sterile suction catheter [yankauer] for each episode suctioning.After completing a single episode of suctioning, wrap the suction catheter around a gloved hand.discard both into a designated trash receptacle.

Based on observation, interview and record review, the facility failed to publicly post California Department of Public Health (CDPH) contact information for residents residing in facility. This failure resulted in residents not being afforded the right to make a complaint to CDPH regarding concerns with their care or the facility. Findings: During an interview on 5/13/25 at 2:04 p.m. with Resident Council members, eight out of eight residents stated they did not know how or where to file complaints to CDPH and could not recall if information was publicly available in the facility. During a concurrent observation and interview on 5/13/25 at 2:56 p.m. with the Activities Director (AD), CDPH contact information was not posted on the first or second floor of the facility. AD confirmed CDPH contact information was not posted in the facility. During a concurrent observation and interview on 5/13/25 at 2:58 p.m. with the Administrator (Admin) on first floor hallway. Admin confirmed CDPH contact information was not posted on first floor hallway. During an interview on 5/13/25 at 3:05 p.m. with the Director of Nursing (DON), the DON stated the facility does not have CDPH contact information posted for residents. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated February 2021, the P&P indicated, These rights include the resident's right to: . communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors .) regarding any matter.

Based on observation, interview, and record review, the facility failed to store and prepare food in a safe and sanitary manner when: 1. Lettuce was not rinsed per packing instructions prior to being chopped and plated onto salad bowls. 2. Two carts used for food transport from the Main Kitchen to the Nourishment Room were dirty. 3. Food items were not discarded after their use-by-date. 4. One bin of contaminated rice was not discarded. 5. Food items were not stored in sealed containers to prevent contamination. 6. Opened food items were not properly labeled with open and use-by-date. These failures had the potential to cause food-borne illnesses in an already medically fragile population. The kitchen served a population of 73 residents. Findings: 1. During a concurrent observation and interview on 5/12/25 at 5:06 p.m. with the Dietary Aide (DA ) in the Main Kitchen, the DA took romaine lettuce from a plastic package, chopped it, and plated the lettuce into salad bowls for distribution to the residents. The DA stated he did not rinse the lettuce prior to chopping because the lettuce came from the company already cleaned. The DA read the instructions on the packaging and confirmed the instructions are to, Rinse Before Use. During an interview on 5/12/25 at 5:10 p.m. with the Kitchen Manager (KM ), the KM stated the DA should have rinsed the lettuce prior to chopping and plating. During a review of the facility's policy and procedure (P&P) titled, Meat and Vegetable Preparation, undated, the P&P indicated, Raw, unprocessed for fruits and vegetables should be thoroughly washed under clean, potable, running water before use. During a review of the facility's P&P titled, General Food Preparation and Handling, undated, the P&P also indicated, Manufacturer's cooking instructions should be followed on any commercially packaged food before using it in any food and ready to eat foods. 2. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD ) in the Main Kitchen, there were two dirty portable carts by the fridge doors. One cart, stocked with bananas, sodas in cans, juices in cups, yogurts, oranges, and condiments, had hair and a purple substance stuck to the surface. The other cart, empty, had a green gunky and wet orange substance on the top surface. The RD stated the carts were used to transport food items from the Main Kitchen to Nourishment Room on the unit where the residents resided. The RD confirmed the carts were dirty, should not be in the clean area of the kitchen, and should have been cleaned prior to being used for food storage and transport. During a review of the facility's policy and procedure (P&P) titled, General Food Preparation and Handling, undated, the P&P indicated, All food service equipment should be cleaned, sanitized, air dried and reassembled after each use. The P&P also indicated, The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. During a review of the facility's P&P titled, Food Storage, undated, the P&P indicated, Food will be stored in an area that is clean, dry and free from contaminants. The P&P also indicated, Food will be stored . by methods designed to prevent contamination or cross contamination. 3. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in refrigerator of the Main Kitchen, the following items were not discarded past their use-by-date: a. Three hamburger buns (use-by-date of 5/10/25) b. One bag of frozen waffles (use-by-date of 5/10/25) c. One bottle of barbeque sauce (use-by-date 2/5/25) The RD stated the items should have been discarded before or on their use-by-date. During a concurrent observation and interview on 5/12/25 at 4:48 p.m. with the RD in the walk-in freezer of the Main Kitchen, the following items were not discarded past their use-by-date: a. One bag of frozen ravioli (use-by-date 5/3/25) b. One bag of carrots (use-by-date 4/8/25) c. Two frozen pies (use-by-date 12/16/24) The RD stated the items should have been discarded before or on their use-by-date. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Refrigerated food storage: .All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. The P&P also indicated, Frozen Foods: .All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 4. During a concurrent observation and interview on 5/12/25 at 5:20 p.m. with the Registered Dietician (RD) in the Main Kitchen, the uncooked white rice stored in a covered bin was contaminated with a green leafy substance. The RD confirmed contaminated rice container and stated, I think that's parsley. The RD confirmed the contaminated rice should have been discarded. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Food will be stored in an area that is clean, dry and free from contaminants. The P&P also indicated, Food will be stored . by methods designed to prevent contamination or cross contamination. 5. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in freezer of the Main Kitchen, the following items were observed open to the air and not properly stored in sealed containers: a. One bag of frozen chicken patties b. One bag of carrots c. One bag of breadsticks The RD stated the items should have been stored in a sealed container. During a concurrent observation and interview on 5/12/25 at 5:01 p.m. with the Kitchen Manager (KM ) in the Dry Storage Room, the following items were observed open to the air and not properly stored in sealed containers: a. One bag of mashed potatoes mix (instant mashed potatoes in a dehydrated form) b. One bag of poultry gravy mix (pre-packaged powder or granule to be mixed with water or broth to create gravy) c. One bag of brown gravy mix The KM stated the bags used to store food items should be sealed closed to prevent contamination. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Refrigerated food storage: .f. All foods should be covered, labeled and dated. The P&P also indicated, Frozen Foods: .c. All foods should be covered, labeled and dated . Food will be stored . by methods designed to prevent contamination or cross contamination . plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods . 6. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in refrigerator of the Main Kitchen, there was one sealed plastic bag, not labeled with a use-by-date, that contained cooked pancakes covered in cling film. The RD confirmed pancakes should have been properly labeled with a use-by-date. During a concurrent observation and interview on 5/12/25 at 4:48 p.m. with the Registered Dietician (RD) in the walk-in freezer of the Main Kitchen, the following items were not properly labeled with an open and/or use-by-date: a. One bag of frozen chicken patties b. One bag of breadsticks The RD confirmed the food items should have been properly labeled with an open and use-by-date. During a concurrent observation and interview on 5/12/25 at 5:01 p.m. with the Kitchen Manager (KM ) in the Dry Storage Room, the one bag of mashed potatoes mix (instant mashed potatoes in a dehydrated form) in a plastic bag was not properly labeled with an open and/or use-by-date. The one bag of brown gravy mix (pre-packaged powder or granule to be mixed with water or broth to create gravy) in a plastic bag was not properly labeled with a use-by-date. The KM confirmed the items were not properly labeled. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, All containers must be legible and accurately labeled and dated. The P&P also indicated, Refrigerated food storage: .f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. The P&P also indicated, Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

Based on interview and record review the facility's Quality Assurance Performance Improvement (QAPI- data-driven approach to improving quality in healthcare facilities) committee failed to identify the need for oversight of the Restorative Nursing Assistance (RNA) program. This failure resulted in residents not receiving the appropriate treatments per physician orders. (Refer to F688). Findings: During a review of the facility's Restorative Program Monthly Audit, dated 5/1/25, the Restorative Program Monthly Audit was completed for the month of April 2025. The Restorative Program Monthly Audit indicated a total of 84 missed visits from 13 Residents reviewed. During a review of the facility's Order Listing Report, dated 5/15/25, the Order Listing Report indicated there are a total of 22 Residents currently receiving RNA services. During an interview on 5/16/25 at 11:16 a.m. with the Director of Nursing (DON) and Director of Rehabilitation (DOR), The DOR stated the DON oversees the RNA program because it falls under nursing and the DOR is only responsible for training staff and putting in RNA orders. The DOR further stated she does not complete any auditing for the RNA program. The DON stated he quickly scans the RNA weekly progress notes but does not verify the treatment provided against the orders. The DON and the DOR both confirmed they were unaware of any issues with the RNA program not fulfilling the physician orders. During a concurrent interview and record review on 5/16/25 at 1:01 p.m. with the Administrator (Admin) and the DON, the QAPI Meeting Minutes dated October 2024 to April 2025 were reviewed. The minutes indicated no focus on the RNA program. The Admin confirmed QAPI did not identify any concerns with the RNA program. During a review of the Facility's Quality Assurance Performance Improvement Plan (QAPIP), undated, the QAPIP indicated, Segments of Care . Inpatient Rehabilitation . Services Rendered . Provide appropriate levels of rehabilitation to the inhouse Residents and coordinate with their MD's [Medical Doctor] . Clinical care will be measured through: Consultant evaluations and feedback of practice, MDS-QI [Minimum Data Set Quality Improvement- an assessment tool used to guide resident care] scores, Family/Resident survey scores, QAPI tools .

Based on observation, interview, and record review, the facility failed to ensure licensed nurses followed professional standards of practice when they documented they administered medications which were not dispensed by the pharmacy for one of 24 sampled residents (Resident 6). This failure resulted in inaccurate documentation and the potential for Resident 6 to experience adverse effects such as shortness of breath. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]) and asthma (a condition which makes it difficult to breathe). During an observation on 5/14/25 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering Resident 6's respiratory medications. LVN 1 did not administer a Budesonide inhaler (medication inhaled into the lungs to prevent inflammation of the airways). LVN 1 stated that she did not have the medication in her medication cart, and she would need to call the pharmacy and request they send the medication. During a record review on 5/14/25 at 1:30 p.m. of Resident 6's Respiratory MAR (Medication Administration Record), dated April 2025 and May 2025, the MAR indicated that the resident received Budesonide on 4/25/25 at 8:00 p.m., 4/27/25 at 8:00 p.m., 4/28/25 at 8:00 a.m. and 8:00 p.m., 4/29/25 at 8:00 p.m., and 4/30/25 at 8:00 a.m. and 8:00 p.m., and 5/1/25- 5/12/25 at 8:00 a.m. and 8:00 p.m. During an interview on 5/15/25 at 10 a.m. with the Pharmacist, the Pharmacist stated, on 4/25/25, the pharmacy sent a fax to the facility requesting clarification of Resident 6's respiratory medications as they were concerned about duplicate therapy. The Pharmacist stated the facility did not respond to the request for clarification, so the pharmacy did not dispense Resident 6's Budesonide. The Pharmacist confirmed the medication was never delivered to the facility and was not available for administration. During a concurrent interview and record review on 5/15/25 at 10:40 a.m. with LVN 2, Resident 6's MAR was reviewed. LVN 2 confirmed she documented that she administered Budesonide to Resident 6 multiple times during the months of April and May 2025. LVN 2 stated she was unaware how she could have administered the medication when it was not dispensed from the pharmacy and stated she would ask her supervisor. During a follow up interview on 5/15/25 at 12:13 p.m. with LVN 2, LVN 2 stated that she would like to check the medication cart to see if the Budesonide was there. LVN 2 verified that Budesonide for Resident 6 was not in the medication cart. LVN 2 stated that she documents after she administers the medications and was not sure what happened. During a concurrent interview and record review on 5/15/25 at 12:17 p.m. with Registered Nurse (RN) 1, RN 1 confirmed the pharmacist sent a request to clarify the order for Budesonide and agreed that the medication was not dispensed. Resident 6's MAR was reviewed with RN 1, RN 1 confirmed she documented she administered Budesonide to Resident 6 on multiple days in May 2025. RN 1 confirmed she did not administer the medication and stated, I made an honest mistake. During a concurrent interview and record review on 5/15/25 at 4:17 p.m. with LVN 3, LVN 3 confirmed he documented he administered Budesonide to Resident 6 on multiple days in April 2025. LVN 3 stated he was not certain if he gave the medication. During an concurrent interview and record review on 5/16/25 at 9:47 a.m. with the Director of Nursing (DON), DON confirmed licensed nurses documented they administered Budesonide on multiple dates in April and May. The DON confirmed the pharmacy did not dispense the medication. DON stated nursing staff should verify all medications listed on the MAR are available in the medication cart and notify the pharmacy when medications are not available. DON stated nursing staff should not have documented Budesonide was administered. During a review of Lippincott Nursing Center online titled, Nursing Documentation, dated August 2024, the document indicated, .Documentation Characteristics .Accurate and relevant .Documentation Entries .Accurate, truthful, and comprehensive . During a review of the American Nurses Association Guidance for Registered Nurses titled, Principals for Nursing Documentation, dated 2010, the guidance indicated, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. If patient documentation is not timely, accurate .it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . During a review of the facility's P&P titled, Administering Medications, dated October 2021, the P&P indicated, .The individual administering medications verifies the resident's identity before giving the resident his/her medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .

Based on observations, interviews, and record reviews, the facility failed to accurately assess and provide necessary services to prevent the development of a facility-acquired pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and worsening of the pressure ulcer, for three out of five sampled residents, Resident 20, Resident 110, and Resident 29 when: 1. The facility did not identify the presence of a pressure ulcer timely for Resident 20, which resulted in the development of an Unstageable (Full thickness tissue loss in which the ulcer is covered with by slough - Slough is necrotic (dead) tissue that needs to be removed from the wound for healing to take place) and/or eschar (Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from the skin. It's commonly seen with pressure ulcer wounds) in the wound bed (the base or floor of the wound) pressure ulcer on her sacrum (The sacrum is a triangular bone composed of five vertebrae (small bones forming the backbone) that make up the second to last portion of the spine) two days after her weekly skin check. This failure resulted in Resident 20 being sent to the hospital for possible wound infection. 2. Resident 110 was admitted to the facility with a Stage 2 (happens when the sore digs deeper below the surface of your skin) pressure ulcer on her sacrum that measured 1 cm (centimeter - a metric unit of length) x (by) 1 cm, and Stage 2 pressure ulcer on her coccyx (tailbone) that measured 1 cm x 1 cm; however, the facility did not include intervention for pressure relief and repositioning. This failure resulted in the worsening of Resident 110's pressure ulcer from a Stage 2 to a Stage 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure [such as tendon, or joint capsule]) pressure ulcer on her sacrum measuring at 6 cm x 4 cm x 1cm x 4 cm, approximately five weeks later. 3. Resident 29 was found to have a Ruptured blister (a small bubble on the skin filled with serum and caused by friction, burning, or other damage) on his right buttock (buttocks are the two rounded fleshy parts of your body that you sit on) measuring 1 cm x 1 cm.; however, the facility did not include interventions for pressure relief and repositioning. This failure resulted in the worsening of Resident 29's wound approximately eight weeks later, from a ruptured blister to a Stage 4 pressure ulcer to his right buttock measuring 6.0 cm x 4.5 cm x 3.5 cm, causing Resident 29 to experience pain and discomfort. Findings: 1. A record review of Resident 20's MDS (Minimum Data Set - health status screening and assessment tool used for all residents) assessments, dated [DATE], indicated in Section M, Skin Conditions, the MDS Nurse made an entry on the MDS assessment that Resident 20 was not at risk of developing pressure ulcers. The MDS assessment indicated Resident 20 did not have one or more unhealed pressure ulcers. The MDS Nurse indicated, Resident 20 did not have other ulcers, wounds, and skin problems. In Section G, Functional Status, the MDS assessment indicated Resident 20 needed extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) with one staff needed to provide physical assistance to perform the task. The MDS assessment in Section G indicated Resident 20 also required one-person extensive assistance to use the toilet. A record review of Resident 20's NSG (Nursing) Weekly Skin Check, dated [DATE], at 12:30 p.m., and [DATE], at 12:31 p.m., conducted by the Treatment Nurse, indicated Resident 20 did not have skin conditions, changes, ulcers, or injuries. Under the Comments/Summary section of these weekly skin check records, the Treatment Nurse entered, No new skin issues. A record review of Resident 20's NSG Weekly Pressure Ulcer Report, dated [DATE], at 5:17 p.m., conducted by the Treatment Nurse, indicated Resident 20 had developed a new onset pressure ulcer. The record indicated the new pressure ulcer was located on the sacrum with the length measured at 7 cm, and the width at 7 cm. Resident 20's new pressure ulcer was classified as, Unstageable. During a concurrent record review and interview on [DATE], at 4:11 p.m., with the Treatment Nurse, she stated she did the skin assessments on Resident 20 on [DATE] and [DATE]. The Treatment Nurse stated she made an, honest mistake, when she did the weekly skin check assessment for Resident 20 on [DATE]. The Treatment Nurse stated she did a head-to-toe assessment on Resident 20 but only checked the front part of her body while Resident 20 was seated on the edge of her bed. The Treatment Nurse stated she documented on [DATE], that Resident 20 had developed a new onset pressure ulcer on her sacrum. During an interview on [DATE], at 4:21 p.m., with the DON (Director of Nursing), she stated she had oversight of the nurses who performed wound care. When the DON was asked about her expectation for head-to-toe assessments, she stated her expectation was that the nurses would assess the front and the back side of the residents. A review of Resident 20's, Care Plan, for her pressure ulcer indicated, Resident 20 noted with unstageable pressure ulcer to sacrum [DATE]. The goal for this pressure ulcer care plan was that Resident 20's pressure ulcer would not exhibit signs and symptoms of infection. The care plan indicated the interventions included administer treatment and dressing as ordered (by a physician) and turning and repositioning Resident 20, and avoid positioning Resident 20 on her pressure ulcer location. A review of Resident 20's, Treatment Administration Record (TAR), dated [DATE], the TAR indicated, Turn and reposition Q2H (every two hours), start date [DATE], 2 p.m. The TAR indicated turning and repositioning of Resident 20 did not happen until one day, twenty hours, and forty-seven minutes, after the pressure ulcer was discovered on [DATE], at 5:17 p.m. A review of Resident 20's, Health Status Note, dated [DATE], at 8:11 p.m., authored by the Treatment Nurse, indicated, Patient (Resident 20) was seen by MD (Resident 20's physician) and assessed patient pressure ulcer on her sacrum. Noted of increased purulent (Purulent drainage is a thick and milky discharge from a wound. It often indicates an infection and needs treatment as soon as possible) drainage, odor, and skin redness surrounding on wound bed. Received order from MD to send to ER (emergency room ) for further evaluation . A review of Resident 20's ED (Emergency Department) Provider Notes, dated [DATE], at 2:48 p.m., indicated, Patient (Resident 20) presents with, 'weeping' (an injury that is producing excessive fluid during healing or from inflammation) sacral decubitus (pressure ulcer). Under History of Present Illness, the provider note indicated, . the patient has had a wound present for a month, she states that it is getting worse she might have a low-grade fever the last couple of days . A review of Resident 20's, Hospital Medicine H&P (History and Physical) Note, dated [DATE], at 9:29 p.m., indicated, Chief Complaint, was low back wound, pain. The hospital attending physician indicated, Patient (Resident 20) stated that she has been suffering from wound on her back since more than one month which has gradually got worse . Under Physical Exam, the attending hospital physician commented on Resident 20's skin as, Ulcer with dead tissue, pus (a generally yellowish white fluid formed in infected tissue, consisting of white blood cells (responsible for protecting the body from infection), cellular debris, and necrotic tissue), surrounding erythema (redness) on low back. The H&P note indicated on Resident 20's mental status, She is alert and oriented to person, place, and time. A review of Resident 20's, Surgery H&P Note, dated [DATE], at 12:20 p.m., indicated, .A bedside I&D (incision and drainage) was performed in the ED and patient (Resident 20) admitted to medicine services with IV (Intravenous-within a vein) Vancomycin and Zosyn (antibiotics). On exam it appears opened to a large wound with purulent drainage . A review of Resident 20's, Hospital Progress Notes, dated [DATE], indicated that a specimen collected on Resident 20's pressure ulcer on [DATE], at 6:34 p.m., grew moderate MRSA (Methicillin Resistant Staphylococcus Aureus bacteria) and scant growth of Proteus Mirabilis (proteus mirabilis organisms are normal fecal (stool) flora and are present in soil and water). A review of hospital photographs of Resident 20's pressure ulcer, taken on [DATE], and [DATE], indicated the muscle tissue was exposed, consistent with a Stage 4 pressure ulcer. A review of a facility policy and procedure (P&P) titled, Prevention of Pressure Ulcer/ Injuries, dated [DATE], indicated, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Under Mobility/Repositioning, the P&P indicated, Choose a frequency for repositioning based on the resident's mobility, support surface in use, skin condition and tolerance, and the resident's stated preference. Under, Monitoring, the P&P indicated, Evaluate, report, and document potential changes in the skin. A review of an article from the National Library of Medicine, titled, Advances in Wound Care, dated [DATE], under causation, (cause of pressure ulcer), it indicated, .Pressure ulcers occur over predictable pressure points where bony protuberances (a body part that bulges (protrudes) outward from a surface) are more likely to compress tissues when the patient is in prolonged contact with hard surfaces . The article indicated that the bony protuberances are the following: occiput (back of the head), scapula (shoulder blade), elbow, sacrum, ischium (lower and back sides of the hip bone), and heels . The diagram of the bony protuberances in this article indicated that all predictable pressure points are on the back side of the patient or resident and not the front side. 2. A review of Resident 110's, Admission Summary, note authored by the Treatment Nurse, indicated Resident 110 was admitted to the facility on [DATE]. The admission summary note indicated a skin assessment was completed. A review of Resident 110's NSG (Nursing) Weekly Pressure Ulcer Reports, dated [DATE], at 8:20,p.m., indicated Resident 110 had a Stage 2 pressure ulcer on her sacrum measuring at 1 cm x 1 cm. The NSG (Nursing) Weekly Pressure Ulcer Reports, dated [DATE] at 8:23 p.m., indicated Resident 110 also had a Stage 2 pressure ulcer on her coccyx measuring at 1 cm x 1 cm. Both assessments were conducted by the Treatment Nurse. A review of Resident 110's, Care Plan, for her pressure ulcer, initiated on [DATE], indicated, admitted with actual impairment to skin integrity: Sacrum pressure ulcer UTD (Unable to determine). The goal for this focused problem was that the pressure ulcer would develop clean and intact skin by the facility's review date of the care plan. The care plan for Resident 110's pressure ulcer included four interventions that did not address how to relieve the pressure on Resident 110's pressure ulcer. A review of Resident 110's NSG Weekly Pressure Ulcer Report, dated, [DATE], at 5:52 p.m., authored by the Treatment Nurse, indicated the pressure ulcer on Resident 110's sacrum was measured at 10 cm x 10 cm, and now was an unstageable pressure ulcer. The new measurement indicated the size of the pressure ulcer had increased by 9 cm x 9 cm. A review of Resident 110's, Order Summary Report, with a date range from [DATE]- [DATE], indicated Physician P wrote an order on [DATE], that indicated, Reposition every 2 hours while in bed. The order summary report indicated there was no previous repositioning orders after Resident 110's pressure ulcers on the sacrum and coccyx were identified on [DATE]. The report indicated there was no order for a specialized mattress used for residents with pressure ulcers. The order summary report indicated Physician P wrote an order to, send wound culture (a test to find germs, such as bacteria, a virus, or a fungus, that can cause an infection) on [DATE]. A review of Resident 110's Medication Administration Record (MAR), dated [DATE], indicated the facility staff started the repositioning schedule for Resident 110 on [DATE]. A review of Resident 110's IDT (Interdisciplinary Team-typically consists of a staff member from each department in the facility) Note, dated [DATE], at 3:52 p.m., indicated, .Resident (Resident 110) had a low grade fever on ,d+[DATE] and WBC's (White Blood Cells) were elevated, MD (Physician P) started resident on PO (by mouth) ATB (antibiotic), wound culture is pending . A review of Resident's 110's, Lab results, indicated the wound culture collected on [DATE], at 11:30 a.m., was not performed because of incorrect specimen type/media. Another wound specimen was collected on Resident 110 on [DATE], at 2:30 p.m., and the wound culture was not performed by the laboratory because the facility used an expired collection tube, expired [DATE], per the laboratory technician. A review of the Resident 110's, Order Summary Report, dated [DATE]-[DATE], indicated Resident 110 was transferred to theER on [DATE], due to a fall. A review of Resident 110's, Hospital Medicine Progress Note dated [DATE], at 9:56 a.m., indicated, (Resident 110) with complex medical history, resident at a nursing facility, who presented after a fall. She was found to have extensive sacral decubitus ulcer (pressure ulcer) with exposed bone in the center and superinfection. She was placed on antibiotic therapy. She was seen by a plastic surgery (a surgical specialty involved with the reconstruction of facial and body tissue defects due to illness, trauma, or birth disorders) in consultation. She underwent bedside debridement (the removal of damaged tissue or foreign objects from a wound) to her sacral wound on [DATE]. Bone cultures taken during the bedside debridement are growing Pseudomonas (Pseudomonas aeruginosa is a bacteria that's commonly found in the environment, for example in soil and water) and Streptococcus (is a type of bacteria that can cause skin, soft tissue, and respiratory tract infections) . On page 148 of this document, a photo taken on [DATE], indicated the size of Resident 110's wound was 6 cm x 4 cm x 1 cm x 4 cm, undermining (Undermining in pressure ulcers can occur due to the pressure and friction that is placed on the skin and underlying tissue, leading to tissue damage and the formation of a pocket under the wound surface) almost circumferentially (around the circumference [the perimeter of a circle]) with exposed bone in the center, per the wound description. During an interview on [DATE], at 1:55 p.m., with Licensed Staff J, she stated, if she needed to know what the interventions were for a resident with a pressure ulcer, she would look at that resident's orders and care plans. Licensed Staff J stated, if a care plan revision for any change in condition was needed, she would report this to the DON or to the Treatment Nurse. Licensed Staff J stated she could revise the care plan if she needed to. During an interview on [DATE], at 4:20 p.m., with the DON, she stated the Treatment Nurse should have classified Resident 110's pressure ulcers as unstageable instead of a Stage 2. When the DON was asked why was there no revision on Resident 110's care plan after the pressure ulcer got worse and infected, she stated she would look for that information, but did not provide any revised care plan for Resident 110's pressure ulcer. A review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated [DATE], indicated under treatment and management, The physician will order wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents (used locally, where the medicine is applied on the area being treated). Under monitoring, the P&P indicated, The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. A review of an article from the National Library of Medicine, titled, Advances in Wound Care, dated [DATE], indicated under prevention, Any patient who has been determined to be at risk for development of a pressure ulcer or who already has a pressure ulcer needs to have a plan for repositioning . 44968 3. During a record review for Resident 29, the Face sheet (A one-page summary of important information about a resident) indicated Resident 29 was admitted on [DATE], with diagnoses including but not limited to Cutaneous T-cell lymphoma (CTCL- is a rare type of cancer that begins in white blood cells; Malignant Neoplasm of Prostate (when cells in the prostate gland [found only in males; the hollow organ where urine is stored] start to grow out of control); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 29, the Minimum Data Set (MDS), dated [DATE], indicated Resident 29 had a BIMS score of 7 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 8 to 12 is moderately impaired, and 00 to 7 is severe impairment). The MDS indicated Resident 29 required extensive one-person physical assistance with bed mobility. The MDS indicated Resident 29 was at risk of developing pressure ulcers. The MDS indicated Resident 29 did not have unhealed pressure ulcers during the assessment period ([DATE] to [DATE]). During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated [DATE] at 8:14 a.m., indicated Resident 29 had a new non-pressure (not related to pressure, shear, or friction) area to his right buttock. The document indicated, Ruptured blister on the right outer buttock area, measuring 1 cm x 1 cm. During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated [DATE] at 1:47 p.m., indicated Resident 29 had a ruptured blister on the right outer buttock area, measuring 1 cm x 1 cm. During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated [DATE] at 10:06 p.m., indicated Resident 29 had a right buttock skin loss (unintended damage to and loss of the upper layer of the skin)/blister measuring 4.5 cm x 4.0 cm x UTD (unable to determine/unstageable). During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated [DATE] at 7:39 p.m., indicated Resident 29 had a right buttock skin loss/blister measuring 6 cm x 4.0 cm x 5 cm. During an interview with the Director of Nursing (DON) on [DATE] at 2:11 p.m., when the DON was asked about Resident 29's right buttock wound, the DON stated Resident 29's wound was a non-pressure ulcer wound. During a record review for Resident 29, the document titled, Weekly Pressure Ulcer Report dated [DATE] at 9:12 p.m., indicated, Resident 29 had a Stage 4 pressure ulcer to his right buttock measuring 6.0 cm x 4.5 cm x 3.5 cm. During an interview with the DON on [DATE] at 9:18 a.m., the DON stated a hospice nurse (a professional in charge of providing care, comfort, and support to clients navigating the difficult time at the end of their lives) assessed Resident 29's right buttock wound on [DATE], and determined the wound was a pressure ulcer. During an observation on [DATE] at 9:32 a.m., Resident 29 was in his room, lying on his bed, asleep. Resident 29 was turned on his left side facing the window with a pillow on his back. During an observation on [DATE] at 12:06 p.m., Resident 29 was in his room, lying on his left side facing the window with a pillow on his back. Resident 29 was heard saying, Hello. During an observation on [DATE] at 12:21 p.m., Resident 29 was in his room, lying on his left side facing the window with a pillow on his back. Resident 29 was again heard saying, Hello. Unlicensed Staff B heard Resident 29, entered Resident 29's room, and assisted Resident 29 to reposition him on his back. During an observation on [DATE] at 9:34 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed slightly elevated. During an observation on [DATE] at 11:36 a.m., Resident 29 was in his room on his bed with his eyes closed. Resident 29 was lying on his back with the head of bed slightly elevated. During an observation on [DATE] at 12:52 p.m., Resident 29 was in his room on his bed with his eyes closed. Resident 29 was lying on his back with the head of bed elevated at approximately 45 degrees. During an observation on [DATE] at 2:45 p.m., Resident 29 was in his room lying on his bed awake. The head of bed was elevated at approximately 45 degrees. During a wound treatment observation in Resident 29's room on [DATE] at 2:51 p.m., Family Member C was also in the room and stated, the wound still looked big, but at least it is not black anymore. Family Member C stated it was hard for Resident 29 to be turned every two hours because the facility did not have enough staff. Family Member C stated it could take four hours sometimes for someone to turn and reposition Resident 29 in bed. Family Member C stated Resident 29 must be turned every two hours to heal his wound. During an observation on [DATE] at 8:58 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed elevated at approximately 30 degrees. During an interview with Unlicensed Staff D on [DATE] at 10:29 a.m., Unlicensed Staff D stated he was assigned to work with Resident 29. When Unlicensed Staff D was asked how often Resident 29 was turned and repositioned in bed, Unlicensed Staff D stated he would reposition Resident 29 as needed. During an observation on [DATE] at 10:45 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed elevated at approximately 30 degrees. During an interview with Licensed Staff E on [DATE] at 10:48 a.m., when Licensed Staff E was asked about the facility policy on skin assessment, Licensed Staff E stated nurses were to complete a skin assessment every week for all residents with or without any skin issue. Licensed Staff E stated nurses were expected to perform a visual skin assessment of the resident from head-to-toe. During an observation on [DATE] at 10:52 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed elevated at approximately 30 degrees. During an interview with Care Giver L on [DATE] at 1:45 p.m., when asked if Resident 29 refused turning on his side, Care Giver L stated, No. He stated Resident 29 thought he was supposed to turn every four hours, however, Care Giver L stated Resident 29 would comply if reminded it was time for him to turn on his side. During an observation on [DATE] at 1:51 p.m., Resident 29 was in his room on his bed with eyes closed. Resident 29 was lying on his back with the head and foot of bed elevated. During a record review for Resident 29 and concurrent interview with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on [DATE] at 10:22 a.m., the Care Plan, created on [DATE], indicated, [Resident 29] has actual skin alterations related to diagnosis and co-morbidities. Care Plan interventions included: - Treatment as ordered; - Supplements as ordered; - On LAL (low air loss) mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) - RD (Registered Dietitian) evaluation when applicable; and - Medications as ordered; Review to be done by IDT. When the MDSC was asked what other interventions should be included in Resident 29's care plan to prevent his wound from worsening, the MDSC stated Resident 29 should be turned and repositioned in bed every two hours to prevent the wound from worsening and prevent further skin breakdown. Review of the facility policy and procedure titled, Repositioning, effective date [DATE], indicated, It is the policy of this facility to provide guidelines for the evaluation of resident repositioning needs, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. The policy indicated: - Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. - Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. - Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. - Frequency of repositioning a bed- or chair-bound resident should be determined by condition of the skin and overall condition of the resident.

Based on observation, interviews and records review, the facility did not ensure a pain management program was provided to relieve pain and discomfort for one of three sampled residents (Resident 29), when staff did not administer pain medication to Resident 29 before wound treatment, as ordered by a physician. This failure resulted in Resident 29 experiencing pain and discomfort during wound treatment. (Reference F686) Findings: During a record review for Resident 29, the Face sheet (A one-page summary of important information about a resident) indicated Resident 29 was admitted on [DATE], with diagnoses including but not limited to Cutaneous T-cell lymphoma (CTCL- is a rare type of cancer that begins in white blood cells[responsible for protecting your body from infection]); Malignant Neoplasm of Prostate (when cells in the prostate gland [found only in males; the hollow organ where urine is stored] start to grow out of control); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 29, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 4/25/23, indicated, Resident 29 had a BIMS score of 07 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated 7/14/23 at 9:06 a.m., indicated Resident 29 had a right buttock skin loss (unintended damage to and loss of the upper layer of the skin)/blister (a small bubble on the skin filled with fluid and caused by friction, burning, or other damage) which measured 4.5 cm (centimeter - a metric unit of length) x (by) 4.0 cm x UTD (unstageable - full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough [thick, stringy, yellow dead tissue] and/or eschar [dark, crusty dead tissue] in the wound bed). The document indicated the wound had 75 percent eschar. During a record review for Resident 29, the Treatment Administration Record (TAR) for July 2023, indicated a doctor's order, written on 7/20/23, to, Cleanse right buttock skin loss blister with dakins (antiseptic [prevent the growth of disease-causing microorganisms] solution), apply santyl (a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) then pack with wet to dry gauze (a medical fabric) with NS (Normal Saline [used to clean wounds, clear sinuses, and treat dehydration]) and cover with foam dressing (technique used to fill a deep wound with material to promote wound closure from the inside out) every day. During a record review for Resident 29, the Medication Administration Record (MAR) for August 2023, indicated a doctor's order, written on 6/09/23, for Tylenol tablet (drug used to relieve pain) to be given every four hours as needed for mild pain. During a record review for Resident 29, the MAR for August 2023, indicated a doctor's order, written on 7/27/23, to administer pain medication prior to wound treatment; however, the MAR did not indicated which pain medication should be used. During a record review for Resident 29, the document titled, Weekly Pressure Ulcer Report, dated 8/14/23 at 9:12 p.m., indicated Resident 29 had a Stage IV (Full thickness skin loss with extensive destruction; tissue necrosis (tissue death); or damage to muscle, bone, or supporting structure [such as tendon, or joint capsule]) pressure ulcer to his right buttock measuring 6.0 cm x 4.5 cm x 3.5 cm. During a wound treatment observation in Resident 29's room on 8/16/23 at 12:52 p.m., Resident 29 had an open wound to his right buttock. When the Treatment Nurse asked Resident 29 if he had pain, Resident 29 stated he had back pain. Resident 29 had tensed muscles (muscles become tight and stiff, often because you are anxious or frightened) while holding onto the bed rail, and jolted (move with sudden lurches [an abrupt uncontrolled movement]), and was heard saying, Ouch, when the Treatment Nurse removed the gauze pack from Resident 29's right buttock wound. The Treatment Nurse immediately stopped the procedure and stated she would get an order from the doctor for pain medication. The Treatment Nurse stated she would attempt to do wound treatment after Resident 29 received additional pain medication. During an interview with Licensed Staff F on 8/16/23 at 1:02 p.m., when asked if she administered pain medication to Resident 29 prior to his wound treatment, Licensed Staff F stated she gave Resident 29 his scheduled 0.25 ml (milliliter -a unit of volume) of oral morphine (drug indicated for the relief of moderate to severe pain) at around 11:45 a.m. Licensed Staff F stated Resident 29 also have an order for Tylenol for pain as needed; however, Licensed Staff F stated Resident 29 did not receive Tylenol prior to his wound treatment. During a wound treatment observation in Resident 29's room on 8/16/23 at 2:51 p.m., Resident 29 was turned on his left side with the assistance of Unlicensed Staff H. Resident 29 was jolting while the Treatment Nurse wiped the wound bed with wet gauze. Family Member C was also in the room and stated, [Resident 29] almost jumped off the bed. During a record review for Resident 29 and concurrent interview with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/22/23 at 10:18 a.m., the MAR for August 2023, indicated a doctor's order, written on 7/27/23, to administer pain medication prior to wound treatment. The MDSC verified Resident 29 had a doctor's order, written on 6/09/23, for Tylenol tablet to be given every four hours as needed for mild pain, however, the MAR did not have licensed nurse's initials under the Tylenol order from 8/01/23 to 8/13/23 and 8/15/23. The MDSC stated Resident 29 did not receive Tylenol on 8/01/23 to 8/13/23 and 8/15/23, prior to wound treatment. The MDSC also verified the MAR indicated a doctor's order, written on 7/17/23, for Morphine Sulfate 0.25 ml to be given every six hours for respiratory (breathing) distress. The MDSC concurred the Morphine Sulfate order was not ordered by the doctor for pain management. Review of the Facility policy and procedure titled, Pressure Ulcer Treatment, revised in December 2007, under Interventions/Care Strategies indicated, Pressure ulcer treatment requires a comprehensive approach, including: Debridement (the removal of damaged tissue or foreign objects from a wound), Managing infections, Managing systemic issues (edema (swelling), venous insufficiency (occurs when your leg veins don't allow blood to flow back up to your heart), etc.), Maximizing the potential for healing, and Pain control. Steps in the procedure include but not limited to, Assess the resident's level of pain and provide analgesics (pain killer), as ordered, before wound care. Review of the Facility policy and procedure titled, Pain Assessment and Management, revised on 7/01/22 indicated, The purposes of this procedure are to help the staff identify pain in the resident. and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The policy indicated, Pain management, is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. The policy indicated, Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including but not limited to Pressure, venous (relating to a vein) or arterial ulcers (also known as ischemic ulcer - reduced blood flow to an area of the body).

Based on observation, interviews, and records review, the facility failed to ensure one of two sampled residents (Resident 1) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue, usually over a bony area, or related to a medical or other device) received necessary interventions and services to promote healing and pain control when: 1. The facility did not provide pain medication to Resident 1 prior to wound treatment. This failure resulted to Resident 1 to experience pain and discomfort. 2. The facility did not complete the Nutritional Comprehensive Assessment for Resident 1 upon admission. This failure had the potential for further wound deterioration and delayed wound healing. (Reference F692) 3. The facility used two incontinence briefs at a time for Resident 1. This deficient practice had the potential to compromise Resident 1 ' s skin integrity which could contribute to further wound deterioration, delayed wound healing and the development of new skin breakdown. Findings: 1. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Stage 4 Pressure Ulcer (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure [such as tendon, or joint capsule]); Severe Protein Calorie Malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients); Diabetes Mellitus (disease that result in too much sugar in the blood); and Functional Quadriplegia (Complete inability to move due to severe disability or frailty). During a record review for Resident 1, the Pain Care Plan initiated on 1/26/23 indicated Resident 1 was at risk for pain related to generalized body pain. Care Plan interventions indicated: Anticipate the resident's need for pain relief & respond to any complaints of pain. Provide pain interventions & follow up for effectiveness of interventions as applicable; Evaluate the effectiveness of pain interventions every shift and PRN; Review for compliance, alleviating of symptoms, dosing schedules & resident satisfaction with results, impact on functional ability and impact on cognition. During a record review for Resident 1, the Pressure Ulcer Care Plan initiated on 2/10/23 indicated Resident 1 was admitted with stage 4 pressure ulcer to bilateral buttocks and unstageable pressure ulcer (full thickness skin loss in which the base of the ulcer is covered by slough and /or eschar (dead tissue) to coccyx (tailbone). Care Plan interventions indicated: Monitor and document wound healing. Measure length, width, and depth where possible. Assess and document status of peri wound tissue, wound bed, and healing progress weekly.; Monitor and report to MD signs and symptoms of infection or worsening of skin condition; and Wound consult and treatment with follow-up as indicated. During a record review for Resident 1, the Physician ' s Order indicated an order for Tylenol (treat minor aches and pains and reduces fever) written on 3/25/23 to be given for fever and mild pain as needed. During a record review for Resident 1, the Treatment Administration Record (TAR) indicated a wound treatment order written on 4/13/23 to be given two times a day. During a record review for Resident 1, the Medication Administration Record (MAR) for April 2023 indicated an order for Tylenol written on 3/25/23 to be given for fever and mild pain as needed. The MAR from 4/01/23 to 4/19/23 did not have licensed nurses ' initials indicating Resident 1 received pain medication. During an observation in Resident 1 ' s room on 4/20/23 at 1:01 p.m., Licensed Staff D was observed providing pressure ulcer treatment to Resident 1 with the assistance of the Assistant Director of Nursing (ADON). Caregiver A was in the room to provide assistance with turning Resident 1 to his side. The wound appeared clean, no discharge (cells, bacteria, and fluid produced by the body), with minimal slough (dead skin tissues) noted at the bottom of the wound, wound bed was pale red in color with approximately 1.5 centimeter (a unit of length) of undermined (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) wound tissue. Resident 1 was observed grimacing and verbalized, hurts a couple of times while Licensed staff D cleansed the wound using kerlix gauze (a thin, translucent fabric with a loose open weave). When Caregiver A was asked what Resident 1 had said, he stated, he said it hurts. Licensed staff D acknowledged Resident 1 was in pain and asked Resident 1 to bear with her as she continued cleaning the wound. When Licensed staff D was asked if Resident 1 was medicated for pain prior to wound treatment. Licensed staff D stated Licensed Staff E gave Resident 1 his pain medication in the morning of 4/20/23. During an interview with Licensed Staff E on 4/20/23 at 3:28 p.m., when Licensed Staff E was asked about the time Resident 1 received his pain medication on 4/20/23, Licensed Staff E stated she did not give Resident 1 any pain medication. Licensed Staff E stated Resident 1 could experience pain during wound treatment and should have pain medication prior to wound treatment; however, she stated Resident 1did not show any signs of pain/ discomfort. When Licensed Staff E was asked how she would assess for non-verbal signs of pain, she stated, facial grimacing, moves hand a lot, tried to roll back. Review of the Facility policy and procedure titled Pressure Ulcer Treatment revised in December 2007 under Interventions/Care Strategies indicated, Pressure ulcer treatment requires a comprehensive approach, including: Debridement, Managing infections, Managing systemic issues (edema, venous insufficiency, etc.), Maximizing the potential for healing, and Pain control. Steps in the procedure include but not limited to Assess the resident's level of pain and provide analgesics, as ordered, before wound care. Review of the Facility policy and procedure titled Pain Assessment and Management effective date June 2016 indicated, The purposes of this procedure are to help the staff identify pain in the resident. and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Procedure indicated, Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. The policy indicated, Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain including but not limited to Pressure, venous (relating to a vein) or arterial ulcers (also known as ischemic ulcer - reduced blood flow to an area of the body). 2. During a record review for Resident 1, the Care plan initiated on 2/09/23 indicated [Resident 1] required enteral feeding (also known as tube feeding - a way of delivering nutrition directly to your stomach or small intestine [part of the digestive system]). Care Plan intervention includes but not limited to: Registered Dietician (RD) to evaluate quarterly and as needed; Monitor caloric intake, estimate needs. Make recommendations for changes to enteral feeding as needed. During a record review for Resident 1, the document titled Nutrition Comprehensive assessment dated [DATE] under Primary Nutrition Diagnosis indicated, On PEG tube feeding (Percutaneous Endoscopic Gastrostomy - allows nutrition, fluids, and medications to be delivered directly into the stomach, eliminating the need to swallow by bypassing the mouth and esophagus) since 1/13/23 - not at calculated goal rate. During an interview and concurrent record review with the RD on 5/18/23 at 11:10 a.m. about the facility policy on resident ' s nutritional assessment, the RD stated newly admitted residents would be assessed within 7 days from admission. When the RD was asked about the process of determining resident ' s nutritional needs, she stated, it would be based either on resident ' s ideal body weight or actual body weight. Review of the document titled Nutrition Comprehensive assessment dated [DATE] with the RD indicated Resident 1 ' s admission weight was 108 lbs. The RD stated the nutrition comprehensive assessment for Resident 1 was completed two weeks late. During a review of the document titled After Visit Summary dated 1/26/23 with the RD on 5/18/23 at 11:17 a.m., the document indicated Resident 1 ' s weight was 128.4 lbs. The RD verified Resident 1 had 20 lbs. (16%) weight loss from 1/26/23 to 2/01/23. Review of the Facility policy and procedure titled Pressure Ulcer Treatment revised in December 2007 under Interventions and Preventive Measures indicated, Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. Review of the Facility policy and procedure titled Weight Management revised on 6/16/16 indicated, The facility strives to maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible; and to provide a therapeutic diet for residents with nutritional problems. 3. During a record review for Resident 1, the Face sheet indicated Resident 1 had a diagnoses including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Functional Quadriplegia (Complete inability to move due to severe disability or frailty); and Gastrostomy Status. During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 7/6/22 indicated Resident 1 had a BIMS score of 00 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 was always incontinent of bowel and bladder function (no control of the flow of urine and the release of stool). The MDS indicated Resident 1 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assistance with toilet use. During a wound treatment observation in Resident 1 ' s room on 4/20/23 at 1:01 p.m., Licensed Staff D was observed providing pressure ulcer treatment to Resident 1 with the assistance of the Assistant Director of Nursing (ADON). Caregiver A was in the room to provide assistance with turning Resident 1 to his side. Resident 1 was observed wearing two incontinence briefs. Blue brief was under the yellow brief. When the ADON was asked if there was a reason for Resident 1 to have two incontinence brief on at a time, she stated she did not know he was wearing two briefs. The ADON stated Family Member B was very involve with Resident 1 ' s care and probably instructed the CNAs (Certified Nursing Assistants) to put two diapers on at a time. During an Interview with Caregiver A on 4/20/23 at 1:17 p.m., when Caregiver A was asked about reason for Resident 1 to have two incontinence brief on at a time, Caregiver A stated, [Resident 1 had frequent urination and bowel movement due to the tube feeding. However, he stated he would check Resident 1 for wetness every one-hour to one and a half hour. During a review of the Incontinence Care Plan initiated on 1/26/23 indicated, [Resident 1] was incontinent with bladder and bowel. Care Plan goal indicated, Will remain free from skin breakdown due to incontinence and brief use. Care Plan interventions indicated, Provide incontinence care after episodes and apply skin protectant cream.; and report any signs and symptoms of breakdown to the license nurse. Review of the Facility policy and procedure titled Activities of Daily living (ADL) effective date 7/01/20 indicated, Resident who are unable to carry out activities of daily living will receive the services necessary to maintain good nutrition, grooming and personal hygiene.

Based on interview, and records review, the facility failed to ensure that nutritional care and services were provided to one of two sampled Residents (Resident 1) when: a. The facility did not obtain Resident 1 ' s weight on admission and did not monitor Resident 1 ' s weekly weights. b. The facility did not complete the Nutritional Comprehensive Assessment for Resident upon admission. This failure resulted to a twenty (20) lbs. (pounds - any of various units of mass and weight) which yielded to 16 percent (%) weight loss for a period of seven days. Findings: a. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Severe Protein Calorie Malnutrition (inadequate intake of food) as a source of protein, calories, and other essential nutrients); Diabetes Mellitus (disease that result in too much sugar in the blood); Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Functional Quadriplegia (Complete inability to move due to severe disability or frailty); and Gastrostomy Status (a surgical opening into the stomach). During a review of the document titled After Summary Visit dated 1/26/23 indicated Resident 1 ' s weight was 128.4 lbs. Review of the Physician ' s Order written on 1/26/23 indicated, Admission Weight. one time only for weight monitoring for 1 Day. During a telephone interview with Family Member B on 4/19/23 at 3:07 p.m., Family Member B stated Resident 1 was on tube feeding and was supposed to be weighed every Thursday; however, it was not done. Family Member B stated the facility staff had told him that Resident 1 ' s weight on admission was 108 lbs. During an interview and concurrent record review with the Director of Nursing (DON) on 4/20/23 at 3:00 p.m. The DON stated Resident 1 was readmitted to the facility from the hospital on 1/26/23. Review of the facility policy and procedure titled Weight Management effective date June 16, 2016, with the DON indicated, Weight will be obtained upon admission. After review of the document titled Weights and Vitals Summary for Resident 1, The DON stated Resident 1 weighed 108 lbs. on 2/01/23; however, there was no record of Resident 1 ' s admission weight. The DON stated the facility did not implement their policy to obtain Resident 1 ' s weight on admission. During a record review and concurrent interview with the Registered Dietician (RD) on 4/20/23 at 3:25 p.m., the document titled Weights and Vitals Summary indicated Resident 1 ' s weight on 12/02/22 was 133.2 lbs. and on 2/01/23, Resident 1 weighed 108 lbs. The RD stated Resident 1 had a significant weight loss and could have happened during Resident ' s acute hospitalization ; however, RD could not verify Resident ' s admission weight on 1/26/23. During a record review and concurrent interview with the DON on 4/20/23 at 3:42 p.m. the physician ' s order for Resident 1 written on 3/17/23 indicated, Monitor weekly weights times 6 weeks then reevaluate. The DON stated the facility did not Resident 1 until 4/07/23. During an interview with the RD on 5/18/23 at 11:17 a.m., when asked about the facility policy on resident ' s weight monitoring. The RD stated, policy for new admit residents was to obtain resident ' s weight on admission then weekly times 4 weeks, then monthly unless otherwise indicated. a. During a record review for Resident 1, the document titled Nutrition Comprehensive assessment dated [DATE] under Primary Nutrition Diagnosis indicated, On PEG tube (Percutaneous Endoscopic Gastrostomy - allows nutrition, fluids, and medications to be delivered directly into the stomach, eliminating the need to swallow by bypassing the mouth and esophagus) feeding since 1/13/23 not at calculated goal rate. The document indicated under Nutritional Intervention, Weigh Weekly. During an interview and concurrent record review with the RD on 5/18/23 at 11:10 a.m. about the facility policy on resident ' s nutritional assessment, the RD stated newly admitted residents would be assessed within 7 days from admission. When the RD was asked about the process of determining resident ' s nutritional needs, she stated, it would be based either on resident ' s ideal body weight or actual body weight. Review of the document titled Nutrition Comprehensive assessment dated [DATE] with the RD indicated Resident 1 ' s admission weight was 108 lbs. The RD stated the nutrition comprehensive assessment for Resident 1 was completed two weeks late. During a review of the document titled After Visit Summary dated 1/26/23 with the RD on 5/18/23 at 11:17 a.m., the document indicated Resident 1 ' s weight was 128.4 lbs. The RD verified Resident 1 had 20 lbs. (16%) weight loss from 1/26/23 to 2/01/23. Review of the Facility policy and procedure titled Weight Assessment and Intervention revised on 7/01/22 indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation & Implementation includes but not limited to: 1. The nursing staff will measure resident weights on admission, then weekly times 4 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as determined by MD. 2. Weights will be recorded in resident's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian. 4. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) / (usual weight) x 700]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe.

Based on interviews and record reviews, the facility failed to prevent staff from treating one resident (Resident 1) of 50 residents in an abusive manner, when Unlicensed Staff A treated Resident 1 in a physically and mentally abusive manner. This failure resulted in Resident 1 being in pain. The treatment left Resident 1, in shock about being treated in an abusive manner by staff. Findings: During an interview on 10/18/17 at 2:22 p.m., Complainant X stated Resident 1 had reported being treated, roughly by staff on the morning of 10/14/17. Complainant X stated Resident 1 had stated the incident had occurred the previous night shift. Complainant X stated Resident 1 told her that Unlicensed Staff A had hurt her and treated her rough in the process, when changing her wet brief (adult undergarment). Complainant X stated Resident 1 had told her Unlicensed Staff A had, thrown her around on the bed, and had caused Resident 1 pain. Resident 1 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was identified as alert and oriented by the facility. Resident 1's BIMS (Brief Interview of Mental Status) Score was 15 out of 15 indicating Resident 1 was cognitively intact (mental process of knowing, including aspects such as awareness, perception, reasoning, and judgment). During an interview on 10/19/17 at 11:30 a.m., Resident 1 stated she had asked Unlicensed Staff A to change her wet brief around 1 a.m. on 10/14/17. Resident 1 stated Unlicensed Staff A, kept throwing me back and forth on the bed when changing her brief. Resident 1 stated she had, cried out in pain, and told Unlicensed Staff A, You are hurting me. Resident 1 stated Unlicensed Staff A, threw me this way and threw me that way, and Resident 1 stated she had been in pain during the incident. Resident 1 stated she had been, shocked about the way she had been treated, and stated, I just could not believe it. During an interview on 10/19/17 at 11:50 a.m., Resident 2, identified by the facility as alert and oriented and Resident 1's roommate, stated she had been present during the incident of the early morning hours of 10/14/17. Resident 2 stated Unlicensed Staff A had responded to her call for assistance and assisted her into her wheelchair. Resident 2 had entered the bathroom on her own and overheard parts of the interaction and conversation between Resident 1 and Unlicensed Staff A. Resident 2 stated she had heard Unlicensed Staff A speak harshly to Resident 1, and she had then heard Resident 1 cry out in pain. Resident 1 had repeatedly said, Ouch, ouch, you are hurting me, and, Why are you doing this to me? Resident 2 stated she had come out of the bathroom and observed Unlicensed Staff A holding Resident 1's, bottom up in the air, like a butcher would hold up a large piece of meat. Resident 2 had yelled at Unlicensed Staff A, What are you doing to her? Resident 2 stated Resident 1 had told her she was, shocked about being, manhandled in the middle of the night. During an interview on 10/19/17 at 1:30 p.m., Management Staff A stated Resident 2 had told her how Unlicensed Staff A had treated Resident 1, like a slab of meat. Management Staff A stated Unlicensed Staff A was no longer allowed to work at the facility. A document titled, Progress Notes, dated 10/14/17 at 19:30 (7:30 p.m.), written by Management Staff B, revealed, Interviewed patient regarding allegations of rough handling by N[NAME] (overnight) shift CNA (Certified Nursing Assistant) around 0100 (1 a.m.) when performing pericare on 10/14/17. A document titled, Progress Notes dated 10/14/17 at 23:07 (11:07 p.m.), written by Licensed Staff C, revealed, Suspected abuse from CNA occurred N[NAME] shift . A document titled, Abuse Prohibition and Prevention Program, dated (MONTH) (YEAR), Revision Date (MONTH) (YEAR), listed under, Purpose .To ensure the facility is doing all that is within its control to prevent occurrences. A document titled, Re: Self -Report, dated 10/19/17, written by Management Staff A, revealed in a section titled, Conclusion .We found that the CNA did not provide care to the patient by the standards of professionalism and [MEDICATION NAME] that is expected by the facility; thus the patient experienced rough handling when acquiring care.

Based on interviews and record reviews, the facility failed to treat one (Resident 1) of 50 resident with dignity and respect, when Unlicensed Staff A refused to change Resident 1's wet brief (adult undergarment) and argued with Resident 1 about whether it needed to be changed or not. This failure by staff to assist Resident 1 when Resident 1 asked for assistance, left Resident 1 feeling disrespected and, shaky about how she was treated. Findings: During an interview on 10/18/17 at 2:22 p.m., Complainant X stated Resident 1 reported Unlicensed Staff A refused to change her wet brief, despite Resident 1 asking for it to be changed. Unlicensed Staff A had argued with Resident 1 about it not needing to be changed. During an interview on 10/19/17 at 11:30 a.m., Resident 1 stated she had asked Unlicensed Staff A to assist her and change her wet brief around 1 a.m. on 10/14/17. Resident 1 stated Unlicensed Staff A argued with her and told her several time she did not need to have her brief changed. She had insisted, You are not wet. Resident 1 stated she told Unlicensed Staff A she could feel her brief was wet, and Unlicensed Staff A, finally changed her brief. During an interview on 10/19/17 at 11:50 a.m., Resident 2, stated she had been present during the incident on the early morning hours of 10/14/17. Resident 2 stated she was Resident 1's roommate. Resident 2 stated she heard Resident 1 ask Unlicensed Staff A to assist her and change her brief. Unlicensed Staff A had argued with Resident 1 and repeatedly stated, You're not wet, when Resident 1 had told her, It's wet, I can feel it. Resident 2 stated she had heard Unlicensed Staff A speak in a harsh tone to Resident 1. Review of Resident 2's MDS (an assessment tool), dated 10/6/17, revealed a BIMS (Brief Interview for Mental Status) score of 15. A score of 13-15 indicates intact cognition. A facility policy and procedure document titled, Dignity, dated (MONTH) 16, (YEAR) revealed 1. Residents shall be treated with dignity and respect at all times . 9. Staff shall speak respectfully to residents at all times .

Based on observation, interview and record review, the facility failed to provide active interventions like turning and how often it should be done for Resident 2 who was admitted to the facility without a pressure ulcer, P.U. (injury to skin and underlying tissue resulting from prolonged pressure on the skin. P.U. most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.) which resulted in Resident 2 developing an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (a dry, dark scab or falling away of dead skin) pressure ulcer. This failure resulted in pain and delayed healing. Findings: Review of the facility Order Summary Report indicated, Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to perform everyday activities). Review of the MDS (Minimum Data Set) an Admission Assessment tool dated 11/19/16 indicated Resident 2 had severely impaired cognition (understanding, comprehension); required two plus persons physical assist for bed mobility, transfer, toilet use and personal hygiene; incontinent of bladder and bowel and without pressure sore. Review of the Braden Scale (assessment tool used for predicting pressure sore risk) indicated Resident 2 At Risk with a score of 16. Interventions linked to the At Risk Braden Scores of 15 to 18 are: frequent repositioning/turning; maximize patient's mobility; off-load (to get rid of something unpleasant or burdensome) patient heels for protection; use a pressure-distribution support surface (a support surface takes the weight of the patient when lying or sitting, and is intended to spread out (redistribute) the pressure exerted on the tissues in contact with that surface. The term support surface can apply to specialist beds, mattresses and mattress overlays, and also to chair and wheelchair cushions.) if patient is bed bound or chair bound. During a concurrent (occurring at the same time) observation and interview Resident 2 was sitted on a wheelchair in the dining room on 1/27/17 at 1:10 p.m., Family Member 3 stated that except on weekends, she visits from four to five hours everyday and that Resident 2 was seated in the wheelchair from 9 a.m. to 2 p.m. and repositioning every two hours while in bed was not done. Review of the facility's Weekly Pressure Ulcer BWAT(Bates Wound Assessment Tool) Report indicated on 12/14/16 at 2:12 p.m., Resident 2 had an unstageable pressure ulcer on the sacrum (a large, triangular bone at the base of the spine) measuring 0.8 cm in length and 0.6 cm in width. On 12/21/16 and 12/28/16 at 1:36 p.m., the unstageable pressure ulcer measured 0.9 cm long x 0.5 cm wide and a depth of 0.1 cm. On 1/4/17 at 1:36 p.m., the unstageable pressure ulcer measured 1.6 cm long x 0.6 cm wide and 0.1 cm deep. On 1/11/17 at 1:36 p.m., the unstageable pressure ulcer measured 1.6 cm long x 0.8 cm wide and 0.1 cm deep. On 1/18/17 at 1:36 p.m., the unstageable pressure ulcer measured 2 cm long x 1.0 cm wide and 0.1 cm deep. Review of Resident 2's undated Care Plan indicated stage 2 pressure ulcer (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) related to immobility. New interventions (action taken to improve a situation) listed indicated to document location of wound, amount of drainage, peri-wound area (is the tissue surrounding the wound itself), pain, [MEDICAL CONDITION] (medical term for swelling), and circumference measurements. Evaluate wound for: Size, Depth, Margins: peri-wound skin (the area of skin surrounding a wound), [DIAGNOSES REDACTED] (skin condition characterized by redness or rash), scars, [MEDICAL CONDITION], skin temperature, sensation, and pain, sinuses (a hollow, air-filled cavity) undermining (erode, wear away, eat away at), exudates (any fluid that filters from the circulatory system into [MEDICAL CONDITION] or areas of inflammation. It can be a pus-like or clear fluid.), [MEDICAL CONDITION], granulation (the healing surface of a wound), infection, necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply), eschar, gangrene (part of your body tissue dies because the tissue is not getting enough blood from your circulatory system.) Document progress in wound healing on an ongoing basis. Notify physician as indicated. During an interview on 3/3/17, at 1:58 p.m., Licensed Staff D stated the interventions listed in the care plan were mainly to document, it was not an active intervention of turning and how often it was to be done. It was just to document and evaluate. The facility failed to develop a care plan to prevent and care for Resident 2's pressure ulcer when no regular repositioning/turning was done. During an interview on 4/17/17, at 10:31 a.m., Unlicensed Staff E stated she looked after Resident 2. When asked what are the possible causes why a resident would get a pressure sore, Unlicensed Staff E stated, too much time in the wheelchair, dressing change not attended promptly when diaper is wet or soiled, no repositioning, the aide is too busy and cannot do the work right. Review of the facility manual NCD (Nursing Center Division)-19 Pressure Ulcer indicated patients are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to: Those who have sustained a [MEDICAL CONDITION], injury or illness that requires bed rest or wheelchair use. Other factors that increase the risk of pressure sores include: Age.