Every finding on record at Springs Road Healthcare

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 58 when:1. Dietary Supervisor (DS) and Dietary Aide (DA) 1 were not wearing a beard net while inside the kitchen.2. [NAME] residue was present on the floor surface of the food warmer.3. The top surface of the knife holder had accumulated dust and residue.4. Black residue was present on the floor beneath the dishwasher area.5. Three quarter size hotel pans were stacked wet while stored away.6. Flies were present in the kitchen area and dry storage area.7. Four lunch trays containing uncovered desserts were transported through the hallway.These failures had potential to cause food-borne illnesses in a highly susceptible population who received food from the kitchen.Findings:1. During an observation on 6/9/26 at 8:04 a.m. at the kitchen's initial tour, DS had a beard but was not wearing a beard net while in the kitchen during the initial tour.During an observation on 6/10/26 at 10:05 a.m. in the kitchen, DA 1 had a beard but prepared pudding for lunch without wearing a beard net.During a concurrent observation and interview on 6/10/26 at 10:22 a.m. with Registered Dietician (RD) in the dry storage area, the door leading to the kitchen displayed a sign stating, 'Proper hair restraint worn beyond this point.' RD stated that hair restraints included beard nets.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated that beard nets were worn in the kitchen for sanitation and infection control purposes.During a review of the facility's policy & procedure (P&P) titled, Food Preparation and Service, revised 4/26, the P&P indicated, .staff must. wear hair/beard covering during tray assembly.2. During a concurrent observation and interview on 6/9/26 at 8:06 a.m. during the kitchen's initial tour with DS, the food warmer's floor surface had brown residue. DS confirmed the presence of the residue.3. During a concurrent observation and interview on 6/9/26 at 8:09 a.m. during the kitchen's initial tour with the DS, the top surface of the knife holder had dust and residue. When wiped with a finger, the residue transferred onto the finger. DS confirmed the presence of the dust and residue and removed the knife holder from the wall.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated that equipment needed to be kept clean to prevent bacterial growth.During a review of the facility's P&P titled, Sanitation, Food Services, revised 10/24, the P&P indicated, . 2. All utensils, counters, shelves and equipment shall be kept clean. 4. During a concurrent observation and interview on 6/9/26 at 8:13 a.m. during the kitchen's initial tour with DS, the floor beneath the dishwasher area had black residue. The DS confirmed the presence of black residue.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated that it was important to keep the kitchen area clean for infection control purposes and to prevent bacterial growth.During a review of the facility's P&P titled, Sanitation, Food Services, revised 10/24, the P&P indicated, . 1. All kitchen, kitchen areas. shall be kept clean. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule.to prevent accumulation of grime. 5. During a concurrent observation and interview on 6/9/26 at 8:26 a.m. during the kitchen's initial tour with DS, three quarter-size hotel pans were stacked while still wet. DS confirmed that the pans were wet and stated that they should have been air-dried before stacking.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated that stacking pans while wet could promote bacterial growth and that the pans should be dried before stacking.The facility did not provide a P&P regarding storage of cleaned equipment and utensils. 6. During an observation on 6/10/26 at 12:20 p.m. during tray line in the kitchen, flies were observed in the kitchen area. DA 1 and DA 2 were observed waving the flies away from the tray line. DS confirmed that he had observed flies earlier.During an observation on 6/10/26 at 1:21 p.m. in the dry storage area/DS office, flies were observed in the dry storage area/office. The door leading from the dry storage area to the kitchen was wide open. DS confirmed the presence of flies in the dry storage area/office.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated flies should not be present in the kitchen because they could transfer bacteria and contribute to foodborne illnesses.During a review of facility's P&P titled, Sanitization, Food Services, revised 10/24, the P&P indicated, .1. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 7. During a concurrent observation and interview on 6/9/26 at 12:13 p.m. outside the kitchen, food cart 2 was observed outside the kitchen. Minimum Data Set Coordinator (MDSC) removed a tray containing an uncovered dessert from the food cart and walked through the hallway to the dining room. Infection Preventionist A (IP-A) stated that the resident wanted to eat in the dining room instead of the resident's room, which was why MDSC removed the tray from the food cart.During a concurrent observation and interview on 6/9/26 at 12:21 p.m. with Certified Nursing Assistant (CNA) 1 outside of room [ROOM NUMBER], food cart 2 was placed right beside the door of room [ROOM NUMBER], IP-A handed a tray containing an uncovered dessert to CNA 1. CNA 1 confirmed that the dessert was uncovered and walked the tray from room [ROOM NUMBER], located at the end of the hallway, back to room [ROOM NUMBER]. At 12:22 p.m., IP-A took another tray containing an uncovered dessert and walked through the hallway to room [ROOM NUMBER].During a concurrent observation and interview on 6/9/26 at 12:24 p.m., food cart 2 was still outside room [ROOM NUMBER], CNA 1 took a tray containing an uncovered dessert and walked it to room [ROOM NUMBER]. CNA 1 confirmed that the dessert was uncovered. During an interview on 6/9/26 at 12:32 p.m. with MDSC, MDSC confirmed that he took a tray from outside the kitchen to the dining room because the resident wanted to eat in the dining room instead of the resident's room.During an interview on 6/11/26 at 9:33 a.m. with RD, RD stated when distributing meal trays, the food cart should be wheeled to the resident's room and the tray removed and given to the resident. RD stated that all food should remain covered while being transported through the hallway to prevent contamination.During a review of the facility's P&P titled, Food Preparation and Service, revised 4/26, the P&P indicated, .all food trays must be covered at all times when transported from the kitchen or serving area to residents room.food must be.protected from contamination.no uncovered food tray may be transported through the hallways.all trays must be covered with individual tray lids or transported in enclosed carts.cover must remain in place throughout transport and must not be removed until the tray is in front of the resident.

Based on observation, interview and record review, the facility failed to secure resident medical records containing Protected Health Information (PHI, any individually identifiable health information held, transmitted, or maintained by the health facility), for four Residents (Resident 11, Resident 39, Resident 59, and Resident 69) out of census of 58 residents, when the Treatment Nurse (TN) left printed wound treatment records on top of an unattended cart.This failure had the potential for unauthorized access by visitors, families, and other residents to Resident 11's, Resident 39's, Resident 59's, and Resident 69's medical records containing PHI.Findings: During an observation on 6/9/26 at 9:49 a.m. in the hallway outside of rooms 25 through 28 the TN left a paper stack of resident medical records unsecured on top of the treatment cart. Visitors, family members, and residents were observed walking past by the treatment cart within a viewing distance of the open, unsecured, and unprotected resident medical records. During a concurrent observation and interview on 6/9/26 at 9:53 a.m. with the Infection Preventionist B (IP B) in the hallway outside of rooms 25 through 28, the IP B confirmed the presence of resident medical records containing PHI in the form of wound treatment documentation that had been sitting on top of the treatment cart with no staff present. The IP B confirmed that the documents were unsecured and had the possibility of unauthorized access by other residents and visitors. During a concurrent interview and record review on 6/9/26 at 9:57 a.m. the TN stated she had left the treatment documents unattended on the cart when she walked away from the cart. The TN acknowledged she should have locked the documents up so residents and visitors could not access them. The TN confirmed the medical records included resident names, status of wounds, and treatments ordered for Resident 11, Resident 39, Resident 59, and Resident 69. A review of facility policy and procedure titled, Protected Health Information (PHI), Management and protection of, revised April 2024, indicated, . It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on interview and record review the facility failed to ensure services meet professional standards of quality for four residents (Resident 16, Resident 39, Resident 74, and Resident 6) for a census of 18, when:Medications were given without meals, as prescribed for Resident 16, Resident 39, and Resident 74;Medication with a box warning ((also known as black box warning- the strictest, most serious safety alert mandated by the U.S. Food and Drug Administration (FDA [a federal agency of the United States government responsible for protecting public health]) was being administered for Resident 6 without monitoring for side effects to highlight severe, life-threatening, or permanently disabling risks)).These failures had the potential to cause:Residents 16, Resident 39, and Resident 74 to have adverse side effects related to medications being administered without meals;Staff not monitoring Resident 6 for side effects related to taking medications with a box warning; Findings:1. A review of Resident 16's Face Sheet (a document indicating a resident medical information) indicated Resident 16 was admitted to the facility on [DATE] with diagnosis which included Herpesvirus infection (HSV, common, lifelong viral infections causing painful blisters or ulcers), and Asymptomatic Human Immunodeficiency virus infection (HIV, a virus that attacks the body's immune system). A review of Resident 16's Order Summary Report (OSR, indicates prescribed medication and treatment orders), for active orders dated 6/12/26, indicated, .Symtuza [antiviral medication] Tablet .Give 1 tablet by mouth one time a day . (with a meal) . A review of Resident 39's Face Sheet indicated Resident 39 was re-admitted to the facility on [DATE] with diagnosis, which included anemia (body lacks enough healthy red blood cells to effectively carry oxygen to vital tissues). A review of Resident 39's OSR, for active orders dated 6/12/26, indicated, .Ferrous Sulfate [iron supplement] Oral Tablet . Give 1 tablet by mouth one time a day for anemia. take with breakfast.A review of Resident 74's Face Sheet indicated Resident 74 was admitted to the facility on [DATE] with diagnosis, which included type 2 diabetes mellitus (high blood sugar). A review of Resident 74's OSR, for active orders as of 6/12/26, indicated, .Metformin [medication to manage blood sugar] . Give 1 tablet.w/ [with] meals.During an interview on 6/11/26 at 1:18 p.m., the Nurse Practitioner (NP) stated it was of utmost importance for nursing to follow prescriber direction for timing medication administrations, such as before meals, with meals, or on an empty stomach to prevent harm to the [resident].During an interview on 6/11/26 at 3:50 p.m., the Dietary Supervisor (DS) stated lunch trays for residents in rooms 25 through 28 (where Resident 16, Resident 39, and Resident 74 resided) were served at approximately 12:15 p.m. on 6/10/26.During a phone interview on 6/12/26 at 12:50 p.m. the facility's Pharmacy Consultant (PC- a medication expert who advises healthcare providers on the safe and appropriate use of medications) stated when a prescriber provides directions for medication to be given with a meal, the medication should be provided with a meal, and clarified not just a snack but a meal, to prevent side effects and ensure treatment effectiveness. The PC further confirmed that Symtuza absolutely needs to be taken with a meal, Ferrous Sulfate should be taken with a meal especially in elderly populations for tolerability, and Metformin absolutely needs to be taken with a meal. The PC confirmed administering these medications between 11:06 a.m. and 11:34 a.m. when lunch was not served until 12:15 p.m. was not considered given with a meal and had the potential to cause side effects and treatment failure.A review of facility policy and procedure titled, Administering Medications, revised April 2025, indicated, .Medications are administered in a safe and timely manner and as prescribed medications are administered in accordance with prescriber orders .2. A review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility in May 2026 with diagnoses including depression (mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in daily life).A review of Resident 6's care plan (CP- a personalized, written document that outlines how staff will manage a resident's medical, physical, and personal care needs daily) titled, Antidepressant (Sertraline)[a medication to treat depression]., initiated 5/9/26, indicated interventions/tasks staff were expected to perform included, ANTIDEPRESSANT BLACK BOX Warning: Suicidality and antidepressant drugs. Closely observe and appropriately monitor patients .for clinical worsening, suicidality, or unusual changes in behavior and Black Box Warning: Monitor S/E [side effects] such as sedation, dry mouth, urine retention, tachycardia [an abnormally fast heartbeat], muscle tremors, drowsiness, skin rash, agitation, dizziness, confusion, headache, blurred vision & notify MD [Medical Doctor] promptly.A review of Resident 6's OSR, dated 6/11/26, indicated an active order for, Sertraline HCl [hydrochloride] Oral Tablet 100 MG [milligram; a unit of measure] . Give 1 tablet by mouth one time a day for depression. No documented evidence of an order to monitor for the box warning risks and side effects.During an interview on 6/11/26 at 12:17 p.m., LN 5 stated some medications have serious side effects and adverse reactions. The medications with increased risks will have a box warning of side effects and adverse reactions that should be monitored. LN 5 stated nurses know to monitor for these box warning side effects and adverse reactions through an order in the eMAR. LN 5 clarified if there was not a monitoring order, she would not know to monitor for the box warning side effects or adverse reactions.During a concurrent interview and record review on 6/11/26 at 12:21 p.m., with the Director of Staff Development (DSD- a licensed nurse responsible for planning, implementing, and overseeing educational programs for nursing and support staff), Resident 6's OSR, care plans and eMar, dated 5/8/26 through 6/11/26 were reviewed. The DSD confirmed Resident 6 had an order for Sertraline. The DSD also confirmed Sertraline had a box warning care plan that indicated staff were to monitor side effects and adverse reactions, and he would expect to see an order for monitoring of those box warning side effects and adverse reactions. The DSD further confirmed there was no order for monitoring the box warning side effects and adverse reactions. A review of FDA document titled, Guidance for Industry: Warnings and Precautions, Contradictions, and Boxed Warning Sections of Labeling for Human Prescriptions Drug and Biological Products, dated 10/6/11, indicated, .A boxed warning is ordinarily used to highlight for prescribers. there is an adverse reaction so serious in proportion to the potential benefit form the drug (e.g., a fatal, life-threatening or permanently disabling adverse reactions) that it is essential that it be considered in assessing the risks and benefits of using the drug.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for Resident 33 and Resident 22 and for census of 58 when:1. Resident 33 was found to have medications at the bedside.2. An opened, unlabeled box of Lidocaine Patches 5% was found in the medication cart, containing one unopened packet and 2 opened packets; and3. Resident 22's white envelope containing twenty-five dollars in cash were found inside the narcotic box in medication cart.These failures had the potential for diversion of unlabeled medications and risk resident's safety. Stored personal valuables in the narcotic cabinet compromise the security of the controlled medications.1.Review of Resident 33's Face Sheet (a summary page in a resident's medical record that contains key identifying information about the resident) indicated that Resident 33 was admitted May of 2026 with several diagnoses including atherosclerotic heart disease (a condition where arteries supplying blood to the heart muscle become narrowed or blocked by fatty deposits), Muscle weakness (generalized) and other abnormalities of gait and mobility. Review of Resident 33's Minimum Data Set-(MDS-a federally mandated resident assessment tool) dated 5/17/26, the MDS indicated that Resident 33 was cognitively intact. Review of Resident 33's Order Summary Report indicated no provider orders authorizing Resident 33 to store or self-administer medications at the bedside. Review of Resident 33's Interdisciplinary Team (IDT-a team of health professional that plans a Resident's care and updates a Resident's plan of care), the IDT notes dated 5/13/26, 5/20/26, 5/27/26 and 6/3/26 indicated no medication administration assessments were done. During an interview on 6/9/26 at 10:50 a.m. with Resident 33, observed medications on Resident 33's dresser beside her bed, which included an opened box of [Brand name topical pain relief patches], a container of opened [brand name vitamins] and a container of magnesium glycinate (a dietary supplement that helps with muscle and nerve function) 200 mg (milligram-a unit of measurement). Resident 33 stated her friend brought these to her. During an interview on 6/9/26 at 10:58 a.m. with Licensed Nurse (LN), LN 2 confirmed this finding and stated that Resident 33 should not have medications at the bedside. LN 2 stated that if a Resident brings medications from home the LN will secure the medications and send a message to the provider to obtain orders for Resident use and storage. LN 2 stated potential negative outcome of residents having medications at the bedside is other residents may take the medications and there is risk of overdose if the resident is left to manage his own medications. During an interview 06/12/2026 8:03 a.m. with the Director of Nursing (DON), the DON stated that residents should not have medications at the bedside unless a provider order is obtained, a cognitive and self-administration assessment is done by the Interdisciplinary Team. The DON further stated the potential negative outcome is that the resident could overdose and it is not safe for the resident. Review of the facility Policy and Procedure (P&P) titled, Self-Administration of Medications, dated December 2025, the P&P indicated, Residents have the right to self-administer medications if the Interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 2. During a concurrent observation and interview on 6/9/26 at 1:38 p.m. with the Director of Nursing (DON) at medication cart Station One, an opened, unlabeled box containing one unopened packet and two opened packets of Lidocaine Patches 5% were found stored with the resident's medications. The DON confirmed the observation and stated Lidocaine Patch 5% patches were individually prescribed by the physician based on residents' diagnoses or complaints. The DON further stated all medications used in the facility should have been labeled with appropriate and cautionary instructions to keep residents safe, and that the nursing staff should have discarded the opened patches. 3. During a concurrent observation and interview on 6/9/26 at 1:40 p.m. with the DON at medication cart Station One, Resident 22's white envelope containing twenty five dollars in cash was found inside the narcotic box. The DON stated Resident 22 had been discharged from the facility on May 29th, and the envelope should have been surrendered to the Business Office to be kept securely and returned to Resident 22 prior to discharge. The DON further stated personal belongings should not have been stored inside the narcotic box because doing so compromised the safety of controlled medications. During an interview on 6/12/26 at 1:05 p.m., the Pharmacy Consultant (PC) stated unlabeled medications should not have been kept in the cart to prevent medication errors and potential diversion. The PC further stated all medications should have been labeled and maintained in compliance with regulatory standards to ensure accurate dosage administration and resident safety. The PC added that medications such as Lidocaine Patches 5% were prescribed by the physician specific to the resident's diagnosis and use by other residents posed a risk. The PC also stated personal belongings, such as cash, should not have been kept inside the narcotic box because doing so introduced a risk of theft and cross contamination of medications. During a review of the facility's policy and procedures, titled Labeling of Medication Containers, revised April 2025, indicated, All medications maintained in the facility are properly labeled in accordance with currents state and federal guidelines and regulations.1. Medications labels must be legible at all times.2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy.3. Labels for individual resident medications include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. name, address, telephone number of the of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use. During a review of the facility's policy and procedures, titled Storage of Medications, revised November 2025, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.3. The nursing staff is responsible for maintaining medication storage.8. Schedule 11-V controlled medications are stored in separately locked, permanently affixed compartments.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1.Licensed Nurse (LN) 1 did not wear gown and gloves as indicated in Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug-resistant organisms) guidance before entering the room and helped reposition Resident 9; 2. LN 3 took Resident 75's blood sugar and used disinfectant to clean the glucometers (hand-held devices that measure a person's blood glucose/sugar levels) that were not recommended by the manufacturer; Infection Preventionist (IP) B sanitized the glucometer using alcohol wipes before and after resident use; LN 3 stated she/he sanitized glucometer before and after resident use, using the alcohol wipes or the purple-top wipes (germicidal wipes); and, 3. Resident 48's nasal cannula was not stored in a bag. These failures had the potential to compromise resident's health and safety and potentially lead to the spread of communicable illnesses. Failure to sanitize glucometers with manufacturer's recommended disinfectants may damage the device and impair its performance. Findings: 1. During a review of the admission Record (AR) for Resident 9, the AR indicated Resident 9 and had been admitted to the facility on [DATE] with diagnoses including history of other infectious and parasitic diseases, and type 2 Diabetes (body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 9's Order Summary Report, (OSR) dated 6/3/26, the OSR indicated, Resident 9 had left calf pressure injury (happens on areas of the skin that are under pressure) and left knee multiple incision site monitored for signs and symptoms of infections. During a review of Resident 9's Care Plan, (CP) dated 3/5/26, the CP indicated, Resident 9 had a Mid/Low Risk Braden Scale score of 18 (clinical tool used to assess a patient's risk of developing pressure injuries). During a review of Resident 9's CP dated 5/11/26, the CP indicated Resident 9 had a left lower leg (calf) unstageable pressure injury as evaluated by the wound physician. During a concurrent observation and interview with LN 1 on 6/9/26 at 9 a.m., Resident 9's room had an EBP signage (guidance on what and how to properly wear the PPE) posted by the door and a bin that contained PPE supplies. LN 1 entered Resident's 9's room and did not wear gown and gloves. LN 1 proceeded with her task, touched Resident 9's pillow, touched Resident 9's left shoulder and assisted him to reposition on his bed. LN 1 did not sanitize her hands after assisting Resident 9. LN 1 confirmed Resident 9 is on EBP precautions and acknowledged that she did not wear gown and gloves while performing direct care to Resident 9. LN 1 acknowledged that she did not sanitize her hands after direct care and stated she should have practiced infection control to prevent the spread of infection to other residents. 2. During a review of the AR for Resident 75, the AR indicated, Resident 75 had been admitted to the facility on [DATE] with diagnoses including Bacteremia (presence of bacteria in the blood stream), and type 2 Diabetes. During a review of Resident 75's OSR dated 6/10/26, the OSR indicated, Resident 75 had an order for Blood Sugar Check per Finger Stick Q [every] AC [before meals] and HS [bedtime] During a concurrent observation and interview with LN 3 on 6/11/26 at 12 p.m., LN 3 used the facility's glucometer to check Resident 75's blood sugar level. LN 3 took out the wipes container [name of the wipes product] from her medication cart, pulled out one sheet, and cleaned the glucometer. LN 3 stated that she used the wipes (as she pointed out on the wipes container) all the time after utilizing the glucometer, and she did not know what the rest of the nursing staff used to clean the glucometer. During an interview with Director of Nursing (DON) on 6/12/26 at 1:26 p.m., the DON stated her expectations from the nursing staff were to promote infection control to prevent the spread of infection in the facility. The DON further stated that the EBP signage was posted by the resident's room to remind them to practice infection prevention and the bin contained with PPE for their use. The DON agreed that the facility did not use the manufacturer's recommendation to disinfect the glucometer and use other sanitizing wipes [name of sanitizing wipes] to clean the glucometer. During a review of the facility's policy and procedure titled, Enhanced Barrier Precaution, update 9/18/25, indicated, PURPOSE.To provide guidance and recommendations for implementing Enhanced Barrier Precautions (EBP) to include the use of glove and gown during high-contact care activities for residents with chronic wounds. in addition to residents who have an infection. During a review of the manufacturer's Healthcare Professional Operator's Manual (HPOM), the HPOM indicated, .NOTE: Only one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeably had not been evaluated. An EPA- registered disinfecting wipe such as [name of wipes]. The [name of wipes] disinfectant products have been shown to be safe in disinfecting the [name of the BSM] system. The facility was asked multiple times but failed to provide the facility's policy and procedure regarding disinfecting glucometer after use. 3. During a review of Resident 48's Face Sheet (FS-front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 48 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation and acute respiratory failure with hypoxia (lungs suddenly stop working well enough to transfer oxygen causing low oxygen levels in the body). During a review of Resident 48's Order Summary Report (OSR), the OSR indicated, Resident 48 had an order for oxygen at 2 LPM (liters per minute-flow rate and volume of supplemental oxygen delivered per minute) via NC (nasal cannula-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) PRN (given as needed or requested) to keep O2 sat (oxygen saturation-measurement of how much oxygen the blood is carrying as a percentage) above 90%. May titrate up to 5 L (liters) for SOB (shortness of breath)/wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs.) During a concurrent observation and interview on 6/9/26 at 9:09 a.m. with Licensed Nurse (LN) 1 in Resident 48's room, Resident 48's nasal cannula was resting on top of the oxygen concentrator and not in a bag. LN 1 confirmed that the nasal cannula was not stored in a bag and stated that it should be kept in a bag when not in use. During an interview on 6/11/26 at 8:19 a.m. with Infection Preventionist A (IP-A), IP-A stated that the nasal cannula should be stored in a bag when not in use for infection control purposes to help prevent bacterial contamination. During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised 11/25, the P&P indicated, .Infection Control Considerations Related to Oxygen Administration.8. Keep oxygen cannulae and tubing used PRN in a plastic bag when not in use.

Based on observation, interview and record review the facility failed to develop a communication/language barrier (an obstacle that prevents two or more people from understanding each other, that can lead to miscommunication) comprehensive care plan (CP- a personalized, written document that outlines how staff will manage a resident's medical, physical, and personal care needs daily) for one resident (Resident 6) out of 18 sampled residents, when there was no documented evidence of Resident 6's care plan addressing his preference to communicate in Spanish.This failure had the potential for miscommunication and misunderstanding when discussing medications, treatments, and care needs.Findings:A review of Resident 6's Face Sheet, indicated he was admitted to the facility on [DATE] and his preadmission document titled, [Resident initials] referral, uploaded to his chart on 5/6/26, indicated Resident 6 was Spanish speaking.During a concurrent observation and interview on 6/9/26 at 10:36 a.m., in the hallway outside of room [ROOM NUMBER], Resident 6 was greeted in English and asked if he could be interviewed. Resident 6 shook his head no and stated he speaks Spanish and understood little English. During an interview on 6/10/26 at 10:29 a.m. using a Spanish translator over the phone, Resident 6 stated he preferred to communicate with staff in Spanish.During an interview on 6/11/26 at 8:43 a.m., Licensed Nurse (LN) 5 stated accuracy of care plans (CPs) are important to understand the care and needs of each resident.During a concurrent interview and record review on 6/11/26 at 8:51 a.m., with the Director of Staff Development (DSD), Resident 6's care plan (CP) was reviewed. The DSD stated Resident 6's CP was important to be accurate since it outlined Resident 6's care and being inaccurate could lead to a negative outcome. The DSD stated he expected communication barriers, such as speaking different languages to be reflected on the resident's CP. The DSD confirmed no documented evidence of any care plan interventions relating to Resident 6's preference of communicating using Spanish language.During a concurrent interview, record review and observation on 6/11/26 at 9:03 a.m. with the Minimum Data Set Coordinator (MDSC- a licensed healthcare professional who oversees the clinical assessment process for facility residents), Resident 6's comprehensive CP, initiated 5/9/26, was reviewed. The MDSC talked to Resident 6 in his room, and Resident 6 stated in Spanish he preferred communication regarding medications and treatments to be in Spanish. The MDSC confirmed Resident 6's primary and preferred language was Spanish, that there was not a Spanish speaking/communication CP, and that there should be a comprehensive CP addressing the communication barrier and his preference for Spanish communications.During a concurrent interview and record review on 6/12/26 at 11:39 a.m. with the Admissions Coordinator (ADC), Resident 6's pre-admission document titled, [Resident initials] referral, that was uploaded to the resident's chart on 5/6/26, was reviewed. The ADC confirmed the document indicated Resident 6 was a Spanish speaker.A review of facility policy and procedure (P&P) titled, translation and/or Interpretation, revised 10/21/25, indicated, .Upon admission, staff shall assess and document each resident's preferred spoken and written language . Language needs shall be reviewed and updated as necessary and upon resident preference .A review of facility P&P titled, Resident participation-Assessment/Care Plans, revised December 2025, indicated, .The resident and his or her representative are encouraged to participate in the .development and implementation of the resident's care plan The care planning process will .Incorporate the resident's personal and cultural preferences .

Based on observation, interview, and record review, the facility failed to ensure its medication error rate remained below five percent (5%) for two residents (Resident 25 and Resident 3) out of 18 sampled residents, when:Licensed Nurse (LN) 3 did not wear gloves when administering prescribed hazardous medication; and,LN 1 did not follow the physician's order when administering Resident 33's prescribed medications.These failures resulted in the facility's medication error rate of 6.45%, which had the potential for harm, worsening of existing conditions, or the development of new illnesses for Resident 25 and Resident 33.Findings:1. During a medication administration observation on 6/9/26 at 8:45 a.m., in Resident 25's room LN 3 did not wear gloves when dispensing the medication into a cup, and administering Topiramate (primarily used to treat and prevent seizures [epilepsy] and to prevent migraine headaches) tablet 100 mg (milligram, unit of measure) to Resident 25.A review of Resident 25's Order Summary Report (OSR) dated 2/21/25, indicated, Topiramate Tablet 100 MG Give 1.5 tablet by mouth two times a day for seizure, must wear gloves when administering medication, and must wear gloves and mask if crushing medication.The Medication Administration Record, (MAR), dated 2/21/25, also indicated, Topiramate Tablet 100 MG Give 1.5 tablet by mouth two times a day for seizure, must wear gloves when administering medication.During an interview with LN 3 on 6/9/26 at 11:04 a.m., LN 3 acknowledged she did not wear gloves when she administered Topiramate tablet to Resident 25. She stated that she should have worn gloves because the medication is hazardous.During a phone interview on 6/12/26 at 1:13 p.m., with the Pharmacy Consultant (PC), the PC stated nurses should follow the doctor's order, and wear gloves when administering or dispensing Topiramate to Resident 25. The PC emphasized the importance of protecting themselves or possibly other residents, as this medication was classified as hazardous. The PC further stated, the nursing staff must know the drug action, and the precautionary measures of the medications they administer.2. A review of Resident 33's OSR dated 5/10/26, indicated, Cosopt PF Ophthalmic Solution 2-0.5 % (Dorzolamide Hydrochloride and Timolol Maleate) instill 1 drop in both eyes two times a day for Glaucoma (caused by a buildup of fluid pressure inside the eye, which can lead to permanent vision loss or blindness). The MAR, dated 5/10/26 indicated, Cosopt PF Ophthalmic Solution 2-0.5 % (Dorzolamide Hydrochloride and Timolol Maleate) instill 1 drop in both eyes two times a day for Glaucoma.During a concurrent medication administration observation and interview on 6/11/26 at 9:39 a.m., inside Resident 33's room at bedside, LN 1 instilled one (1) drop of Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution (DHTMOS, a prescription used to lower high pressure in the eyes) to Resident 33's left eye. Afterward, LN 1 confirmed she instilled one eye drop of DHTMOS to Resident 33's left eye. When asked to recheck the DHTMOS label, LN 1 stated, she should have verified the medication against the physician's order before administering the eye drop. LN 1 acknowledged she should have instilled one eye drop to both left and right eye.During a phone interview on 6/12/26 at 1:13 p.m., with the PC, the PC stated nurses should follow the doctor's order and ensure they give the correct medication, dosage, route, time to the appropriate resident.During an interview on 6/12/26 at 1:26 p.m., with the Director of Nursing (DON), the DON stated that she expected the staff to follow the physician's order when administering prescribed medications.During a review of the facility's policy and procedures, titled Administering Medications (AM), revised April 2025, indicated, Medications are administered in a safe and timely manner, and as prescribed.10. The individual administering the medication 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 interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) Physician Orders for Life-Sustaining Treatment (POLST- a medical order that tells healthcare providers what treatments a patient wants or does not want, especially in serious illness or end-of-life care) was not implemented following the resident's return from the emergency room.This failure has resulted in Resident 1's POLST not implemented and reduced the facility's potential to provide necessary care and services to attain or maintain the resident's highest practicable wellbeing. Findings: During a review of Resident 1's admission record (AR- Front page of the chart that contains a summary of basic information about the resident), the AR indicated, Resident 1 was initially admitted to the facility 10/2018 with diagnoses including Acute Respiratory failure (a life threatening emergency where the lungs suddenly cannot get enough oxygen into the blood or remove carbon dioxide, often causing severe shortness of breath, confusion, and blue-tinted skin) with hypoxia (the body tissues- such as the brain, heart, and muscles- do not receive enough oxygen to function properly), and dysphagia (difficulty swallowing). The AR indicated he was his own self responsible party.During a review of Resident 1's POLST dated 10/16/2018 indicated, .Do Not Attempt Resuscitation.Medical Interventions: Comfort-Focused Treatment (relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction.)During a review of Resident 1's Speech and Language Pathology Discharge summary, dated [DATE], indicated, .Discharge Recommendations and Status. Oral Intake = Soft and Bite Sized texture, mildly thick liquids consistency, small portions. Strategies: .to facilitate safety and efficiency. It is recommended the patient use following strategies during oral intake: general swallow precautions.upright posture during meals.During a review of Resident 1's Care plan for acute respiratory failure with hypoxia initiated 10/13/24, indicated, .maintain a clear airway.if secretions cannot be cleared, suction as needed.During a review of a Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication form (a structured communication tool used in healthcare to share critical patient information clearly and quickly) dated 12/22/25, indicated, .Resident 1 had shortness of breath, respiratory rate of 30 breaths per minute, Oxygen saturation (O2 sat- measures percentage of oxygen in the red blood cells are carrying, indicating how well the heart and lungs are functioning) was at 62 %. Nurse Practitioner 1 notified and recommended to send patient to emergency room.During a review of Resident 1's hospitalization emergency room (ER) notes, dated 12/22/25, indicated, Resident 1 arrived at the emergency room at 3 a.m. Resident 1 was evaluated, and indicated his vital signs as follows: pulse 108 beats/minute, respiration 34 breaths/minute, blood pressure 59/46, O2 sat (O2 sat- measures percentage of oxygen in the red blood cells are carrying, indicating how well the heart and lungs are functioning) 95% on non -rebreather mask (a high-concentration oxygen delivery device designed for acute respiratory emergencies.)Resident 1's ER Physical examination (PE) dated,12/22/25, indicated, . he is ill-appearing, unresponsive to tactile (sense of touch) stimulation, eyes closed.tachycardia (medical term for resting heart rate that is too fast),.murmur (unusual swishing sound heard during a heartbeat).tachypnea (abnormally fast and shallow breathing), rhonchi ( snoring-like lung sound heard through a stethoscope [stethoscope- a medical tool used to listen to sounds in the body] when large airways are blocked by mucus or fluid) present.Resident 1's ER notes dated, 12/22/25, indicated, .No further treatment at this time given his DO NOT Resuscitate and comfort care status. Patient [Resident] appear comfortable at this time and okay for return to the nursing home . Resident 1 was discharged from ER [DATE] at 5:19 a.m. back to the facility.No documented evidence of completed nursing evaluation upon return of Resident 1 to the facility from the ER, vital signs, evaluation of respiratory status and comfort measures including suctioning, evaluation of level of consciousness.During a concurrent interview and record review on 3/20/26 at 2:23 p.m. with Director of Nursing (DON), Resident 1's progress notes were reviewed. The DON confirmed there was no documented evidence that assessments, and implementation of comfort measures were provided per Resident 1's POLST upon his return from the ER to the facility. The DON stated her expectations were: for the Licensed nurse to perform vital signs, assess, treat the symptoms, and follow the physician orders and document timely.During a review of the facility's policy and procedure titled, Physician Orders for Life-sustaining Treatment (OR POLST), updated 2/2026, indicated, .Whenever a resident exhibits a sudden and/ or marked adverse change in signs, symptoms and/or behavior LN (Licensed Nurse) staff will.iii Update plan of care of the resident to include continuing reassessment of the resident's needs to ensure that all appropriate and desired care is being provided to the extent possible.

Based on interview and record review, the facility failed to provide professional standards of care for one of three sampled residents (Resident 1) when the x-ray (used to detect broken bones) order for Resident 1 was not carried out correctly.This failure resulted to an x-ray performed on Resident 1's right knee instead of the left knee. Resident 1's x-ray on the left knee indicated a fracture of the distal femur (a break in the thigh bone just above the knee joint) which required further evaluation and treatment in the acute care hospital.A review of the admission Record indicated Resident 1 was admitted April of 2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy (long -term high blood sugar damages multiple nerves which leads to pain, tingling, burning, or numbness in the feet or hands) and weakness.A review of Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status) dated 2/17/26 indicated Resident 1 was cognitively intact with a score of 14.A review of Resident 1's Order Summary Report indicated the following physician orders:- on 2/18/26 the order indicated, May X-ray (L) knee r/t [related to] pain.; and,- on 2/22/26 the order indicated, Monitor (L) thigh skin discoloration for any changes [every] shift. A review of Resident 1's Nurse's Note dated 2/18/26 at 3:40 p.m. indicated, [Resident 1] verbalize [sic] that he bumped his Left knee at the church bathroom last Sunday 2/15/2026.Asked resident if he fell outside facility and said NO. Noted Left knee more prominent that [sic] right knee. No redness noted on left knee, skin intact, with faint yellowish skin discoloration noted on the left lateral thigh. Able to move left foot and able to wiggle toes. Medicated x1 with PRN [as needed] Norco [used to treat moderate to severe pain] for 7/10 [7 out of 10, ten being worst pain ever] left knee pain with relief noted. Supported LLE [left lower extremity] with pillow. Seen and examined by visiting MD [Medical Doctor] with order for x ray on left knee.Further review of Resident 1's clinical records did not indicate follow up monitoring of Resident 1's left knee from 2/19/26 to 2/22/26.A review of Resident 1's Nurse's Note dated 2/24/26 at 12:13 a.m. indicated, Xray [sic] of left knee taken tonight and fracture of the left knee is found. Reported to [name of physician] and ordered to be sent to [name of hospital] for treatment.given Norco around 2017 [8:17 p.m.] with c/o [complained of] 8/10 left knee pain with some relief. Was refusing to be changed because of pain when he is moved. Transferred to ER [Emergency Room] around 2235 [10:35 p.m.] .A review of Resident 1's Medication Administration Record (MAR) for February 2026 indicated Resident 1 received Norco once or twice from 2/16/26 to 2/23/26 for pain between 7 to 8.A review of the Interdisciplinary (IDT) Note dated 2/25/26 indicated, .On 2/19/26, due to a data entry error on the diagnostic requisition, the X-ray was performed on the right knee, which showed no fracture.On 2/23/26.[Resident 1] stated he had fallen on 2/15/26 while at church but was unable to describe how or where the alleged fall occurred.The corrected X-ray on the left knee was completed on 2/23/26 and revealed an acute [sudden onset] mildly displaced supracondylar fracture of the distal femur [break on the thigh bone just above the knee joint where the bone pieces are slightly out of alignment] .The MD was notified of the results during the evening shift on 2/23/26 and ordered to transfer to [name of hospital] for further evaluation and treatment. Follow-up with [name of hospital] confirmed that [Resident 1] was admitted .following surgery for retrograde intramedullary nailing of the left femur [surgical procedure where a metal rod is inserted into the broken thigh bone through the knee and into the bone cavity to stabilize the fracture].During a concurrent interview and record review on 2/25/26 at 12:49 p.m. with the Director of Nursing (DON), Resident 1's Nurse's note and IDT note were reviewed. The DON stated Resident 1's x-ray order was on the left knee and for some reason the nurse clicked on the right knee. The DON further stated the x-ray on the left knee was done on 2/23/26. During an interview on 2/25/26 starting at 1:03 p.m. with the Licensed Nurse 1 (LN 1) and DON, in the conference room, the LN 1 stated she wrote the Nurse's Note on 2/18/26 for Resident 1. The LN 1 further stated she called the physician and the physician ordered x-ray of the left knee because Resident 1 was complaining of pain. The LN 1 added, another licensed nurse carried out the order, and the x-ray request was made for the right knee instead of the left knee. The LN 1 acknowledged there were no follow up notes made regarding Resident 1's left knee. The DON stated there should be a follow up note after 2/18/26 when Resident 1 verbalized he bumped his left knee while at church on 2/15/26. The LN 1 and the DON acknowledged Resident 1 could have been sent out in the hospital earlier if the x-ray was done on the right body part [left knee]. A review of the facility's policy and procedure revised April 2007 and titled, Request for Diagnostic Services indicated, .Orders for diagnostic services will be promptly carried out as instructed by the physician's order.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the California Department of Public Health (CDPH).This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including gastroenteritis (an inflammation of the stomach and intestines, causing symptoms like nausea, vomiting, diarrhea, abdominal cramps). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in December 2018 with multiple diagnosis including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During an interview on 7/11/25 at 11:59 a.m. with Resident 1, Resident 1 stated Resident 2 hit him with a cane on his shin. Resident 1 further stated the incident happened the previous week. During a review of Resident 1's and Resident 2's medical records, there was no documented evidence that indicated the alleged abuse was reported to appropriate agencies prior to 7/11/25. During a follow up interview on 7/17/25 at 11:36 a.m. with Resident 1, Resident 1 stated he immediately notified staff when Resident 2 hit him with a cane on his left shin. Resident 1 further stated he was moved to a different room after the incident. During an interview on 7/17/25 at 11:54 a.m. with Licensed Nurse (LN) 3, LN 3 stated approximately 2 weeks ago, she was notified by Resident 1 that he was hit with a cane on his left shin by Resident 2. LN 3 further stated she immediately notified the Director of Staff Development (DSD) of the alleged abuse so it could be investigated. During an interview on 7/17/25 at 12:05 p.m. with DSD, DSD confirmed LN 3 notified him of alleged abuse between Resident 1 and Resident 2 immediately after the incident. DSD further stated he did not report alleged abuse to the appropriate agencies because he was not sure if alleged abuse happened. DSD acknowledged alleged abuse should have been reported. DSD further stated there was a risk of injury and prolonged abuse when alleged abuse was not reported. During a review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting, revised July 2024, the P&P indicated, .All reports of resident abuse.shall be promptly reported to local, state, and federal agencies.and thoroughly investigated by the facility.All alleged violations involving abuse.will be reported.an alleged violation of abuse.will be reported immediately, but no later than: Two (2) hours.or Twenty -four (24) hours.

Based on observation, interview and record record review, the facility failed to ensure four of 21 sampled residents (Residents 108, 53, 1, and 10) in a census of 61 privacy when curtains did not reach around personal space and vertical blind slats were missing. These failures resulted Resident 10 felt ashamed and increased the potential for increased feelings of reduced self esteem and embarrassment. Findings: Resident 108 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness and difficulty walking. During a review of Resident 108's Minimum Data Set (MDS, an assessment tool), dated 3/4/25, the MDS indicated Resident 108 had moderate memory impairment. During a review of Resident 108's care plan (CP), titled Potential for alteration r/t [related to] .ADL support for .toileting ., dated 3/6/25, the CP indicated Provide privacy . During a concurrent observation and interview in a shared bedroom on 3/10/25 at 9:02 a.m., as Resident 108's curtains were being checked for coverage of the resident's personal space, Resident 108 began independently disrobing at her bedside. The curtains did not reach around her bed and she was visible from the hallway with her upper body naked and exposed. Resident 108 was asked how it made her feel and she responded, Not good! Resident 53 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 had moderate impairment of her memory. During a review of Resident 53's CP, untitled, dated 1/27/25, the CP indicated MAINTAIN RESIDENT'S PRIVACY . During an observation of Resident 53's personal space on 3/10/25 at 9:03 a.m., the privacy curtains did not reach around the bed for privacy and one slat of vertical blinds was missing across sliding door with the courtyard visible outside. During a concurrent observation and interview on 3/10/25 at 9:04 a.m. with the Social Services Assistant (SSA), the SSA verified the curtain did not reach around residents space and a vertical blind was missing, so that Resident 108 and Resident 53 did not have complete privacy. During an interview on 3/10/25 at 10:58 a.m. with Resident 53, Resident 53 stated, That missing slat bothers me. I've mentioned it several times [to staff]. I don't know why they haven't replaced it .You can see directly into [Resident 108 and Resident 53's] room from across the patio from another room. I've seen it [from another room across the courtyard]. Resident 1 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderate impairment of her memory. During a review of Resident 1's CP, titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 1/17/25, the CP indicated Provide privacy . During a concurrent observation and interview on 3/10/25 at 9:30 a.m. with Resident 1, a slat was missing from the vertical blinds covering a window. Resident 1 stated, At night I don't like it because I think people are spying on me. I've seen people out there [on the patio] . Resident 10 was admitted to the facility in the fall of 2024 with diagnoses which included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 10's CP titled ALTERATION IN ELIMINATION .ADL support for .toileting ., dated 11/26/24, the CP indicated Provide privacy . During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident had severe memory impairment. During an observation on 3/10/25 at 9:58 a.m. Resident 10 was observed from the doorway of the bedroom while she was being changed. The privacy curtain was pulled forward on both sides but at the foot of the bed, the resident's perineal [the bottom region of your pelvic cavity] area was visible from the doorway. Resident 20's back, buttocks and perineal area were exposed. During a concurrent observation and interview on 3/10/25 at 10:01 a.m. with Certified Nurse's Assistant (CNA)1, CNA 1 acknowledged Resident 10 's bottom was exposed, yet CNA 1 continued to change Resident 10 without pulling the moveable curtain (available at the foot of a roommate's bed), as other people walked in the hallway past the open doorway of Resident 10's room. CNA 1 indicated the curtain was for use to provide privacy for each of the three residents in the room and verified it could be pulled across the foot of each bed. CNA 1 stated she didn't want to bother [to pull it across] because it got her roommate, upset when you move her stuff around. During an interview on 3/11/25 at 9:09 a.m. with Resident 10, Resident 10 was asked how the exposure made her feel. Resident 10 indicated she felt ashamed when people saw her being changed and wanted privacy. Resident 10 also indicated the staff only used the two side curtains. They did not cover the foot of the bed when they changed her. Resident 10 indicated even her roommates saw her when [staff] did not pull the curtains at the foot of the bed. During an interview on 3/10/25 at 10:22 a.m. with the Administrator (ADM), the ADM stated his expectations for privacy was, Residents should be given privacy when being changed or cared for. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON stated, Curtains should be pulled all the way around for privacy. During a review of the Maintenance Log (ML), dated 1/25, 2/25 and 3/25, no entry was found for repair of the curtains or blinds in the rooms of Residents 108, Resident 53, or Resident 1. During a review of the facility policy and procedure (P&P), dated 2/24, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, feeling of self worth and self esteem .promote and protect resident privacy, including bodily privacy during assistance with personal care .

Based on observation, interview and record review, the facility failed to accurately label medications for a census of 61 when: 1. Resident 54's insulin order was not reflected correctly on the medication label, and 2. The medications lacked resident labels and open dates, and the label was unclear and difficult to read. These failures had the potential for residents to receive the wrong medications, incorrect dosages of medications, and expired medications. Findings: 1. During a concurrent observation and interview on 3/11/25 at 8:55 a.m. during medication administration with Licensed Nurse ( LN 1), LN 1 administered 14 units (unit of measurement) of Humulin N (is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes [a chronic condition that affects the way the body processes blood sugar]) 100Units/ml (milliliter, unit of measurement) to Resident 54. The resident's medication label both on the box, and the vial indicated inject 10 units . LN 1 verified in Resident 54's Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident) included the physician order for Humulin N 14 units every morning and 14 units every night. LN 1 confirmed that Resident 54 had a change to their medication dosage and that it was not correctly reflected on Resident 54's medication label. During an interview on 3/13/25 at 10:46 a.m. with the Director of Nursing (DON), the DON was asked what the expectations were for labeling medications with a change in order. The DON stated, If the order changes, per policy, we need to place a sticker, 'change in direction', that will be put on the medication. The DON stated that the pharmacist should be called for a new, accurate resident label and that the label would be delivered during the scheduled delivery time. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy .Labels for individual resident medications include all necessary information such as .cautionary statements .The nursing staff must inform the pharmacy of any changes in physician orders for a medication . 2. A concurrent observation and interview on 3/11/25 at 2:23 p.m. with LN 1, one of two medication storage carts was inspected. During the observation, one bottle of Biktarvy (a medication to treat human immunodeficiency virus [HIV]) 50 mg/200 mg/25 mg (milligram, unit of measurement), two Breyna Inhalation Aerosol (inhaler, a medication that is delivered in a fine mist and inhaled through the mouth and into the lungs) 160 mcg/4.5 mcg(microgram, unit of measurement), and one unidentifiable inhalation aerosol were found with no resident labels. One Symbicort Inhalation Aerosol 160 mcg/4.5 mcg was found with an resident label that was difficult to read. Two Anoro Ellipta Inhalation Powder (a dry, powdered form of medication that is inhaled into the lungs) 62.5 mcg/25 mcg, and one bottle of Lidocaine Viscous 2% Oral Topical Solution (a medication used to treat pain in the mouth or throat) were found without open dates. LN 1 confirmed that the three inhalation aerosols and the Biktarvy were missing resident labels and Lidocaine and inhalation powder had no open dates, and one label on an inhalation aerosol were difficult to read. During an interview on 3/13/25 at 10:46 a.m. with the DON, the DON was asked what the expectations were regarding illegible labels, open date labeling, and medications with no resident label. The DON stated that you should be able to read the label. The DON confirmed that the label on the inhaler was difficult to read and needed to be replaced. The DON stated that if a medication was not labeled, the pharmacy needed to be contacted and the medication to be verified with the pharmacy. Further stating, The medication should be sent to the pharmacy for confirmation, and to be properly labeled. The DON stated once a medication was opened, an open date needed to be labeled on the medication. The DON confirmed that there were no open dates on the Lidocaine and both inhalation powders, and that she expected them to be discarded. The DON confirmed that the three inhalation aerosols had no resident labels. During a review of the facility's P&P titled, Labeling of Medication Containers, dated 2001, the P&P indicated, Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. During a review of the facility's P&P titled, Storage of Medications, dated 2001, the P&P indicated, Drug containers that have missing, incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storing.

Based on interview and record review, the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for one of three sampled residents (Resident 35) when two tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for drug diversion (when healthcare staff obtain and use prescription medicines illegally), and inaccurate monitoring of the amount and frequency of medications given to the resident. Findings: Resident 35 was admitted to the facility in 2019. Current principal diagnosis was acute respiratory failure (when the body does not get enough oxygen or there is too much carbon dioxide in the body). During a review of Resident 35's physician orders (PO) dated 3/13/25, the PO indicated, Percocet (oxycodone-acetaminophen, medications used to relieve pain) Oral Tablet 10-325 MG (milligram, unit of measurement, used for medication dosage and/or amount) Give 1 tablet .every 4 hours as needed for .pain. During a review of Resident 35's CONTROLLED DRUG RECORD (CDR), Individual Patient's Narcotic Record (a form that keeps count of the number of narcotics dispensed to a resident), indicated one tablet of Percocet was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 2/23/25 at 10:06 a.m. and one table of Percocet was removed on 2/27/25 at 6:45 p.m. During a review of Resident 35's MAR dated 2/1/25 - 2/28/25, the MAR did not show documentation of Percocet being administered on 2/23/25 at 10:06 a.m. or on 2/27/25 at 6:45 p.m. There were a total of two Percocet that were signed out from the narcotic medication card but were not documented as given to Resident 35. During a concurrent interview and record review on 3/13/25 at 10:39 a.m. with the Director of Nursing (DON) of Resident 35's records, the DON confirmed the CDR documentation did not match the MAR documentation. The DON confirmed there was no way of knowing if narcotics were given to Resident 35, and it should have been documented in the residents MAR if given. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, dated 2001, the P&P indicated, Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose .

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 34) received a thorough monthly pharmacy medication regimen review (MRR). This failure placed Resident 34 at risk for receiving unnecessary, ineffective, and/or excessive dose of Lorazepam (a psychotropic medication to treat anxiety). Findings: Resident 34 was admitted to the facility with diagnoses including thickening and hardening of the walls of the arteries in the brain and anxiety disorder. Review of the admission MDS (Minimum Data Set, an assessment tool) indicated the resident scored 5/15 in the BIMS (Brief Interview for Mental Status, a cognitive assessment) which suggested he had severe cognitive impairment. Review of Resident 34's medical record indicated the resident had a physician order, dated 5/31/24, for Lorazepam 0.5 MG (milligram) to give 1 tablet by mouth every 6 hours as needed for anxiety for 14 day(s). There was no physician order to renew Lorazepam 0.5mg 14 days after the 5/31/24 order until 10/12/24. Review of the Medication Administration Record (MAR) from May 2024 through October 2024 indicated Resident 34 received Lorazepam 0.5 mg until 10/3/24. During a concurrent interview and records review on 3/12/25 at 9 a.m., with the Director of Nursing (DON), the DON confirmed that as needed Lorazepam 0.5mg was ordered on 5/31/24 for a 14-day period, but it continued to be administered until 10/3/2024 for Resident 34 without a physician order for continuation. The DON also verified there had been no monthly MRR for Resident 34 from May 2024 through December 2024 and acknowledged the irregularities in Lorazepam administration could have been identified by the pharmacist, had the MMR been performed. In a telephone interview on 3/12/2025 at 2:12 p.m., with the Pharmacy Consultant (PC), the PC confirmed the monthly MRR was not provided for Resident 34 from May 2024 through October 2024 and acknowledged MRR should have been provided monthly. The PC stated, It [Lorazepam 0.5 mg] was ordered for 14 days, my understanding is that when it's written that way it should automatically stop [after 14 days]. During a review of the Facility's May 2019 policy and procedure (P&P), Medication Regimen Reviews, indicated, The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .the Consultant Pharmacist provides a written report to the attending physicians .the report contains .d. The pharmacist's recommendation. During a review of the facility's P&P titled, Psychotropic Medications Use, dated April 8, 2022, the P&P indicated, .PRN orders for psychotropic drugs are limited to 14 days .Pharmacy will review psychotropic medication usage on admission, monthly, and as needed.

Based on observation, interview and record review, the facility failed to ensure infection prevention and control program were maintained and to provide a sanitary environment when two lounge chairs in the dining/activity room were worn out, threadbare and available for resident use. This failure increased the risk for the transmission of communicable diseases. Findings: During an observation on 3/10/25 at 12:03 p.m., two large wing-back lounge chairs made of imitation leather were badly worn with mesh and foam showing through and available for use in the dining/activity room for use. Resident 51 was seen moving between and sitting in both lounge chairs. During a concurrent observation and interview on 3/10/25 at 12:05 p.m. with the Infection Preventionist (IP), the IP verified observation and stated, The lounge chairs used to be covered in leather. [The material] appears to be man made with the fabric lining and foam showing through. It can't be sanitized properly due to the mesh fabric. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON was asked her expectations and stated, When the furniture is worn, we need to replace because it [because we] can't sanitize it. During an interview on 3/13/25 at 10:03 a.m. with the Maintenance Supervisor (MS), the MS was asked if the worn lounge chairs had been put in the maintenance log and he stated, No one reported the two lounge chairs upholstery was deteriorating . During a further interview on 3/13/25 at 10:56 a.m. with the IP, the IP said, We were aware [of the deterioration of the lounge chairs] . The IP also indicated that multiple residents used the lounge chairs. During a review of the Maintenance Log, dated 1/25, 2/25 and 3/25, no request for repair or replacement of the two worn lounge chairs was found. During a review of the facility policy and procedure (P&P), titled Infection Control, revised 10/24, the P&P indicated The objectives of our infection control policies and practices are to .Prevent .infections in the facility .Maintain a .sanitary .environment for .residents .

Based on interviews and record reviews, the facility failed to ensure the physician ' s order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/10/24 indicated intact cognition. A review of Resident 1 ' s pain monitoring on the electronic medical record (EMAR, an electronic health record that keeps track of when medications are given to the residents) for 11/2024 indicated Resident 1 complained of pain 26 out of 27 days since his admission on 11/3/24. Resident 1 ' s EMAR for 11/2024 indicated an order for oxycodone (narcotic, analgesic) 5 milligram (mg, unit of measure) 1 tablet every 6 hours as needed (PRN) for severe pain. A review of Resident 1 ' s pain monitoring on the EMAR for 12/2024 indicated Resident 1 complained of pain 24 out of 26 days from 12/1/24 up to 12/26/24. Resident 1 ' s EMAR for 12/2024 indicated an order for oxycodone 5 mg half (1/2) tablet every 6 hours PRN-start date of 11/29/24 and discontinued date of 12/13/24, for moderate pain. Resident 1 ' s EMAR for 12/2024 also indicated an order for oxycodone 5 mg 1/2 tablet every 4 hours PRN -start date of 12/13/24 for moderate pain. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated staff did not know how to adequately manage his pain. Resident 1 stated he knew he was undermedicated for pain. Resident 1 stated nurses were not following the doctor ' s order for pain management, or they just don ' t bother to read the order. Resident 1 stated due to staff not following the physician order for his pain management, his pain was not adequately controlled. During a concurrent interview and EMAR record review for 11/2024 and 12/2024 on 12/26/24 at 2:46 p.m., the Director of Nursing (DON) stated the facility uses a numeric rating scale (NRS, consist of a series of numbers rating pain intensity, typically from 0 to 10) when identifying pain intensity. The DON stated the facility interprets a pain level (PL) of 1 to 3 to indicate mild pain, a PL of 4 to 6 to indicate moderate pain and PL of 7 to 10 indicate severe pain. The DON stated pain medications were administered based on severity parameters as ordered by the physician. The DON stated it was important to follow the physician ' s orders for pain management so resident could achieve optimal pain relief. The DON stated this was important to improve residents ' quality of life. A concurrent interview and 12/2024 EMAR record review with the DON indicated on 12/26/24 at 2:46 p.m. indicated oxycodone 5 mg 1/2 tablet by mouth every 6 hours PRN for moderate pain (start date of 11/29/24 and dc date of 12/13/24) was given to the resident on 12/7/24 for a PL 7, 12/11/24 for a PL 8, 12/12/24 for a PL 8, 12/13/24 for a PL 9. The DON verified MD ordered was not followed since Resident 1 was complaining of severe pain and not moderate pain. A review of 12/2024 EMAR with the DON indicated oxycodone 5 mg 1/2 tablet by mouth every 4 hours PRN for moderate pain, start date of 12/13/24, was administered to Resident 1 on 12/14/24 two times when he complained of PL 7 and 8, on 12/17/24 for a PL 9, on 12/21/24 for a PL 7 and on 12/24/24 for PL 2. The DON verified staff did not the follow the physician ' s order. A review of the numeric rating scale adopted from [NAME], [NAME] et al. 1989 indicated 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. A review of the facility ' s policy and procedure (P&P) titled Pain Assessment and Management, revised 3/2020, the P&P indicated, . the pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident choices related to pain management . A review of the facility ' s P&P titled Administering Medications, revised 4/2019, the P&P indicated, . medications are administered in accordance with prescriber orders . Based on interviews and record reviews, the facility failed to ensure the physician's order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1. Findings: A review of Resident 1's face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/10/24 indicated intact cognition. A review of Resident 1's pain monitoring on the electronic medical record (EMAR, an electronic health record that keeps track of when medications are given to the residents) for 11/2024 indicated Resident 1 complained of pain 26 out of 27 days since his admission on 11/3/24. Resident 1's EMAR for 11/2024 indicated an order for oxycodone (narcotic, analgesic) 5 milligram (mg, unit of measure) 1 tablet every 6 hours as needed (PRN) for severe pain. A review of Resident 1's pain monitoring on the EMAR for 12/2024 indicated Resident 1 complained of pain 24 out of 26 days from 12/1/24 up to 12/26/24. Resident 1's EMAR for 12/2024 indicated an order for oxycodone 5 mg half (1/2) tablet every 6 hours PRN-start date of 11/29/24 and discontinued date of 12/13/24, for moderate pain. Resident 1's EMAR for 12/2024 also indicated an order for oxycodone 5 mg 1/2 tablet every 4 hours PRN -start date of 12/13/24 for moderate pain. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated staff did not know how to adequately manage his pain. Resident 1 stated he knew he was undermedicated for pain. Resident 1 stated nurses were not following the doctor's order for pain management, or they just don't bother to read the order. Resident 1 stated due to staff not following the physician order for his pain management, his pain was not adequately controlled. During a concurrent interview and EMAR record review for 11/2024 and 12/2024 on 12/26/24 at 2:46 p.m., the Director of Nursing (DON) stated the facility uses a numeric rating scale (NRS, consist of a series of numbers rating pain intensity, typically from 0 to 10) when identifying pain intensity. The DON stated the facility interprets a pain level (PL) of 1 to 3 to indicate mild pain, a PL of 4 to 6 to indicate moderate pain and PL of 7 to 10 indicate severe pain. The DON stated pain medications were administered based on severity parameters as ordered by the physician. The DON stated it was important to follow the physician's orders for pain management so resident could achieve optimal pain relief. The DON stated this was important to improve residents' quality of life. A concurrent interview and 12/2024 EMAR record review with the DON indicated on 12/26/24 at 2:46 p.m. indicated oxycodone 5 mg 1/2 tablet by mouth every 6 hours PRN for moderate pain (start date of 11/29/24 and dc date of 12/13/24) was given to the resident on 12/7/24 for a PL 7, 12/11/24 for a PL 8, 12/12/24 for a PL 8, 12/13/24 for a PL 9. The DON verified MD ordered was not followed since Resident 1 was complaining of severe pain and not moderate pain. A review of 12/2024 EMAR with the DON indicated oxycodone 5 mg 1/2 tablet by mouth every 4 hours PRN for moderate pain, start date of 12/13/24, was administered to Resident 1 on 12/14/24 two times when he complained of PL 7 and 8, on 12/17/24 for a PL 9, on 12/21/24 for a PL 7 and on 12/24/24 for PL 2. The DON verified staff did not the follow the physician's order. A review of the numeric rating scale adopted from [NAME], [NAME] et al. 1989 indicated 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. A review of the facility's policy and procedure (P&P) titled Pain Assessment and Management , revised 3/2020, the P&P indicated, . the pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident choices related to pain management . A review of the facility's P&P titled Administering Medications , revised 4/2019, the P&P indicated, . medications are administered in accordance with prescriber orders .

Based on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1.There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2.Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3.There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). A review of Resident 1 ' s Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) assessment dated [DATE] indicated he had intact cognition. Resident 1 ' s MDS also indicated he needed maximal assistance (staff provides more than half of the effort) when it comes to transfers. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he wished to be discharged from the facility as soon as possible. Resident 1 stated staff did not talk to him about his discharge plan and his preference to go home with his cousin. Resident 1 stated no one from the facility talked to him about being discharged from the facility and what the current plan was. Resident 1 stated for now all he knew was he can ' t be discharged from the facility. Resident 1 stated the facility nurses, and the social services knew he wished to be discharged from the facility. During a concurrent interview and Social Services Initial assessment dated [DATE] record review on 12/26/24 at 4:37 p.m., the Director of Nursing (DON) stated she was aware Resident 1 wished to be discharged from the facility. The DON verified Resident 1 ' s previous discharged plan was to go home; however, it was now changed since Resident 1 had no one to care for him and has limited funding. The DON stated Resident 1 was custodial (non-medical care provided by non-licensed staff and does not require the constant attention of trained medical professional) as of 12/15/24. The DON stated she was aware of Resident 1 ' s desire to be discharged from the facility. The DON was unsure on whether anyone from her team had spoken to Resident 1 about Resident 1 ' s plan to be discharged to his cousin ' s care. The DON was unable to provide documentation about a new DC plan in place for Resident 1. During a concurrent interview and Social Service Director (SSD) note dated 11/8/24 record review on 12/26/24 4:43 p.m., the Minimum Data Set Coordinator (MDSC) verified there were no plans yet on when to discharge Resident 1 from the facility and there was no note to indicate a new plan to discharge Resident 1 from the facility had been initiated at this time. The MDSC stated it was Resident 1 ' s right to be discharged from the facility if he so wished and it was the facility ' s responsibility to ensure safe discharge from the facility. A review of the facility ' s policy and procedure (P&P) titled Transfer or Discharge- Resident Initiated dated 10/2022, the P&P indicated, Resident Initiated Transfer or Discharge means the resident, or the responsible party had provided written or verbal notice of intent to leave the facility .documentation: written or verbal notice of intent to leave the facility, a discharge plan, documented discussion with the resident, or if appropriate, with his/her representative containing details of discharge planning and arrangements . 46132 Based on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1.There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2.Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3.There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions. Findings: A review of Resident 1's face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). A review of Resident 1's Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) assessment dated [DATE] indicated he had intact cognition. Resident 1's MDS also indicated he needed maximal assistance (staff provides more than half of the effort) when it comes to transfers. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he wished to be discharged from the facility as soon as possible. Resident 1 stated staff did not talk to him about his discharge plan and his preference to go home with his cousin. Resident 1 stated no one from the facility talked to him about being discharged from the facility and what the current plan was. Resident 1 stated for now all he knew was he can't be discharged from the facility. Resident 1 stated the facility nurses, and the social services knew he wished to be discharged from the facility. During a concurrent interview and Social Services Initial assessment dated [DATE] record review on 12/26/24 at 4:37 p.m., the Director of Nursing (DON) stated she was aware Resident 1 wished to be discharged from the facility. The DON verified Resident 1's previous discharged plan was to go home; however, it was now changed since Resident 1 had no one to care for him and has limited funding. The DON stated Resident 1 was custodial (non-medical care provided by non-licensed staff and does not require the constant attention of trained medical professional) as of 12/15/24. The DON stated she was aware of Resident 1's desire to be discharged from the facility. The DON was unsure on whether anyone from her team had spoken to Resident 1 about Resident 1's plan to be discharged to his cousin's care. The DON was unable to provide documentation about a new DC plan in place for Resident 1. During a concurrent interview and Social Service Director (SSD) note dated 11/8/24 record review on 12/26/24 4:43 p.m., the Minimum Data Set Coordinator (MDSC) verified there were no plans yet on when to discharge Resident 1 from the facility and there was no note to indicate a new plan to discharge Resident 1 from the facility had been initiated at this time. The MDSC stated it was Resident 1's right to be discharged from the facility if he so wished and it was the facility's responsibility to ensure safe discharge from the facility. A review of the facility's policy and procedure (P&P) titled Transfer or Discharge- Resident Initiated dated 10/2022, the P&P indicated, Resident Initiated Transfer or Discharge means the resident, or the responsible party had provided written or verbal notice of intent to leave the facility .documentation: written or verbal notice of intent to leave the facility, a discharge plan, documented discussion with the resident, or if appropriate, with his/her representative containing details of discharge planning and arrangements .

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to assess a person's cognitive functioning) dated 11/10/24 score was 15 indicating intact cognition. A review of Resident 1 ' s Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment dated [DATE] indicated he had intact cognition and he needed maximal assistance (when a helper/staff member provides more than half of the effort to help a resident complete an activity) when it comes to transfers. A review of the Interdisciplinary Team (IDT, a group of health care professionals from different disciplines who work together to provide care for patients) note dated 11/18/24 indicated during transfer from bed to the shower chair Resident 1 fell while being transferred by the certified nursing assistant (CNA) with the assistance of 4 students. During an interview on 12/26/24 at 12:36 p.m., Licensed Staff (LS) B stated Resident 1 required an assistance of 2 staff during transfers. LS B stated students were not allowed to assist staff with transfers because they were only at the facility to observe. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he fell while a staff member and 4 students attempted to transfer him from bed to the shower chair. Resident 1 stated the students did not know what they were doing. Resident 1 stated there was no coordination and he felt the students yanking him from different directions. Resident 1 stated he knew students should not be assisting with his transfers. Resident 1 stated he fell because instead of 2 staff assisting him during transfers, there was only 1 staff who assisted him and 4 students. Resident 1 stated this compromised his safety. Resident 1 stated the facility did not follow the protocol. During a concurrent interview and IDT note dated 11/18/24 record review on 12/26/24 at 1:16 p.m., the Director of Nursing (DON) verified the IDT note indicated Resident 1 fell during transfer to shower chair while being assisted by a staff and 4 students. The DON stated Resident 1 required the assistance of 2 staff during transfers. When asked if students were allowed to assist CNAs to transfer residents, the DON stated no. A review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risks, Managing revised 3/2018, the P&P indicated, . staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling . 46132 Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24. Findings: A review of Resident 1's face sheet (demographics) indicated an admitted [DATE] to the facility. Resident 1's diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1's Brief Interview for Mental Status (BIMS, a screening tool used to assess a person's cognitive functioning) dated 11/10/24 score was 15 indicating intact cognition. A review of Resident 1's Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment dated [DATE] indicated he had intact cognition and he needed maximal assistance (when a helper/staff member provides more than half of the effort to help a resident complete an activity) when it comes to transfers. A review of the Interdisciplinary Team (IDT, a group of health care professionals from different disciplines who work together to provide care for patients) note dated 11/18/24 indicated during transfer from bed to the shower chair Resident 1 fell while being transferred by the certified nursing assistant (CNA) with the assistance of 4 students. During an interview on 12/26/24 at 12:36 p.m., Licensed Staff (LS) B stated Resident 1 required an assistance of 2 staff during transfers. LS B stated students were not allowed to assist staff with transfers because they were only at the facility to observe. During an interview on 12/26/24 at 1:10 p.m., Resident 1 stated he fell while a staff member and 4 students attempted to transfer him from bed to the shower chair. Resident 1 stated the students did not know what they were doing. Resident 1 stated there was no coordination and he felt the students yanking him from different directions. Resident 1 stated he knew students should not be assisting with his transfers. Resident 1 stated he fell because instead of 2 staff assisting him during transfers, there was only 1 staff who assisted him and 4 students. Resident 1 stated this compromised his safety. Resident 1 stated the facility did not follow the protocol. During a concurrent interview and IDT note dated 11/18/24 record review on 12/26/24 at 1:16 p.m., the Director of Nursing (DON) verified the IDT note indicated Resident 1 fell during transfer to shower chair while being assisted by a staff and 4 students. The DON stated Resident 1 required the assistance of 2 staff during transfers. When asked if students were allowed to assist CNAs to transfer residents, the DON stated no . A review of the facility's policy and procedure (P&P) titled Falls and Fall Risks, Managing revised 3/2018, the P&P indicated, . staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling .

Based on observation, interview, and record review, the facility failed to provide a safe environment for 3 of 17 sampled residents (Residents 25, 34, and 45). a. For Resident 25, two unlabeled cups, containing medication pills, were left unattended on the bedside table. b. For Resident 34, a white oblong pill was left on a plastic spoon unattended on the table. c. For Resident 45, Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) failed to lower the bed to its lowest position after they completed personal care to Resident 45. These failures had the potential to cause serious bodily injuries, and unauthorized access to narcotics (to treat moderate and severe pain) and medications to Residents in the facility. Findings: a. Review of the Admission Record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, current episode mixed, severe, without psychotic features (changes in a person's mood, energy, and ability to function) and Type 2 Diabetes Mellitus with unspecified complications (a problem in the way the body regulates and uses sugar as fuel). Review of Resident 25's active physician order summary as of 6/5/23, indicated the following medications: 1. Order dated 3/24/23, metformin (for type 2 Diabetes Mellitus) extended release (the medication is released slowly over time) twenty-four hour 500 milligram (mg) give 4 tablets by mouth one time a day. 2. Order dated 3/24/23, Allupurinol (for protein in the urine) 300 milligram (mg) give one tablet by mouth one time a day. 3. Order dated 3/24/23, ezetimibe (for elevated cholesterol levels) tablet 10 milligram (mg) give one tablet by mouth one time a day. 4. Order dated 3/24/23, cyanocobalamin (for vitamin B12 deficiency) tablet 1000 microgram (mcg) by mouth one time a day for supplement. 5. Order dated 3/24/23, fenofibrate (to lower high cholesterol levels) 160 milligram (mg) by mouth one time a day. 6. Order dated 3/24/23, lamotrigine (for shaking and bipolar disorder) 25 milligram (mg) give one tablet by mouth one time a day. 7. Order dated 3/24/23, Losartan potassium (for high blood pressure) 100 milligram (mg) give one tablet by mouth one time a day. 8. Order dated 3/24/23, venlafaxine (for anxiety) extended release twenty-four hour 75 milligram (mg) give one tablet by mouth one time a day. During an observation of Resident 25's room on 6/5/23 at 9:35 AM, two unlabeled medication cups containing eight medication pills, were left unattended on Resident 25's bedside table. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/5/23 at 9:38 AM, LVN 1 confirmed she left the two cups of medication pills on Resident 25's bedside table, unattended for thirty minutes. LVN 1 also stated she did not wait for Resident 25 to consume metformin 500 mg, Allupurinol 300 mg, ezetimibe 10 mg, cyanocobalamin 1000 mcg, fenobibrate 160 mg, lamotrigine 25 mg, Losartan potassium 100 mg, and venlafaxine 75 mg. During an interview with the Director of Nursing (DON) on 6/5/23 at 9:45 AM, the DON confirmed Resident 25 did not have a nursing care plan for self-administration of medications. The facility's policy and procedure, titled, Administering Medications, revised April 2019, indicated, Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions and honoring resident choices and preferences, consistent with his or her care plan. Resident may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely . 33922 b. Review of the Admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome. During a concurrent observation and interview with Resident 34 on 6/5/23 8:40 AM, a white oblong pill sitting on a plastic spoon was on a table next to Resident 34's bed. When asked about the pill, Resident 34 stated, That's my Percocet! (opiate/narcotic pain medication) and immediately picked up the pill, put it in his mouth, and swallowed it. Resident 34 stated the night shift nurse, Licensed Vocational Nurse 5 (LVN 5) brought him the Percocet a few hours prior. Resident 34 reported, Sometimes they watch me swallow the pills but sometimes they don't, and I can keep it for later. During a concurrent interview and record review with (LVN 2) on 6/5/23 at 9:44 AM, Resident 34's Medication Administration Record was reviewed. LVN 5 documented he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM. Resident 34's Percocet supply was observed with LVN 2. LVN 2 confirmed Percocet were white oblong pills. During an interview with on 6/8/23 at 7:30 AM, LVN 5 stated Resident 34 was knowledgeable about his medications and could identify which pill was Percocet. LN 5 confirmed he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM, but denied he left the medication at the bedside. LVN 5 further denied noticing an unsecured white pill sitting on Resident 34's table during his shift. During an interview with the Director of Nursing (DON) on 6/8/23 at 8:15 AM, the DON stated it was unacceptable for nursing staff to leave medications unsecured at the resident's bedside, especially controlled medication. The DON stated it was very concerning that Resident 34 reported nursing staff did not always observe him consume his Percocet, because staff needed to know the exact time the medication was consumed. The DON stated, If the resident is saving them for later, there is opportunity for overdose. During a review of Resident 34's Minimum Data Set (resident assessment tool), dated 3/29/23, Resident 34's Brief Mental Status score was 15, which indicated Resident 34 was cognitively intact. During a review of Resident 34's physician's order, dated 4/21/22, indicated Resident 34 could receive one Percocet 10 mg (milligrams)/350 mg Tylenol tablet every four hours as needed. Review of the facility's policy titled, Controlled Medication Storage, dated 2007, indicated, . Only authorized licensed nursing and pharmacy personnel have access to controlled medications . 41816 c. During an observation on 6/6/23 at 8:25 AM, Resident 45 was receiving personal care by CNA 1 and CNA 2. Following the care, the two CNA's left the room. Resident 45's bed was elevated in the highest position, several feet off the floor. During a concurrent observation and interview on 6/6/23 at 8:28 AM, with CNA 1, CNA 1 stated sometimes the residents will accidentally use the button and raise the bed by themselves, and stated Resident 45 could have raised it herself and then referred me to speak with CNA 2. CNA 1 lowered Resident 45's bed back to the lowest position when prompted. During an interview on 6/7/23 at 8:40 AM, CNA 2 stated when she CNA 1 left the room following providing care on 6/6/23, they must have forgotten and did not return Resident 45's bed to the lowest position as they should have. During a review of Resident 45's Care Plan, dated 5/15/23, the Care Plan indicated Resident 45 had a fall risk assessment of 12, with 10 or above being high risk. The Care Plan indicated the environment would be kept free of hazards by facility staff.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for the care and maintenance of a PICC (Peripherally Inserted Central Catheter) (a long catheter that is inserted through the skin into a large vein just above the heart used for administering antibiotics or fluid) for one of 17 sampled residents (Resident 28). As a result of this failure, Resident 28 was at risk for infection and complications from his PICC. Findings: Review of the Admission Record indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included sepsis (blood infection) and pressure ulcers, and Resident 28 required intravenous (IV) antibiotics (medication given through a vein to treat infection). During a concurrent observation and interview with Resident 28 on 6/6/23 at 8 AM, Resident 28 stated he had a PICC for IV antibiotics, which were discontinued approximately two weeks prior. Resident 28 reported the hub (essential part of the catheter where a syringe or medication tubing would connect) of the PICC broke off two days after the antibiotics were discontinued, and a nurse coiled the tubing and placed a dressing over the tubing. Resident 28 stated, No one has done anything with it since, and I am waiting to have it removed. Resident 28 stated he was concerned he was at risk for infection due to the broken PICC. A catheter was observed in Resident 28's right upper chest. There was no hub at the end of the catheter tubing; instead, the catheter end was exposed. The entire length of the exposed catheter tubing was coiled, and a clear tape dressing was placed on top. The dressing was not dated to indicate when it was changed. During an interview with Registered Nurse 3 (RN 3), who was the charge nurse, on 6/6/23 at 1:42 PM, RN 3 stated she was unaware of any issues with Resident 28's PICC. She stated Resident 28 was waiting for a physician's appointment to have the PICC removed. RN 3 stated the PICC dressing should have been changed weekly and flushed per order. RN 3 stated she had just observed Resident 28's PICC and confirmed the hub was broken off and the dressing was not dated. She stated, I'm not sure how long it's been like that, but the resident says it's been a long time. RN 3 stated she was unaware if the physician was notified the PICC was broken. During a concurrent interview and review of Resident 28's record with the Director of Nursing (DON) on 6/8/23 at 8:15 AM: The physician's order, dated 3/18/23, indicated Resident 28 had a PICC in his right upper chest. The order directed staff to change the PICC dressing and hub every Sunday and monitor the insertion site for signs and symptoms of infection. The Minimum Data Set, dated dated [DATE], indicated Resident 28's Brief Mental Status score was 15 (which indicated Resident 28 was cognitively intact). The physician's order, dated 5/24/23, indicated Resident 28's antibiotics were discontinued. Nursing Notes on 5/7/23 and 5/14/23, indicated nursing staff changed Resident 28's PICC dressing. There was no documentation which indicated the PICC had been assessed or the PICC dressing was changed, on 5/21/23, 5/28/23, or 6/4/23. The DON stated she was unaware of any issues with Resident 28's PICC until it was identified during the survey. The DON confirmed there was no documentation of assessments or dressing changes for Resident 28's PICC after 5/14/23, no documentation which indicated the PICC hub was broken, and no documentation the physician was notified. The DON stated the broken PICC placed Resident 28 at risk for bleeding and infection, and staff should have notified her and the physician when the line broke and documented the notification. Review of the facility's policy titled, Central and Midline Dressing Changes, undated, indicated, The following information should be recorded in the resident's medical record: Date and time the dressing was changed . any complications, interventions that were done . Report any signs and symptoms of complications to the provider, supervisor, and oncoming shift .

Based on observation, interview and record review, the facility failed to ensure two of the two residents (Resident 1 and 2) were free from abuse when: 1.The facility did not document, identify and initiate an investigation of Resident 1 ' s complaint of alleged abuse during transfer. 2. Licensed Therapist A was yelling, saying the F word, and telling Resident 2 to deal with the pain during Resident 2's transfer. These failures resulted in Resident 1's suffering from pain, feeling upset and scared and further potential abuse when the alleged perpetrator continued to have access to Resident 1 and other vulnerable residents, and eventually resulted in Resident 2 ' s suffering from pain, embarrassment and humiliation. Findings: 1.A review of Resident 1 ' s face sheet dated 6/24/22, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/23/22 at 1:36 p.m., Resident 1 was observed laying on bed in an upright position, with cast on left lower leg and bandage on the right lower leg. Resident 1 stated that on 6/20/22 during therapy she was transferred from bed to wheelchair via sliding board which she refused and told Licensed Therapist A don ' t as she was scared it would hurt her legs because of broken ankles. Resident 1 stated that her legs hurt more during transfer because her legs got tangled between Licensed Therapist A ' s legs and Licensed Therapist A pulled her hard literally into the wheelchair and she plopped into the wheelchair. Resident 1 stated that during her transfer back to bed, Licensed Therapist A pushed her into the sliding board, and she fell on the bed with her face almost on the bed and the aid caught her and helped her to bed. Then Licensed Therapist A said, you see we got it done, then walked out of the room without asking her if she was okay. Resident 1 further stated she was crying and upset and felt that Licensed Therapist A was a bully and careless. Resident 1 stated that she was worried that her hip replacement would have been damaged due to the transfer because it was hurting from her toes to her right hip and her right leg got swollen during the night after the incident. Resident 1 stated around 5:30 p.m. on 6/20/22, she reported and filed a grievance to the nurse and told her to keep Licensed Therapist A away from her. Resident 1 stated that the following morning of 6/21/22, Licensed Therapist A came back to see her for more therapy, showed up like nothing happened and she told Licensed Therapist A you ' re fired, get out of here. Resident 1 further stated that she was still upset and was in pain because of the incident. A review of Resident 1 ' s Progress Notes dated 6/20/22, did not show documentation that Resident 1 reported of being pushed during transfer on 6/20/22. Progress Notes dated 6/21/22 at 3:30 p.m. indicated, SSD (Social Services Director) took statement of negative interaction with specific staff member. Progress Notes dated 6/21/22 at 5:23 p.m. indicated, Resident was noted with allegation of verbal abuse from last night with staff. During an interview on 6/23/22, at 4:33 p.m., Administrator B stated that Resident 1 ' s incident started as a grievance which he received the following day on 6/21/22 from the SSD. Administrator B was asked what time they addressed the grievance on 6/21/22, and he stated he cannot recall the time. Administrator B stated he called Licensed Therapist A and suspended her around 4:20 p.m. on 6/21/22. Administrator B was asked if there were any other incidents or complains that involves Licensed Therapist A aside from the incidents of Resident 1 and 2 that was reported, and he stated he cannot recall any other incident that involved Licensed Therapist A. During an interview on 6/24/22, at 9:45 a.m., Director of Nursing (DON) C stated that Licensed Nurse D, reported Resident 1 ' s complaint to the Administrator on 6/20/22 because he was the Abuse Coordinator, prior to calling her on 6/20/22 in the evening. DON C stated that on the following day 6/21/22, the investigation was started, and another allegation of abuse happened involving the same staff with another resident (Resident 2). During an interview on 6/24/22, at 9:58 a.m., Administrator B was asked what time Licensed Nurse D reported the complaint to him, and he stated he cannot recall getting a call from the nurse on the day of the incident. Administrator B was asked about the facility process when a rough handling incident was reported to him. Administrator B stated he was the one who define if the incident was rough handling and because it started as a grievance it could be misinterpreted. Administrator B did not explain the facility process for complaint involving rough handling of resident. Administrator B further stated Licensed Therapist A might be rough on Resident 1 during transfer. During an interview on 6/24/22, at 12:23 p.m., Social Services Staff E stated she did not receive a grievance letter or form on 6/21/22 regarding Resident 1 ' s complaint. Social Services Staff E stated somebody told her to see Resident 1 on 6/21/22 and could not remember who told her. Social Services Staff E stated she typed the statement and discussed it with the Administrator and they decided to report it to CDPH (California Department of Public Health). During a concurrent interview and record review on 6/24/22, at 1:35 p.m., Resident 1 ' s Progress Notes dated 6/20/22 were reviewed with DON C. DON C was asked about the expectations from the licensed nurses when a resident reported an incident of rough handling. DON C stated licensed nurses were expected to document the reported incident. DON C further stated that Licensed Nurse D probably forgot to document it. During an interview on 6/24/22, at 2:48 p.m., Licensed Nurse D stated, Resident 1 reported to her on 6/20/22 between 4 p.m. and 5 p.m. with tensed voice and frustrated that she did not want to do therapy that day, but Licensed Therapist A was too persistent. Licensed Nurse D stated that Resident 1 did not like to use the sliding board, but Licensed Therapist A used it anyway. Licensed Nurse D stated that Resident 1 reported that Licensed Therapist A shoved her from the wheelchair using the sliding board. Licensed Nurse D stated she immediately reported the incident to the Administrator and to the Director of Nursing (DON) on that same day. License Nurse D was asked about documentation of the reported incident, and she stated that Administrator B told her they would conduct the investigation first then charting afterwards. During an interview on 6/29/22, at 9:13 a.m., Licensed Therapist A stated that the transfer of Resident 1 from wheelchair to bed did not go well, she lost her balance and they both end up on the bed. Licensed Therapist A stated the next day she went back to Resident 1 and Resident 1 told her that she pushed her and there was some fear on Resident 1. Licensed Therapist A stated that Resident 1 was adamant that she did not want to do the therapy. Licensed Therapist A stated that she worked the entire day on 6/21/22 and nobody spoke to her about Resident 1 ' s complaint against her. And on her way home the Administrator called her, and she thought it was about Resident 2 ' s incident that day and the Administrator threw in Resident 1 ' s incident too and she was suspended. Licensed Therapist A further stated that there were four resident complaints against her in three weeks but cannot remember the names of the residents and should ask the Administrator for the names of the complainants. During an interview on 6/29/22, at 3:30 p.m., Administrator B was asked about staff documentation of alleged verbal abuse instead of physical abuse when Resident 1 complained of being pushed. Administrator B stated that it needs to be clarified because it was a grievance and not an alleged abuse, and he could not comment on staff documentation. Administrator B stated he could speculate on the approach but did not believe that Resident 1 was pushed, and he did not determine that Resident 1 ' s complaint of being pushed was an alleged abuse. During an interview on 6/30/22, at 9:57 a.m., DON C was asked if Resident 1 ' s complaint of being pushed or shoved was considered an alleged abuse and she replied yes, and was reported to the Abuse Coordinator. During an interview on 7/1/22, at 10:21 a.m., CNA H stated that she assisted Resident 1 when the therapist transferred her from wheelchair to bed on 6/20/22. CNA H stated that Resident 1 told her that it was scary and never wanting to go to the wheelchair again. A review of Resident 1 ' s Physical Therapy Treatment Encounter Notes dated 6/21/22, indicated, Barriers Impacting Treatment: Anxiety about slideboard transfer to w/c (wheelchair), pain and fatigue. A review of facility ' s Grievance Procedure dated 11/2016, indicated, 8. If the grievance involves abuse .the ED (Executive Director) is notified immediately, and an investigation begins. A review of facility ' s Abuse Prohibition Notification policy dated 11/2016, indicated, This Center complies with Federal and State requirements to screen, train, prevent, identify, investigate, protect, and report abuse, neglect, mistreatment .4. Alleged violations involving mistreatment, neglect, or abuse .are reported immediately to the Executive Director (ED) and to other officials in accordance with Federal and State law. At the time of an alleged violation, an investigation is initiated. The alleged victim is protected to prevent harm during the investigation. A review of facility ' s Abuse Protection policy dated 9/2017, indicated, The Center protects residents from physical and psychosocial harm during and after an investigation. 1. The Center responds immediately to allegations in order to protect the alleged victim and integrity of the investigation. 5. The Center suspends and/or removes the alleged perpetrator from patient care area immediately. 2. A review of Resident 2 ' s face sheet dated 6/24/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/23/22, at 2:59 p.m., Resident 2 was observed laying on bed with head of bed elevated, and on oxygen therapy. Resident 2 stated that on 6/21/22 he felt embarrassed when two therapists and other staff transferred him from wheelchair to bed. Resident 2 stated that Licensed Therapist A was demeaning she was telling him what he could not do and to deal with the pain and wasn ' t nice. Resident 2 stated that he did not feel safe when he was instructed to put his legs and feet down on the floor during transfer and he was not feeling good, and Licensed Therapist A was yelling and he eventually slipped on the floor and heard Licensed Therapist A said, he wants to go on the floor anyway. Resident 2 stated that all his extremities were exposed while he was laying on the floor and thought his genitalia was exposed too and he felt embarrassed. Resident 2 stated he did not like Licensed Therapist A ' s attitude and style, he just wanted to go back to his bed without pain and embarrassment, and Licensed Therapist A wasn ' t helpful. Resident 2 further stated that he had tremendous pain on his right lower back when he slipped on the floor and lost his appetite because of the incident. During an interview on 6/24/22, at 10:43 a.m., CNA F stated that it was Resident 2 ' s first time getting out of bed when he slid from the wheelchair and was assisted to the floor. CNA F stated that Resident 2 was assisted to the wheelchair during rehabilitation therapy and after 15 minutes, Resident 2 wanted to go back to bed and mentioned that his knees hurt and was not feeling well. Resident 2 mentioned to call fire department to move him back to bed and Licensed Therapist A explained to Resident 2 that they could do the transfer. CNA F stated that during transfer back to bed, Resident 2 did not stand all the way up, his knees were buckling, and Licensed Therapist A said, straighten out your knees, and Resident 2 sat down on the edge of the wheelchair and was assisted to slide down safely on the floor and was helped back to bed. CNA F stated Licensed Therapist A was yelling to direct the situation and said the F word twice. CNA F stated that she comforted Resident 2 when he was back in bed because he was scared. During an interview on 6/24/22, at 12:01 p.m., Licensed Therapist G stated that Resident 2 did not have briefs when he was laying on the floor and when the staff log rolled him to put the sling for the lift to put him back to bed, Resident 2 ' s buttocks were exposed and had a bowel movement while he was on the floor. During an interview on 6/24/22, at 12:21 p.m., CNA F stated that Resident 2 ' s briefs came off when he stood up from the wheelchair during transfer and did not have briefs when he was on the floor. During an interview on 6/29/22, at 9:13 a.m., Licensed Therapist A stated that she lost composure during Resident 2 ' s transfer from wheelchair to bed. Licensed Therapist A stated she was encouraging Resident 2 during therapy, but he had given up on his mind, he did not move, he received a way out of why he cannot move his legs, and she told him it was weakness. Then Resident 2 stood up the second time and did not pivot and then plopped on the wheelchair and slipped forward and they assisted him on the floor. Licensed Therapist A further stated that the incident was intense, and Resident 2 had diarrhea and it was a difficult, humiliating experience for the resident. A review of Resident 2 ' s Progress Notes dated 6/21/22, at 5:58 p.m., it indicated, Resident 2 with allegation of being verbally abused by staff .also c/o (complaint of) feeling embarrassed during transfer . Progress notes dated 6/22/21, at 1:02 p.m., it indicated, Resident 2 felt embarrassed during transfer when one of the staff talking loud in front of other people .I felt she had a threatening demeanor .I feel like throwing up, she yelled at me, I felt she did not have any compassion . A review of facility ' s Notice of Resident Rights Under Federal Law Rights Related to Care and Treatment dated 11/2016, it indicated, 14. The resident has the right to a dignified existence and self-determination. 15. The resident has the right to be treated with respect and dignity. 17. The resident has the right to be free from verbal, sexual, physical, or mental abuse .

Based on observation, interview, facility policy review, and review of manufacturer's guidelines, the facility did not maintain an effective infection control program designed to prevent the development and transmission of disease and infection for a census of 53 residents, staff, and visitors in the facility when: 1. Dietary Staff A did not know how to correctly prepare the disinfecting solution in the kitchen. 2. One of 26 resident rooms was found with a sticky floor, and 7 of 13 bathroom floors were dirty. 3. There was no facility oversight of contracted housekeeping staff who were diluting the quaternary disinfecting solution (antimicrobial agent that kills bacteria, viruses, molds, fungi on solid surfaces and in water) with an unmeasured amount of additional water, after automatic dispenser had mixed the solution. 4. There were no test strips available for housekeeping staff to test effective strength of the quaternary disinfecting solution. 5. There was no Personal Protective Equipment (PPE) accessible for housekeeping staff prior to mixing or using the quaternary disinfecting solution. These failures rose to the level of an Immediate Jeopardy due to potential to cause harm to all 53 residents, staff, family and visitors in the facility from ineffective cleaning/disinfecting of the facility, and/or exposure to toxic chemical, when the quaternary disinfecting solution was not used according to manufacturer's recommendation. IMMEDIATE JEOPARDY was identified on [DATE] at 11:30 a.m. under F441 (Infection Control). The Administrator was verbally notified on [DATE] at 12:05 p.m. The IMMEDIATE JEOPARDY was abated on [DATE] at 1:25 p.m. Findings: 1. During an observation and concurrent interview on [DATE] at 4:30 p.m., when asked to make a new solution of quaternary disinfecting solution, which is an ammonia based solution to disinfect surfaces such as counter tops and equipment, Dietary Staff A chose the green bucket which was full of soap and water rather than the red bucket which contained the quaternary solution. When advised of the mistake, Dietary Staff A chose the red bucket, emptied the solution into the sink, and filled the bucket with the soap and water solution from the automated dispensing machine. When advised of the mistake, Dietary Staff A emptied the soap and water out of the red bucket, filled the bucket with the quaternary solution from the dispensing machine, and tested the solution with a chlorine test strip which was not the correct test strip to test the concentration of the quaternary disinfecting solution. During an interview on [DATE] at 4:35 p.m., the Dietary Department Manager stated that Dietary Staff C did not understand the surveyor. During a review of facility policies on [DATE], the document titled Policy: Infection Control Policies and Practices Published [DATE] indicated that:All personnel are trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use procedures and equipment related to infection control. 2. During initial tour on [DATE] from 9:40 a.m. to 11:00 a.m., the floor of room [ROOM NUMBER] was sticky. While walking across the floor to get to the bathroom a crackling sound was made as the shoe was pulled away from the floor. Bathroom floors of rooms 15, 17, 18, 22, 26, 28, and 4 were dirty and stained. ,[DATE]. During an interview and concurrent observation on [DATE] at 9:05 a.m., Housekeeping Staff E stated the quatenary disinfectant solution was used to clean all surfaces in the facility, as well as the floors. Housekeeping Staff E stated the quatenary solution was dispensed automatically, but staff had to dilute it because it was very strong. Housekeeping Staff E then went to the housekeeping closet to demonstrate the process, but found several items missing. The dispensing hose, gloves, and test strips were not in the housekeeping closet. Housekeeping Staff E proceeded without these items, using a spray bottle under the dispenser to fill the bottle about 2 inches from the bottom, then proceeded to add water to fill the quart sized spray bottle. Housekeeping Staff E stated he was trained to dilute the quatenary solution that way. During an interview and concurrent observation on [DATE] at 9:25 a.m., Housekeeping Staff D stated the quatenary disinfectant solution was used to clean and disinfect rooms, patient equipment, shower chairs, floors, toilets, nursing station, beds, tables, and the hoyer lift (a piece of equipment with a body sling used to lift a resident from bed or chair safely). Housekeeping Staff D was asked how she knew the quatenary solution was effective. She stated that they have test strips to check for the effectiveness of the solution. Housekeeping Staff D was asked to demonstrate the testing process, but was unable to find the test strips. When asked about mixing the quatenary disinfecting solution, Housekeeping Staff D stated she used her fingernail to measure the amount of solution to place into the empty spray bottle from the dispenser, and then filled the remaining space in the quart sized spray bottle with water, because it was very strong solution. During an interview on [DATE] at 12:15 p.m., Director of Staff Development/Infection Control Nurse (DSD/IC Nurse)stated the contracted cleaning service Supervisor H was responsible for his own staff in regard to training and inservices including infection control. Housekeeping staff was allowed to come to DSD/IC Nurse's inservices, but they were not mandatory. DSD/IC Nurse stated if she had a problem with the housekeepers she would go to the contracted cleaning service supervisor to relay any concerns. During an interview and concurrent observation on [DATE] at 3:25 p.m., Housekeeping Supervisor G stated the quatenary solution dispenser automatically mixed the correct portion of water to chemical, and there was no need for staff to manually mix the solution. Housekeeping Supervisor G stated the dispenser was malfunctioning, but he had made the adjustments and the dispenser was now working properly. Housekeeping Supervisor G stated he had test strips to demonstrate the effectiveness of the quatenary solution, but the test strips found in the office of Housekeeping Supervisor H that Housekeeping Supervisor G was prepared to demonstrate were expired. During interview on [DATE] at 5:20 p.m., Administrator stated that the contracted cleaning service Housekeeping and Laundry Supervisor did his own inservices and training for the housekeeping and laundry staff. When asked what member of the facility staff the contracted cleaning Supervisor would report a problem to, Administrator stated that the contracted cleaning Supervisor would report any problems to his supervisor. When asked what the contract indicated for ensuring that services were provided according to needs of the facility, the facility Administrator stated we make sure that our regulations are included in the contract. 5. During an observation on [DATE] at 9:05 a.m., 9:25 a.m., and 3:25 p.m., there were no gloves, gowns, or protective eye/face wear in the housekeeping closet. During the initial tour on [DATE] from 9:40 a.m. to 11:00 a.m., housekeeping staff were observed cleaning toilets, sinks, floors, and the nursing station and was utilizing gloves as the personal protective equipment (PPE). During review of the Material Safety Data Sheet (MSDS), dated [DATE], it indicated: .Hazard Statements .Causes severe skin burns and eye damage. May cause an allergic skin reaction .Prevention: .Keep only in original container. Do not breathe dust/fume/gas/mist/vapors/spray. Wear protective gloves, protective clothing, and eye/face protection. Wash thoroughly after handling. Contaminated work clothing must not be allowed out of the workplace. Handling and Storage: .Precautions for safe handling: This product is not intended to be used without prior dilution as specified on the product label. Keep out of reach of children. Do not handle until all safety precautions have been read and understood. Do not breathe dust/fume/gas/mist/vapors/spray. Do not get in eyes, on skin, or on clothing. Do not eat, drink or smoke when using this product. Wash thoroughly after handling . Use personal protective equipment (gloves, respirators, etc.) as required . During review of the contract between the Facility and contracted Healthcare Services Group, titled (name of contracted housecleaning service) Service Agreement, dated [DATE], indicated: .Healthcare will provide all management, supervision, labor and materials necessary to perform the housekeeping and laundry services on the premises of the Facility . This Agreement supersedes any and all other agreements related to the services provided for herein, either oral or written between the parties hereto with respect to the engagement of Healthcare by the Client and contains all the covenants and agreements between the parties with respect to its subject matter . IMMEDIATE JEOPARDY was identified on [DATE] at 11:30 a.m. under Infection Control. The Administrator was present during notification of the IJ. A request for an immediate action plan was requested. The facility Action Plan for the IMMEDIATE JEOPARDY was accepted on [DATE] at 1:25 p.m., and included: 1. Housekeeping staff were instructed to proceed with cleaning all the room surfaces i.e. bedrails, over bed-table, night stand, handrails, door knobs, and public restrooms with the (name brand) Sani-Cloth Germicidal Disposable wipes by [DATE]. This was to continue until the facility received the quaternary test strips and in servicing was completed. 2. Housekeeping staff were in serviced on proper dilution ratio and proper handling of quaternary solution for cleaning surfaces with return demonstration [DATE]. 3. For those staff not available, they will be in serviced prior to working on the floor. 4. Housekeeping staff, at end of shift will leave 2 spray bottles of cleaning solution in the clean utility room readily accessible for the staff should they need it. 5. Director of Staff Developer will do in services for housekeeping and nursing staff by [DATE] and those staff not available will be in serviced prior to working on the floor. 6. Housekeeping supervisor will assign an Assistant Housekeeping Supervisor on his days off to oversee housekeeping staff. 7. Housekeeping Supervisor will give Executive Director the daily schedule of who is in charge for the day. Executive Director will be notified of any problems the housekeeping Supervisor has regarding disinfecting. 8. Assigned department heads will do a skills check for proper placement of quaternary, proper flow of water, hoses are in place, and use of appropriate testing strip daily times 30 days then weekly to ensure proper procedure is followed. Housekeeping staff will check test strip expiration dates prior to use and check acceptable range of 848 ppm (parts per million) per manufacturer recommendations. 9. Director of Staff Developer/Infection Control Preventionist, Housekeeping Supervisor and Maintenance Supervisor or Nurse Supervisor will conduct Infection Control Rounds daily times 30 days. 10. Executive Director or Director of Nursing reviews the infection control issues at the Daily Stand-Up Meeting for needed resolution and/or follow-up. 11. Infection Control Committee with composition of department managers meet at least monthly or more often as appropriate. Minutes of Infection Control Committee meetings are submitted to the Quality Assurance Performance Improvement (QAPI) Committee every month which reviews, analyzes, and acts as needed upon the information and recommendations from the Infection Control Committee. 12. Housekeeping Skills Checklist was developed and implemented. Based upon the implementation of the Immediate Action Plan, the IMMEDIATE JEOPARDY was abated on [DATE] at 1:25 p.m. The Administrator was present.

Based on observations, interviews, and document review, the facility failed to ensure a designated smoking environment free from accident hazards for four out of 14 sampled residents (2, 4, 5, and 9). The facility allowed wheelchair-bound residents to cross the facility's parking lot and driveway to comply with the facility's new non-smoking policy. This action had the potential to increase risk for accidents and injuries from motor vehicles. During an observation on 3/17/14 at 8 a.m., Residents 2, 4, 5, and 9 exited the facility by the rear door, on Street #1 side. The residents needed to cross the parking lot and the driveway to reach the sidewalk beyond the left side of the drive way (facing the parking lot from Street #1), less than 50 yards from a very highly-trafficked intersection at Street #2 and Street #1. Residents 4, 5, and 9 were wheelchair-bound with an increased potential for incoming and outgoing drivers' inability to see the residents crossing. The driveway and sidewalk along Street #1 were both uneven and cracked in multiple places with sections of missing cement, which could lead to a potentially dangerous situation for wheelchair-bound and walking residents. During an interview on 3/17/14 at 8:15 a.m., Resident 4 stated the facility changed its policy, becoming a nonsmoking building, and in order to smoke, residents were to sign out (after completion of a smoking assessment, to measure the ability to independently manage both the igniting and smoking of cigarettes) to leave facility property. Resident 4 stated the facility would not assume responsibility for residents once off the property. Resident 4 and 5 both stated there was no shelter from any environmental elements and crossing the drive way was dangerous when cars were entering or exiting the parking lot. Residents 4 and 5 stated that the pavement and broken, uneven sidewalk made it very difficult to get across the parking lot without help. During an interview on 3/17/14 at 10:30 a.m., Management Staff A stated the facility had adopted a non-smoking policy. The residents were evaluated for cognition and level of independent function, and if deemed independent, residents signed consents to exit the facility property to smoke. Management Staff A stated that the facility could not provide a safe location for the residents who continued to smoke, without them needing to cross the parking lot unsupervised. Management Staff A offered no response when asked about residents' safety when crossing the driveway and the entrance to the parking lot to arrive at the sidewalk area beyond the driveway. During document review on 3/18/14 at 2:30 p.m., Residents 2, 4, 5 and 9's medical records reflected evaluations that deemed them independent to leave the facility provided they signed out on the, "Temporary Absence Document," in each respective chart. During an observation and concurrent interview on 3/18/14 at 3:30 p.m., Residents 4 and 5 were seated at the far edge of the parking lot on the sidewalk furthest from the facility parking lot. During the interview a car entering a parking space came within three feet of their chairs, and multiple vehicles rounding the corner of Street #2 and Street #1 came within less than three feet from where Residents 4 and 5 were seated. Resident 4 stated he fell from his wheelchair recently when he overcorrected steering his motorized wheelchair to avoid a car exiting a parking space. An unidentified member of the dietary staff had to help him get back into his wheelchair. During an interview on 3/19/14 at 9 a.m., Management Staff A stated she was aware residents did not consistently sign the temporary release policy document. Management Staff A stated residents could be seen crossing the parking area and driveway and she knew residents were at risk when exiting in wheelchairs and navigating the uneven pavement to reach the area of the sidewalk beyond the edge of the property. During a review of a facility document on 3/19/14 at 10 a.m., titled, "Temporary Absence Release," located in Residents 2, 4, 5, and 9's medical records, revealed the policy was not being enforced. The survey team called an Immediate Jeopardy (IJ) on 3/19/14 at 1:30 p.m., with Management Staff A, C, and D present. On 3/19/14 at 4:15 p.m., a facility document review of the new smoking policy was obtained and approved by the survey team. The facility's plan of action to abate the IJ indicated: 1. Residents who requested to smoke would be evaluated for cognition; 2. Residents would be permitted to smoke in the staff- designated smoking area; 3. Residents must be supervised by staff while going to and returning from the designated smoking area; and 4. Residents would be provided with the appropriate protective equipment to prevent burns and the possibility of fire. Management Staff A was notified that the Immediate Jeopardy was abated on 3/19/14 at 4:30 p.m. During an observation on 3/19/14 at 4:45 p.m., the designated smoking had been equipped with smoking aprons, a fire blanket, ash trays, a metal cigarette butt can, a fire extinguisher, and a designated smoking area sign. During an observation on 3/19/14 at 5 p.m., a staff member accompanied Resident 5 across the parking area to the designated smoking area, waited with Resident 5 while he smoked, and escorted him back into the facility when he was done. During a concurrent observation and interview, for a tour to the water and gas shutoff valves, outside the facility building on 3/17/14 at 7:05 a.m., a resident was smoking without supervision in the facility parking lot. The resident was standing against the wall of the south side of the facility, with a walker near the facility rear door. Unlicensed Staff J validated the observation and identified the resident by his first name. Unlicensed Staff J did not say anything to the resident regarding smoking. During an observation on 3/17/14 at 8:35 a.m., Resident 4 and Resident 5 were smoking without supervision on the sidewalk near the facility parking lot entrance. Both residents used wheelchairs for locomotion. During a concurrent interview, both Resident 4 and Resident 5 stated they had to be off the facility property to smoke. They said the facility staff smoked in an area inside the facility parking lot. The staff smoking area, where the residents described, had chairs and a table. During an observation on 3/17/14 at 1 p.m., Resident 2 and another resident were smoking without supervision on the sidewalk near the facility parking lot entrance. Resident 2 used a wheelchair for locomotion. During a subsequent interview on 3/19/14 at 8:25 a.m., Resident 2 stated the facility staff told her to go off the property to smoke. She stated she previously had to sign out for smoking, but not anymore. She stated she usually went for smoking with a fell ow resident, but the resident went home. Resident 2 stated she needed to go out for smoking with somebody and did not know what to do now since her friend went home. During a resident interview on 3/18/14 at 9 a.m., Resident 4 stated the facility staff told him to smoke off the property on the sidewalk. He stated smoking on the sidewalk was dangerous, and he almost got hit by a car twice. He stated the facility staff had a place to smoke, but it was not for residents' use. Resident 4 stated the facility staff said it was dangerous for the residents to go across the parking lot to the staff smoking area, but he thought it was dangerous for residents who smoked on the sidewalk. He stated he did not want to transfer to another facility nor did he want to quit smoking. During an interview on 3/19/14 at 9:35 a.m., regarding residents' smoking, Licensed Staff O stated she often saw residents, including Resident 2, Resident 4, and Resident 5, smoking on the sidewalk or inside the parking lot, near the sidewalk on the left of the parking lot. She stated she also saw them smoking at the facility parking lot, against the wall, near the facility rear door. During a review of Resident 2's clinical record, the March 2014, Physician order [REDACTED]. During a review of Resident 5's clinical record, the March 2014, Physician order [REDACTED].