Every finding on record at Sun Mar Nursing Center

Based on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. * The facility failed to ensure the ice machine was not cleaned and sanitized according to the manufacturer's instructions. This failure had the potential for the essential equipment to not function in the way they were intended and in turn cause contamination of food, leading to illnesses for the residents. Findings: Review of the facility's matrix (undated) showed 63 residents consumed food prepared in the kitchen. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Review of the ice machine manufacturer guidelines titled Hoshizaki American, Inc. Instruction Manual dated 1/15/14, showed the following: 1. Cleaning Procedure 1. Dilute 5 fl. oz. (148 ml) of recommended cleaner Hoshizaki Scale Away with 1 gallon (3.8 liters) of water. 2. Sanitizing Procedure - Following Cleaning Procedure 1 .Dilute approximately 0.5 fl. oz. (15 ml or 1 tbsp) of a 5.25% sodium hypochlorite solution (chlorine bleach) with 1 gallon (3.8 liters) of warm water. On 8/25/26 at 1009 hours, an observation of the ice machine, interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated sanitizing (reducing the number of harmful microorganisms on a surface to a safe level) the ice machine was performed once a month and Outside Vendor 1 cleaned (remove food, dirt and grease) the machine every six months. When asked how sanitizing was performed, the Maintenance Director stated the ice machine was turned off, all parts were removed and parts were cleaned using Nu Calgon Sanitizing Concentrate (sanitizing solution). The Maintenance Director reviewed the Hoshizaki American, Inc. Instruction Manual Sanitizing Procedure - Following Cleaning Procedure Step 1 and verified the manufacturer guidelines (instructions and recommendations provided by the company that makes a product or piece of equipment) required a diluted bleach solution. The Maintenance Director verified that the required solution was not being used to sanitize the ice machine. When asked why bleach was not used, the Maintenance Director stated Outside Vendor 1 advised not using bleach. The Maintenance Director verified the Nu Calgon Sanitizing Concentrate was not to be used per manufacturer guidelines. On 8/25/26 at 1015 hours, a telephone interview was conducted with Outside Vendor 1. Outside Vendor 1 stated the cleaning was performed once a month for the ice machine. When asked which chemical was used, Outside Vendor 1 stated Manitowac Ice Machine Descaler (solution used to remove lime scale and mineral deposits). The Hoshizaki American, Inc. Instruction Manual Cleaning Procedure Step 1 was reviewed with Outside Vendor 1. Outside Vendor 1 verified the instructions required Hoshizaki Scale Away diluted with water. Outside Vendor 1 verified the recommended chemical was not used. When asked why a non Hoshizaki product was used, Outside Vendor 1 stated it was used because it was what the facility had available. On 08/26/2026 at 1029 hours, an interview was conducted with the RDN. The RDN stated the chemicals used to clean and sanitize the ice machine should match the recommendations in the Hoshizaki American, Inc. Instruction Manual.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident care was provided in a manner that maintained and enhanced the dignity for one of eight residents observed during dining (Resident 25). * The facility failed to ensure CNA 1 was seated at eye level with Resident 25 while assisting the resident with eating. This failure had the potential to negatively impact Resident 25's sense of dignity, self-worth, and well-being.Findings: Review of the facility P&P titled Promoting/Maintaining Resident Dignity dated 5/7/26, showed it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff member are involved in providing care to residents to promote and maintain resident's dignity and respect resident rights. On 8/25/26 at 1233 hours, Resident 25 was observed being assisted with eating by CNA 1 in Resident 25's room. CNA 1 was seated on a chair positioned higher than the resident's bed and was not at eye level with Resident 25 during the meal. Medical record review for Resident 25 was initiated on 8/25/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 6/18/26, showed Resident 25 had no capacity to understand and make medical decisions. Review of Resident 25's MDS assessment dated [DATE], showed Resident 25 was dependent on the staff for eating. On 8/25/26 at 1308 hours, an interview was conducted with CNA 1. CNA 1 verified being seated higher than Resident 25's bed and not at eye level with the resident. When asked about the facility's expectations for assisting residents during meals, CNA 1 stated the staff were expected to be seated at eye level with residents while assisting them with eating. On 8/27/26 at 0941 hours, an interview was conducted with the DON. When asked about the facility's practice for assisting the residents with eating, the DON stated the staff were expected to be seated at eye level with the resident to promote dignity during meals. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents and/or resident representatives were provided with the right to self-determination for one of five sampled residents reviewed for unnecessary medications (Residents 7). * The facility failed to ensure the informed consent for the Abilify (antipsychotic medication) specified nonpharmacological interventions to be provided to Resident 7. This failure had the potential to compromise the resident's right, or the right of the designated representative, to be fully informed regarding the psychotropic medication, including possible nonpharmacological approaches, in order to make an informed decision.Findings: Review of the AFL 25-27 titled AB 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 10/7/25, showed the prescriber must share the material information a reasonable person in the resident's condition and circumstances would consider necessary for the resident or representative to make a decision about the treatment. Material information that the provider shall provide includes but is not limited to how the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. The AFL also showed the facility must check the medical record for proper informed consent prior to an initial administration. Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by 1/1/26, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 2/2026 showed to include reasonable alternative mode(s) of treatment or possible nonpharmacological approaches that could address the Resident's needs. Review of the facility's P&P titled Informed Consent dated 5/7/26, showed the facility to uphold the rights of the residents to participate in the planning and decision-making process concerning their care and treatment. Under the section psychotherapeutic medications or physical restraint showed the information provided to the resident / health care decision maker regarding a decision concerning the administration of a psychotherapeutic medication or physical restraint or device shall include the reasonable alternative intervention and risks, and why the health professional recommending the treatment. Medical record review for Resident 7 was initiated on 8/25/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 7/2/26, showed Resident 7 had no capacity to understand and make medical decisions. Review of Resident 7's Order Summary Report showed a physician's order dated 9/15/21, to administer Abilify 15 mg one tablet by mouth at bedtime for schizophrenia as manifested by episode of delusional thinking that people are trying to harm me. Review of Resident 7's Psychotherapeutic Drug Inform Consent Form showed a consent for Abilify 15 mg, one tablet by mouth at bed time. The informed consent form showed Resident 7's representative was informed on 6/1/26. Under the section titled Reasonable alternative mode of treatment or possible non pharmacological approach that could address the resident's needs, the form noted provide non pharmacological intervention for any mood and behavior and monitor behavior. Further review of the form did not identify any specific reasonable alternative treatments or non-pharmacological approaches that could address the resident's needs. On 8/26/26 at 1023 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 7 had been receiving the Abilify medication and that the informed consent did not identify any possible nonpharmacological approaches to address the resident's needs for which the medication was prescribed. On 8/27/26 at 0941 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure assistance in the formulation of an advance directive was offered for three of four final sampled residents (Residents 2, 9, and 37) reviewed for advance directives. * The facility failed to ensure assistance in the formulation of an advance directive was offered for Residents 2, 9, and 37. These failures had the potential for the residents' healthcare decisions and treatment preferences to be unknown, undocumented, and not honored. Findings: Review of the facility's P&P titled Resident Rights Regarding Treatment and Advance Directives revised 5/7/26, showed on admission, if the resident has not executed an advance directive and is cognitively able to formulate one, ask the resident if they would like to formulate an advance directive. In addition, the P&P showed the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical surgical treatment and to formulate an advanced directive. On admission, the facility will determine if the resident has executed an advance directive, and if not determine whether the resident, if cognitively able to, would like to formulate an advance directive. 1. Medical record review for Resident 2 was initiated on 8/25/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/20/26, showed the resident had the cognitive capacity to understand and make medical decisions. Review of Resident 2's POLST dated 7/22/26, signed by Family Member 1, showed the resident had no advance directive. Review of Resident 2's Advance Directive Acknowledgment form dated 8/11/26, signed by Resident 2 and witnessed by the Assistant Administrator showed the resident had no advance directive and acknowledged being informed of the rights to formulate an advance directive. However, further review of the resident's medical record failed to show the facility had asked the Resident 2 if an advance directive was desired or offered assistance in formulating one. On 8/26/26 at 0936 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated the usual process was to ask the resident during the care conference if they would like to formulate an advance directive, and if so, the SSD would notify the Ombudsman for assistance. The SSD reviewed Resident 2's medical record, verified the resident had the cognitive capacity to formulate an advance directive. The SSD stated the advance directive was offered it and declined. However, the SSD was unable to provide documentation to show the resident was offered or that assistance to formulate an advance directive was declined. On 8/26/26 at 0949 hours, an interview and concurrent medical record review was conducted with the Assistant Administrator. The Assistant Administrator stated the Advance Directive Acknowledgment form was part of the admission packet and was reviewed with residents. The Assistant Administrator stated when reviewing the form with the residents, the residents are not asked if they would like to formulate an advance directive; the process only included asking whether an advance directive already existed. If the resident did not have an advance directive, and the resident had capacity, the SSD was responsible for follow-up. On 8/26/26 at 1204 hours, an interview was conducted with Resident 2 using a telephone interpreter in Foreign Language 1. Resident 2 stated not having heard about advance directives or what they were. 2. Medical record review for Resident 9 was initiated on 8/25/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Advance Directive Acknowledgement dated 4/14/26, showed Resident 9 had not executed an advance directive. However, the document did not indicate whether Resident 9 was offered the opportunity to formulate an advance directive, or whether Resident 9 accepted or declined assistance to formulate an advance directive. Review of Resident 9's H&P examination dated 4/16/26, showed Resident 9 had fluctuating capacity to understand and make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 was cognitively intact. On 8/26/26 at 1239 hours, an interview was conducted with Resident 9, translated by the Ombudsman. Resident 9 stated not receiving any information regarding advance directives from the facility. When asked if an advance directive was desired, Resident 9 stated yes. On 8/26/26 at 1440 hours, an interview and concurrent medical record review for Resident 9 was conducted with the SSD. The SSD stated when a resident had fluctuating capacity, the Ombudsman should be contacted to determine whether the resident could formulate an advance directive. The SSD was unable to provide documented evidence showing whether follow-up occurred, whether Resident 9 was offered the opportunity, or whether Resident 9 accepted or refused assistance to formulate an advance directive. On 8/27/26 at 0941 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 37 was initiated on 8/25/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's POLST dated 7/24/26, showed Resident 37 had no advance directive. Review of Resident 37's Social Services assessment dated [DATE], showed the POLST was selected under the advance directive section. However, further review of Resident 37's medical record failed to show the facility asked the resident if an advance directive was desired or offered assistance in formulating one. Review of Resident 37 H&P examination dated 7/30/26, showed Resident 37 had the capacity to understand and make decisions. On 8/26/26 1440 hours, an interview and concurrent medical record review for Resident 37 was conducted with the SSD. The SSD stated the admission nurse was responsible for completing the Advance Directive Acknowledgement form. The SSD stated if the resident had fluctuating capacity, the Ombudsman would be involved to assist the resident or family. When asked whether an advance directive was offered to Resident 37 per the resident's family member, the SSD verified and acknowledged the discussion and offer had not occur with the resident or family member. On 8/27/26 1455 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop care plans for two of 16 final sampled resident (Residents 4 and 37). * Resident 4 had no care plan addressing the repeated refusal of the medications. * Resident 37 had no care plan addressing the use of the halo ring bed rail. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 5/7/26, showed the facility will develop and implement a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs. 1. Medical record review for Resident 4 was initiated on 8/25/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MAR for August 2026 showed Resident 4 had refused the scheduled medications on the following dates and times: - for atorvastatin sodium (medication to lower cholesterol) 20 mg at 2100 hours, on 8/7 and 8/11/26. - for donepezil HCl (a medication to treat dementia symptoms, confusion, and memory loss) 10 mg at 2100 hours, on 8/7 and 8/11/26. - for sennosides (a laxative) 8.6 mg at 1700 hours, on 8/7, 8/11, and 8/18/26. - for melatonin (a supplement to regulate the sleep cycle) 5 mg at 2100 hours, on 8/7 and 8/11/26. - for mirtazapine (an antidepressant used as an appetite stimulant) 30 mg at 2100 hours, on 8/7/26. - for MVI with minerals (a dietary supplement) one tablet at 1700 hours, on 8/7, 8/11, and 8/18/26. - for Eliquis (a blood thinner to prevent blood clots) 2.5 mg at 1700 hours, on 8/7, 8/11, and 8/18/26. - for memantine HCl (a medication to treat confusion, and memory loss) 10 mg at 1700 hours, on 8/7 and 8/11/26. - for metoprolol tartrate (a medication to treat HTN) 25 mg at 1700 hours, on 8/7, 8/11, and 8/18/26. - for acetaminophen (a pain reliever) 1 gram at 2100 hours, on 8/7 and 8/11/26. Review of Resident 4's Care Plan Report (undated) failed to show a care plan addressing the resident's medication refusal. On 8/26/26 at 1141 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 4 had refused multiple medications, and verified there was no care plan addressing the refusals. RN 1 stated uncertainty whether repeated refusals needed to be addressed in the resident's care plan. On 8/26/26 at 1146 hours, an interview was conducted with the DON. The DON stated if a resident refused multiple medications, the issue should be addressed in the resident's care plan. 2. On 8/25/26 at 0933 hours, during the initial tour of the facility, Resident 37 was observed sitting in bed wearing a back brace support, with a family member present. A halo ring-shaped side rail was observed on the left side of the bed. Medical record review for Resident 37 was initiated on 8/25/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed a physician's order dated 7/24/26, to apply halo safety ring on the left side of the bed as an enabler. Review of Resident 37's Physician Document of Informed Consent dated 7/30/26, for the use of halo safety ring as an enabler. Review of Resident 37's Bed Rails assessment dated [DATE], showed Resident 37 did not need a side rail. Review of Resident 37's plan of care failed to show a care plan addressing the use of the halo safety ring device. On 8/27/26 at 0905 hours, an observation and concurrent interview with CNA 2 at Resident 37's bedside. CNA 2 stated Resident 37 required assistance with the ADLs and verified Resident 37 used the halo ring safety device on the left side of the bed to reposition herself in bed. On 8/27/26 at 1016 hours, an interview and concurrent medical record review for Resident 37 was conducted with LVN 2. LVN 2 verified the physician's order for the halo ring safety device as an enabler. LVN 2 stated the PT was responsible for the assessment and application of the halo ring prior to use. On 8/27/26 at 1114 hours, an interview and concurrent medical record review for Resident 37 was conducted with MDS Coordinator. The MDS Coordinator was asked about the care plan for the use of the halo ring as an enabler. The MDS Coordinator was able to show a care plan for Resident 37's ADLs that included using the halo ring as an intervention. However, the MDS Coordinator verified there was no separate care plan specifically addressing the use of the halo safety ring as an enabler. On 8/27/26 at 1455 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on interview and medical record review, the facility failed to revise the care plans for two of 16 final sampled residents (Residents 4 and 14). * The facility failed to timely revise Resident 4's care plan for a resolved UTI. * The facility failed to timely revise Resident 14's care plan for C. diff contact precautions. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. Medical record review for Resident 4 was initiated on 8/25/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MAR for August 2026 showed the resident completed a three day course of ceftriaxone sodium (an antibiotic) 1 gram via IV for a UTI on 8/5/26. Review of Resident 4's Care Plan Report (undated) showed a problem focus for a UTI initiated on 8/4/26, and revised on 8/12/26. The focus showed the resident had a current UTI, including a UA result positive for bacteria and was at risk for recurrent UTI due to being admitted with a UTI. The interventions included administering the antibiotics as ordered. On 8/26/26 at 1141 hours, an interview and concurrent record review was conducted with RN 1. RN 1 reviewed Resident 4's and stated the resident had been treated with antibiotics for a UTI, but it was resolved. The RN verified the care plan showed the resident currently had a UTI, and it should have been revised. 2. Medical record review for Resident 14 was initiated on 8/25/26. Resident 4 was admitted to the facility on [DATE]. Review of the facility's Matrix For Providers (undated) showed Resident 14 had C. diff. Review of Resident 14's Care Plan Report (undated) showed a problem focus for C. diff initiated on 8/18/26, and revised on 8/24/26. The focus showed the resident had a current C. diff infection. The revision on 8/24/26, showed the resident was free from diarrhea for four days and denied abdominal pain and discomfort. The care plan interventions included placing the resident in contact precautions. On 8/25/26 at 0841 hours, an observation was conducted for Resident 14. There were no isolation signage or PPE at the resident's doorway. On 8/25/26 at 1202 hours, an interview and concurrent medical record review was conducted with the IP. The IP stated the Resident 14's contact precautions for C. diff were discontinued the previous day because the resident had not had loose stool for over three days. The IP stated the care plan was updated to remove C. diff and contact precautions. However, the IP reviewed the resident's current care plan and verified it still showed Resident 14 had C. diff and required contact precautions.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents received appropriate treatment and services to maintain range of motion (ROM) for two of 16 final sampled residents reviewed for position/mobility (Residents 25 and 42). * The facility failed to ensure Resident 25 received RNA services as recommended by PT and OT. * The facility failed to provide documented evidence to show the splints for Resident 42 were applied as ordered by the physician and whether skin assessment was completed before and after splint use. These failures had the potential to result in ROM decline for Residents 25 and 42, leading to further deterioration in the resident's physical well- being. Findings: Review of the facility's P&P titled Restorative Nursing Programs dated 12/19/22, showed the restorative aides will implement the plan for a designated length of time, performing the activities and documenting on the electronics health record. The Restorative Nursing Program Coordinator will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. Review of the facility's P&P titled Restorative Nursing Programs dated 5/7/26, showed facility to provide maintenance restorative services designed to maintain or improve a resident's abilities to the highest practicable level. 1. On 8/25/26 at 0848 hours, Resident 25 was observed lying in bed with the right arm in a flexed position. Medical record review for Resident 25 was initiated on 8/25/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 6/18/26, showed Resident 25 had no capacity to understand and make medical decisions. Review of Resident 25's MDS assessment dated [DATE], showed Resident 25 had impaired ROM in both upper and lower extremities and required total staff assistance for the ADLs. Review of Resident 25's Care Plan Report (undated) showed a care plan problem dated 5/14/25, addressing the resident's bilateral osteoarthritis of the knees and right hand. The goal showed for the resident to remain free of complications, including contractures, joint stiffness, and decline in mobility. The interventions included daily ROM as tolerated. Review of Resident 25's Physical Therapy (PT) Discharge summary dated [DATE], showed the resident received PT services from 6/17 through 8/14/26. Further review of the document showed the restorative and functional maintenance programs were established, and RNA training for ROM was completed. Review of Resident 25's Occupational Therapy (OT) Discharge summary dated [DATE], showed the resident received OT services from 6/17 through 8/14/26. Further review of the document showed ROM program was established and training was completed to provide passive ROM to the right and left upper extremities. However, further review of Resident 25's medical record failed to show documentation Resident 25 received RNA services or ROM interventions for any extremity after 8/14/26. On 8/26/26 at 0923 hours, an interview and concurrent medical record review for Resident 25 was conducted with the Rehabilitation Director. The Rehabilitation Director stated residents with impaired ROM should receive services to maintain or improve ROM and prevent further decline. The Rehabilitation Director verified Resident 25 received PT and OT services from 6/17 through 8/14/26 and verified no ROM services were provided after 8/14/26. The Rehabilitation Director stated the rehab department failed to refer Resident 25 to RNA services and acknowledged that not providing RNA services could lead to further decline in ROM for Resident 25. On 8/26/26 at 0954 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 verified Resident 25 was not referred for RNA services and did not receive ROM exercises after 8/14/26. On 8/27/26 at 0941 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 8/25/26 at 0910 hours and 8/26/26 at 1438 hours, Resident 42 was observed in bed, awake and alert, both arms contracted. No splint devices were applied on either arm. Medical record review for Resident 42 was initiated on 8/26/26. Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 8/27/26, showed the following physician's orders: - dated 9/9/21, to apply bilateral elbow extension splint and left WHFO to correct and control the contracture deformities; and - dated 9/9/21, to apply bilateral AFO to correct and control the bilateral ankle and foot deformities. Review of Resident 42's Documentation Survey Report for the month of July 2026 showed the application of the left elbow extension splint, left WHFO splint to the left wrist, and left PRAFO splint for the left ankle/foot. However, further review of the report failed to show documented evidence the times the splint devices were applied and removed. In addition, there was no documented evidence to show skin assessments were conducted before and after the splint application. On 8/27/26 at 0849 hours, an interview was conducted with RNA 1. RNA 1 stated working with ROM for the upper and lower extremities and placing the splints to both ankles, hands, and elbows seven days per week for one hour daily. RNA 1 stated Resident 42 was able to tolerate the splints and AFO without complaints of pain or discomfort. RNA 1 stated the resident's skin was checked before and after applying the splint device, and no skin problems were noted. RNA 1 stated documentation was completed in the computer for the treatment provided and showed the recorded treatment in the medical record. When asked about the time entered for the splint application, RNA 1 stated entering three minutes reflected the time spent putting on the splints, not the total time the devices remained on the resident. RNA 1 stated the splints were usually applied from 1030 to 1130 hours each day. When asked whether the application and removal times were documented, RNA 1 stated documentation was not completed. RNA 1 stated skin assessments conducted before and after splint application were not documented. On 8/27/26 at 1142 hours, an interview and concurrent medical record review for Resident 42 was conducted with RN 1. RN 1 verified the recorded log contained no documentation to show when the splints were applied or removed and no documentation of skin assessments. On 8/27/26 at 1455 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to complete the follow up process for the pharmacy consultant's recommendations for one of five final sampled residents (Resident 2) investigated for unnecessary medications. * The facility failed to follow up the pharmacy consultant's recommendation to obtain TSH level related to the resident's sertraline (antidepressant) medication use. This failure had the potential to result in negative outcomes from unnecessary medication use. Findings: Review of PubMed showed a medical study titled Effects of Various Antidepressants on Serum Thyroid Hormone Levels In Patients With Major Depressive Disorder dated May 2008 indicating TSH significantly increased among the residents who received sertraline. Review of the facility's P&P titled Medication Regimen Review revised 5/7/26, showed a pharmacist will review all the residents' medication regimens monthly, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with mediations. The facility staff will act on all recommendations. Review of the Consultant Pharmacist's Medication Regimen Review for July 2026 showed Resident 2 had a physician's order for sertraline medication. The pharmacist recommended: Please consider obtaining a TSH level for monitoring purposes. In the Follow-Through column, a handwritten note showed scheduled on 8/20/26. Medical record review for Resident 2 was initiated on 8/25/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/20/26, showed the resident had major depressive disorder. Review of Resident 2's Order Summary Report showed a physician's order dated 7/17/26, for sertraline HCl 50 mg by mouth at bedtime for depression. Review of Resident 2's EHR failed to show a TSH laboratory test was completed at the facility, or ordered by the physician. On 8/26/26 at 1129 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the Medication Regimen Review for July 2026 and the pharmacy consultant's recommendations to monitor Resident 2's TSH level. RN 1 stated the follow-through comment showed it had been scheduled for 8/20/26. RN 1 reviewed Resident 2's EHR and verified there was no physician's order for a TSH level, and no TSH lab result. RN 1 checked the laboratory portal and requisition binder, and verified there were no record to show a TSH level had been completed or scheduled. On 8/26/26 at 1556 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the notes in the follow through column were the RN 2's notes for Resident 2 on the July 2026 Medication Regimen Review. RN 2 stated upon receiving the pharmacist's recommendations, RN 2 spoke to Resident 2's NP in-person while the NP was rounding on the resident's. RN 2 stated the NP agreed with the pharmacist's recommendations, and RN 2 scheduled the TSH laboratory test to be completed on 8/20/26. RN 2 stated the NP rounded every Thursday and could not recall when the initial verbal order was received. RN 2 stated upon later reviewing the resident's acute care records, RN 2 noted Resident 2 had a TSH test completed on 7/10/26, prior to admission. RN 2 stated during a subsequent Thursday visit, the NP advised the TSH could be rechecked after one month. RN 2 verified the NP's verbal order was not entered into the resident's EHR, resulting in the recommendation not being carried out.

Based on observation, interview, and facility document review, the facility failed to follow the planned menu for two final sampled residents (Residents 7 and 20) and one nonsampled resident (Resident 24). * Residents 7, 20, and 24 did not receive roasted seaweed on their lunch trays. This failure had the potential to result in residents not receiving planned items that contribute to meeting nutritional needs. Findings: Review of the facility's Week At A Glance menu showed the planned lunch on 8/25/26, included white radish soup, kimchi, chicken with four colored vegetables, steamed white rice, seasoned yellow pickled radish, apple crisp, and beverage choice. On 8/25/26 at 1150 hours, an observation of the lunch tray line was conducted with the DSS. The roasted seaweed was observed being placed on the residents' meal trays, although roasted seaweed was not listed on the Week At A Glance menu. The DSS stated all the residents, except those on pureed food diets unless approved by ST, received roasted seaweed. The DSS stated the roasted seaweed was listed on the meal tray tickets. On 8/25/26 at 1250 hours, a dining observation was conducted in the dining room with LVN 1. Residents 7, 20, and 24 did not have the roasted seaweed on their meal trays. However, their meal tray tickets showed Food Adds: Other-Roasted Seaweed - 1 each. LVN 1 verified the meal trays for Residents 7, 20, and 24 did not include the roasted seaweed and confirmed the meal tickets listed roasted seaweed as part of the lunch meal.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed as ordered by the physician for one of eight residents (Resident 16) observed during dining. * The facility failed to ensure Resident 16 received the correct therapeutic diet per the physician's order. This failure posed a risk for choking or aspiration (a condition in which the food, liquids, saliva, or vomit is breathed into the airway) episodes.Findings: Review of the facility's P&P titled Therapeutic Diet Orders dated 12/19/22, showed the facility provides all the residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. On 8/25/26 at 1004 hours, during the initial tour of the facility, Resident 16 was observed in bed eating. A water pitcher labeled as thickened water was observed. On 8/25/26 at 1222 hours, during the lunch observation, Resident 16 was observed in a wheelchair inside the room. CNA 3 brought a meal tray to Resident 16, opened all the lids; and the liquids observed on the tray were not thickened. CNA 3 was asked for the meal ticket and the ticket provided belonged to a different resident. CNA 3 began assisting Resident 16 with the pureed food before realizing the tray was incorrect. CNA 3 checked the meal ticket, verified the wrong tray had been delivered, removed the tray, and notified the kitchen staff. CNA 3 returned with a new tray for Resident 16. Review the meal ticket showed: Regular soft & bite sized texture - mildly thick Nectar. The liquids on the tray were thickened. CNA 3 verified the correct tray for Resident 16 was delivered. Medical record review for Resident 16 was initiated on 8/26/26. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Annual Physical Examination dated 4/23/26, showed Resident 16 had no capacity to understand and make medical decisions. Review of Resident 16's Nutritional assessment dated [DATE], showed the diet included mildly thick liquid consistency. Review of Resident 16's Speech Therapy Rehab Screen dated 7/29/25, showed Resident 16 was observed coughing during oral intake despite diet modification. Review of Resident 16's Order Summary Report date 8/26/26, showed a physician's order dated 8/6/25, to provide regular diet soft and bite sized texture, mildly thick consistency and fortified foods. On 8/26/26 at 1416 hours, an interview for Resident 16 was conducted with the IP. The IP stated being responsible for checking the food cart to ensure the food trays matched the physician diet orders, including name of the resident, texture and the liquid consistency. The IP stated after checking the food cart, the CNAs distributed the individual food tray of the residents. The IP stated monitoring the CNAs was done to ensure the right trays were delivered correctly. The IP was informed of the observation involving Resident 16 receiving an incorrect food tray and verified Resident 16 should have received the correct therapeutic diet tray. On 8/27/26 1455 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate infection control surveillance for two nonsampled residents (Residents 66 and 67) for the months of June and July 2026. * The facility infection control documents showed Resident 66 had pneumonia, however, the resident's symptoms and diagnostic testing results did not meet criteria for a true infection. * The facility documents showed Resident 67 had bronchitis, however, the resident's symptoms and diagnostic testing results did not meet the criteria for a true infection. These failures resulted in inaccurate infection surveillance data being presented to the healthcare provider and the Quality Assurance and Assessment (QAA) Committee.Findings: Review of the facility's P&P titled Surveillance revised 5/7/26, showed infection surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data, and presents the data to QAA Committee. The CDC's NHSN Long Term Care Criteria, updated McGeer Criteria or other nationally recognized surveillance criteria will be used to define infections. On 8/27/26 at 0821 hours, review of the facility's Infection Control McGeer's Surveillance binder and data was conducted with the IP. The IP stated the facility used the McGeer's criteria to determine whether an infection was a true infection. The surveillance data presented to the QAA Committee included a breakdown of infection types, room mapping, classification of healthcare associated versus community associated infections, and whether each infection met the McGeer's criteria. a. Review of the facility's Infection Surveillance Monitoring Log for July 2026 showed Resident 67 had bronchitis. The log showed the resident's bronchitis was a HAI that met the McGeer's criteria. Review of Resident 67's Infection Screening Evaluation dated 7/23/26, showed the resident did not have a recent CXR, and the evaluation showed the McGeer's Criteria was met for a suspected common cold or pharyngitis. Review of Resident 67's Antibiotic Time Out evaluation dated 7/27/26, showed a diagnosis of bronchitis. However, review of Resident 67's EHR failed to show the resident's symptoms met the criteria for bronchitis, resulting in inaccurate infection surveillance data presented to QAA Committee. The IP verified the findings. b. Review of the facility's Infection Surveillance Monitoring Log for June 2026 showed Resident 66 had pneumonia. The log showed the resident's pneumonia was a HAI that met the McGeer's criteria. Review of Resident 66's Infection Screening Evaluation dated 6/28/26, showed the resident had a recent CXR with the findings consistent with pneumonia. Review of Resident 66's Radiology Results Report dated 6/29/26, showed a CXR was performed and the results did not show evidence of pneumonia. The IP stated Resident 66's suspected pneumonia met McGeer's criteria because the CXR results showed congestion, which the IP interpreted as supporting the diagnosis of pneumonia. The IP further stated if the CXR results did not show the findings consistent with pneumonia, then Resident 66's suspected pneumonia would not meet the McGeer's criteria for a true infection. On 8/27/26 at 1404 hours, a telephone interview was conducted with the Medical Director. After Resident 66's CXR results were read to the Medical Director, and the Medical Director stated the radiology report was not consistent with pneumonia. Cross reference F881.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure appropriate antibiotic stewardship practices were followed for two nonsampled residents (Residents 66 and 67). * The facility failed to notify the physician to reevaluate the antibiotic usage when Resident 66 and 67's suspected infections did not meet the McGeer's criteria. These failures had the potential for unnecessary antibiotic treatment, exposing the residents to avoidable risks including adverse drug reactions and the development of multidrug resistant organisms (MDROs). Findings: Review of the facility's P&P titled Antibiotic Stewardship Program revised 5/7/26, showed the program is to optimize the treatment of infections white reducing the adverse events associated with antibiotic use. Nursing will monitor the resident's response to the antibiotic, review testing results and will consult the physician to determine if an adjustment is needed. On 8/27/26 at 0821 hours, review of the facility's Infection Control McGeer's Surveillance binder and data was conducted with the IP. The IP stated the facility used the McGeer's criteria to determine whether an infection was a true infection. If an infection did not meet criteria, then the physician was notified to reevaluate antibiotic use. a. Review of the facility's Infection Surveillance Monitoring Log for July 2026 showed Resident 67 had bronchitis. Review of Resident 67's Infection Screening Evaluation dated 7/23/26, showed the resident did not have a recent CXR, and the evaluation showed the McGeer's criteria was met for a suspected common cold or pharyngitis, not bronchitis. Review of Resident 67's Antibiotic Time Out evaluation dated 7/27/26, showed a diagnosis of bronchitis. The form failed to show the physician was notified the resident's infection met the McGeer criteria for a common cold or pharyngitis, and not bronchitis. Review of Resident 67's EHR failed to show the resident's suspected infection met the McGeer criteria for bronchitis. In addition, the medical record failed to show the physician was notified the resident's suspected infection did not meet criteria. The IP verified the findings. b. Review of the facility's Infection Surveillance Monitoring Log for June 2026 showed Resident 66 had pneumonia. Review of Resident 66's Infection Screening Evaluation dated 6/28/26, showed the resident had a recent CXR with the findings consistent with pneumonia. Review of Resident 66's Radiology Results Report dated 6/29/26, showed a CXR was performed and the results did not show evidence of pneumonia. The IP stated Resident 66's suspected pneumonia met McGeer's criteria because the CXR results showed congestion, which the IP interpreted as supporting the diagnosis of pneumonia. The IP further stated if the CXR results did not show the findings consistent with pneumonia, then Resident 66's suspected pneumonia would not meet the McGeer's criteria for a true infection. On 8/27/26 at 1404 hours, a telephone interview was conducted with the Medical Director. After Resident 66's CXR results were read to the Medical Director, and the Medical Director stated the radiology report was not consistent with pneumonia. Cross reference F880.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the resident entrapment assessment was completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of the side rails for one of one final sampled residents (Resident 37) reviewed for side rails. * The facility failed to complete the Zone 4 (gap between the headboard and the halo ring) entrapment measurement for Resident 37's halo safety ring. This failure resulted in an incomplete entrapment assessment and created the potential for resident harm, including entrapment, serious injury, or death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 2006 the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly residents .especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:- Zone 1: within the rail;- Zone 2: under the rail, between the rail supports or next to a single rail support;- Zone 3: between the rail and the mattress;- Zone 4: under the rail, at the ends of the rail;- Zone 5: between split bed rails;- Zone 6: between the end of the rail and the side edge of the head or foot board; and- Zone 7: between the head or foot board and the mattress end. On 8/25/26 at 0933 hours, Resident 37 was observed sitting in bed with left side halo ring elevated. Medical record review for Resident 37 was initiated on 8/26/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Bed Rail assessment dated [DATE], showed the bed was checked to ensure the bed was appropriate for the resident dimension. Alternatives attempted included lowering the bed to the floor, using pillows, providing assisted toileting, frequent staff monitoring, visual and verbal reminders to use the call light. Review of Resident 37's Order Summary Report dated 8/27/26, showed a physician' order dated 7/24/26, to apply halo safety ring on the left side of the bed as an enabler. Review of Resident 37's Bed System Measurement Device Test Results Worksheet dated 7/24/26, showed the measurement of Zone 2 for the left side halo safety ring. However, the worksheet failed to show the measurement for Zone 4. On 8/27/26 at 0905 hours, an observation and concurrent interview with CNA 2 at Resident 37's bedside. CNA 2 stated Resident 37 required assistance with the ADLs and verified Resident 37 used the halo ring safety device on the left side of the bed to reposition herself in bed. On 8/27/26 at 1016 hours, an interview and concurrent medical record review for Resident 37 was conducted with LVN 2. LVN 2 verified the physician's order for the halo ring safety device as an enabler. LVN 2 stated the PT was responsible for the assessment and application of the halo ring prior to use. On 8/27/26 at 1450 hours, an interview and concurrent facility document review for Resident 37 was conducted with the Maintenance Director. The Maintenance Director acknowledged Resident 37 used a halo safety ring at the bedside. When asked if the halo safety ring was considered a side rail, the Maintenance Director verified it was. The Maintenance Director stated the facility had the equipment to measure the gaps between the rail and the bed. The Maintenance Director showed a copy of the side rail assessment, however, when asked whether Zone 4 had been measured, the Maintenance Director verified and acknowledged that no measurement had been completed. On 8/27/26 at 1455 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the necessary care and services. * The facility failed to ensure Resident 1 received adequate supervision to prevent an elopement (when a resident leaves a safe area without authorization). This failure had the potential to place the resident at risk for accident or injury.Findings: Review of the facility's Elopement and Wandering Residents revised on 5/7/26, showed the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. In procedure for locating missing resident if the resident is not located in the building or on the grounds, administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. Review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form dated 6/29/26, showed on 6/29/25 at 1750 hours, a CNA reported Resident 1 was not in the room when dinner trays were being delivered. At 1900 hours, the facility received a call from a community member reporting the resident was wandering in the street near a bus station. Resident 1 returned to the facility at 1920 hours. Review of the CMS Intake Information Report for Intake Number 3065145 dated 6/29/26, showed the incident date as 6/28/26. Review of the facility's document failed to show documentation of facility exit door and security alarm checks prior to Resident 1's elopement on 6/28/26. Closed medical record review of Resident 1 was initiated on 7/8/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/11/26, showed Resident 1 had fluctuating capacity to understand and make decisions related to dementia. On 7/9/26 at 1220 hours, an interview was conducted with RN 1. RN 1 stated she did not know how Resident 1exited the facility and stated she did not see the resident walk through the front door. RN 1 stated there was an alarm on the back door near the kitchen; however, she did not hear the alarm activate. RN 1 stated the facility staff searched the facility and the nearby area but could not locate the resident. RN 1 stated she did not call the police department. RN 1 added she received a call from a community member reporting Resident 1 was found wandering near a bus station. On 7/9/26 at 1244 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 frequently verbalized wanting to go home. LVN 2 stated there should be an alarm in the back door; however, she did not hear any alarm at the time the resident left the facility. On 7/9/26 at 1445 hours, an interview was conducted with the Administrator. The Administrator verified Resident 1 left the facility though the back door near the kitchen, as seen on camera footage. The Administrator stated the camera footage did not show whether the door alarm activated. The Administrator stated the facility did not call the police because the staff attempted to locate the resident first. The Administrator verified a community member contacted the police and informed the facility on 6/28/26 at 1900 hours, the resident was found wandering in the street near a bus station. The Administrator verified there was no documentation of exit door alarm checks prior to Resident 1's elopement. On 7/29/26 at 1645 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan timely and implement care plan interventions for one of three sampled residents (Resident 1). * Resident 1 did not have a care plan for constipation. Additionally, Resident 1's care plan for diarrhea and loose stools was not developed in a timely manner. There was no monitoring for Resident1's signs and symptoms of dehydration as identified in the care plan. These failures had the potential risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Review of the facility's P&P titled Comprehensive Care Plan dated October 2022 showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychological needs that are identified in the comprehensive assessment. Medical record review for Resident 1 was initiated on 2/3/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/29/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Nursing Progress Notes dated 4/2/25, showed Resident 1 had loose stools on 4/2/25. The Progress Notes further showed a physician's order to discontinue the docusate sodium (stool softener), to hold Geri-Kot tablet (laxative), and to give Lactobacillus (probiotics to maintain gut health). Review of Resident 1's Order Summary Report showed the following orders:- dated 4/5/25, discontinue docusate sodium oral tablet one tablet via GT in the morning for bowel movement, hold if loose stool; - dated 4/5/25, hold Geri-Kot tablet 8.6 mg one tablet via g-tube for bowel management, hold if loose stool ordered; and- dated 4/5/25, give Lactobacillus oral tablet one tablet via GT two times a day for supplement. Review of Resident 1's care plan for diarrhea and loose stools initiated on 4/9/26, showed interventions including to monitor, document and report as needed for signs and symptoms of dehydration (dry skin and mucous membranes, poor skin turgor, weight loss, anorexia, malaise, hypotension, increase heart rate, fever, abnormal electrolyte levels). Resident 1's care plan for the diarrhea and loose stools was initiated seven days after the first episode of diarrhea/ loose stools started (on 4/2/25). Review of Resident 1's medical record failed to show a care plan was developed for the resident's constipation, and failed to show the resident was monitored for signs and symptoms of dehydration. Review of Resident 1's Nursing Progress Notes dated 4/16/25, showed the resident's abdomen was non- tender, bowel sounds present, diarrhea noted and complaints of nausea. The physician was notified and an order was initiated for loperamide HCl (medication to treat diarrhea) two mg one tablet via GT every eight hours for loose stool or diarrhea. Review of Resident 1's Nursing Progress Notes dated 4/17/25, showed the resident was transferred to the acute care hospital for abnormal vital signs and was admitted to the ICU. On 1/3/26 at 0946 hours, an interview and concurrent medical record review for Resident 1 was conducted with the MDS Coordinator. The MDS Coordinator stated one of her responsibilities was to coordinate the initiation of care plans. The MDS Coordinator stated the admitting supervisors would initiate the basic care plans, and she would add the diagnosis related care plans and medications. The MDS Coordinator stated the charge nurses working the shift complete the episodic care plans when the episode occurs with a timeframe as soon as it happens. The MDS Coordinator further stated care plans are checked the following day by a charge nurse, MDS coordinators, and the DON. The MDS Coordinator verified Resident 1 did not have a care plan for constipation despite Resident 1 taking a laxative and stool softer every day. The MDS Coordinator also verified Resident 1 had loose stools starting 4/2/25, and the care plan was not initiated until 4/9/25. The MDS Coordinator stated the care plan should have been initiated as soon as the episode of diarrhea occurred. The MDS Coordinator stated the care plans were not done until the change of condition was reported. On 1/3/26 at 1414 hours, an interview and concurrent medical record review for Resident 1 was conducted with the IP. The IP stated she checked and completed the infection related care plans. When asked what happened to Resident 1's care plan to address episodes of loose stools, the IP stated the loose stools were just one time on 4/2/25, thus the care plan was initiated on 4/9/25, when the change of condition was reported and documented. The IP reviewed Resident 1's progress notes showing the resident had loose stools. The IP verified the above findings and stated, I will get back to you.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the opened food items in the freezer were properly stored, dated, and labeled. * The facility failed to discard the items in the refrigerator that were past the use-by date, as per the facility's P&P. * The facility failed to ensure the juice boxes and thickener (for the juice dispenser) were properly labeled and discarded. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the plastic cup was not stored inside the flour container. * The facility failed to air dry the kitchen equipment. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 61 residents who received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Type Report dated 6/9/25, showed 61 of 61 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Review of Sanitation revised 9/26/18, showed all the food stored should be dated when it is placed in the storeroom, refrigerator, or freezer. The food in all the refrigerators should have a use-by-date. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. On 6/9/25 at 0750 hours, an observation of Freezer 1 was conducted with the DSS. The following were observed: - an opened bag of the frozen hashbrowns. The bag was not observed labeled with the opened date or stored inside a sealed bag. - an opened blue bag containing the frozen Danishes. The label showed received on 5/28/25. The label was not observed with the opened dated or stored inside a sealed bag. - an opened bag of the frozen cinnamon rolls. The bag was not observed stored inside a sealed bag and two cinnamon rolls were observed outside of the bag and touching the other items nearby. The DSS verified the above findings. The DSS stated the opened bags should be stored inside a closed Ziplock bag after it was opened and before placing in the freezer. The DSS further stated the bags should be labeled with the opened date when it was first opened, to determine when the items should be discarded. 2. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded accordingly. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed the refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: iv. labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen/discarded. On 6/9/25 at 0750 hours, an observation of Refrigerator 1 was conducted with the DSS. The following were observed: - a clear plastic container was observed with limes, cucumbers, oranges, and lemons. The label on the plastic container showed items: lime, cucumber, orange, lemon; received on 5/28/25, and to use-by 6/6/25. - a clear plastic container with carrots inside. The label showed: carrots, prepped on 5/26/25, and use-by 6/7/25. The DSS verified the above findings. The DSS stated the items in the plastic containers should have been removed from the refrigerator and discarded by the use-by date. The DSS stated the kitchen aide was responsible for removing the expired items in the refrigerator, once a week and the evening cook was responsible for checking the refrigerators and freezers during their shift and removing the expired items. 3. Review of the facility's P&P titled Date Marking for Food Safety revised 1/30/25, showed the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking of the food at the time the food is opened or prepared. The marking system shall include the date of opening, and the date the item must be consumed or discarded. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - a bag of the cranberry juice connected to the juice dispenser. The bag of juice was not observed labeled with the opened date. The DSS stated she did not know when the juice was opened. - a box of the blush grape juice concentrate connected to juice dispenser. The label on the box showed the opened date of 4/29/25, and the use-by date of 5/29/25. - a box of the apple juice concentrate connected to juice dispenser. The label showed the received date 5/20/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a box of the orange juice concentrate connected to the juice dispenser. The label showed the received date of 5/30/25, however the label was undated with the opened or use-by date. The DSS stated she did not know when the juice was opened. - a bag of thickener liquid connected to the juice dispenser. The bag was not observed labeled with the opened date. The DSS stated did not know when the bag was opened. The DSS verified the above findings. The DSS stated the juices should be discarded after one month of opening. 4. According to the US FDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the US FDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Food Safety and Food Storage revised 1/30/25, showed food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: e. equipment used in the handling of food, including dishes, utensils, mixers. grinders, and other equipment that comes in contact with food. All the equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Review of the facility's P&P titled Can Opener revised 8/31/18, showed to sanitize the can open after each meal and more frequently if needed. To scrub the shank, paying special attention to the blade and moving parts. To use the sanitizing solution and brush or run through the dish machine. To scrub the base plate (attached to the table). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - two clear plastic containers containing clean cooking utensils were observed with multiple dry particles and debris at the bottom of the bins. - a blue-handled rice scooper observed with yellow colored food residue. - a white-handled rice scooper observed with light brown colored dry food residue. - a portion server observed with dried, white-colored residue. - a stationary can opener observed with dry yellow colored sticky residue on the blade and brownish black colored residue on the can opener gear (the spinning part of the can opener, behind the blade) - multiple steam pans in the dry storage room, observed with dry, white particles on the pans. The DSS verified the above findings. The DSS stated the cooking utensils should be clean and completely dry before placed in the bin. The DSS stated the bins storing the clean kitchen utensils should be completely closed when not in use and the bins should be clean. 5. According to the US FDA Food Code 2022, Section 4-201.11, Equipment and Utensils- Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. According to the US FDA Food Code 2022, Section 4-202.11, Food-Contact Surfaces, the purpose of the requirements for multi-use food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor or foodborne pathogenic organism. Surfaces which have imperfections such as cracks, chips, or pits allow microorganism to attach and form biofilms. Once established, these biofilms can release pathogens to food. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - one white slotted portion scooper observed with a melted handle. - one white silicone spatula observed chipped and cracked. The DSS verified the above findings and stated the spatula and the portion scooper should be removed and replaced. 6. According to the US FDA Food Code 2022, 3-304.11, Food Contact with Equipment and Utensils, food shall only contact surfaces of: a. equipment and utensils that are cleaned as specified under Part 4-6 of this Code and Sanitized as specified under Part 4-7 of this code; b. single-service and single-use articles. According to the US FDA Food Code 2022, 3-304.12, In-Use Utensils, Between-Use Storage, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon; (C) On a clean portion of the food preparation table or cooking equipment only if the in-use utensil and the food-contact surface of the food preparation table or cooking equipment are cleaned and sanitized at a frequency specified under §§ 4-602.11 and 4-702.11; (D) In running water of sufficient velocity to flush particulates to the drain, if used with moist food such as ice cream or mashed potatoes; (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food; or (F) In a container of water if the water is maintained at a temperature of at least 57 degrees Celcius (135 degrees F) and the container is cleaned at a frequency specified under Subparagraph 4-602.11(D)(7). On 6/9/25 at 0750 hours, during the initial tour of the kitchen, a clear container labeled flour was observed in the emergency food storage room. A plastic cup was observed inside the flour container. The DSS verified the above finding and stated the scoops/cups used to scoop the flour should be kept outside of the container, and not inside. 7. According to the US FDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. On 6/9/25 at 0750 hours, during the initial tour of the kitchen, the following was observed: - a green-handled rice scooper observed stored wet inside the clean kitchen utensils container. - a 4-oz stainless steel measuring cup observed stored wet inside the clean kitchen utensils container. - a stainless-steel spatula observed stored wet inside the clean kitchen utensils container. - three blenders observed stored on the shelf, upright and wet. - one blender lid observed wet, with food particles on the lid. - two steam pans observed stacked, upside down and wet. The DSS verified the above findings and stated the kitchen equipment should be clean and completely dry before stored. On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings.

2. On 6/11/25 at 0911 hours, Resident 1 was observed sitting on her wheelchair in the hallway outside her room. Resident 1 was observed with her right hand shaking. Medical record review for Resident 1 was initiated on 6/11/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's annual H&P examination dated 7/19/24, showed Resident 1's diagnoses included paranoid Schizophrenia, psychosis, dementia, and post status stroke with left side paralysis. Resident 1 had no capacity to understand and make medical decisions. Review of Resident 1's MAR for 6/2025 showed Resident 1 was being administered Abilify 15 mg, with a start date 9/15/21, at bedtime for schizophrenia manifested by episodes of delusional thinking that people were trying to harm her. Further review of the MAR failed to show for non-pharmacological interventions were attempted prior to the administration of the Abilify medication to Resident 1. Review of Resident 1's Psychopharmaceutical Summary Sheet showed Resident 1 had episodes of delusional thinking people were trying to harm her. Review of Resident 1's plan of care revised 6/10/25, showed a care plan problem for Schizophrenia. The interventions included to administer Abilify medication as ordered, document side effects, and monitor for effectiveness. The non-pharmacological interventions included to encourage the resident to express her feelings, provide calm environment, redirect, reassure, and reorient the resident as needed. On 6/12/25 at 1630 hours, an interview was conducted with RN 4. When asked about the non-pharmacological interventions for Resident 1's Abilify medication, RN 4 checked Resident 1's MAR. RN 4 stated the non-pharmacological interventions were documented in the resident's progress notes. RN 4 was not able to find the progress notes related to the non-pharmacological interventions provided for Resident 1's Abilify medication use. On 6/13/25 at 1534 hours, an interview was conducted with the MRD. When asked where in Resident 1's medical record the staff documented the non-pharmacological interventions provided for Resident 1's Abilify medication use, the MRD stated it was documented in the resident's progress notes. When informed the progress notes failed to show the non-pharmacological interventions attempted prior to administering the Abilify medication, the MRD stated she would look for them and would provide them if found. On 06/13/25 at 1630 hours, the DON was informed of and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Residents 42) and one nonsampled resident (Resident 1) reviewed for unnecessary medications were provided with the non-pharmacological interventions for the use of psychotropic medications+. * The facility failed to ensure Resident 42 was provided with non-pharmacological interventions for the use of Remeron (antidepressant) medication. * The facility failed to ensure Resident 1 was provided with non-pharmacological interventions for the use of Abilify (antipsychotic) medication. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medications revised 1/30/25, showed it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The Policy Explanation and Compliance Guidelines section showed the non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 1/30/25, showed the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: - The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 1. On 6/10/25 at 0854 hours, Resident 42 was observed sitting in a wheelchair and just came back from physical therapy. Resident 42 stated she felt better and ready to go home. Medical record review for Resident 42 was initiated on 6/10/25. Resident 42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 42's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 42's Psychiatric Evaluation Note dated 5/21/25, showed the resident was diagnosed with MDD. Review of Resident 42's Order Summary Report dated 6/13/25, showed a physician's order dated 4/30/25, for Remeron oral tablet 15 mg (mirtazapine), give one tablet by mouth at bedtime for depression manifested by episodes of verbalization of sadness. Further medical record review for Resident 42 failed to show documented evidence the non-pharmacological interventions were provided for the use of the Remeron medication. On 6/13/25 at 1022 hours, an interview and concurrent medical record review for Resident 42 was conducted with RN 1. RN 1 verified there was no non-pharmacological intervention for Resident 42's use of the Remeron medication. RN 1 further stated the licensed nurse should document the non-pharmacological intervention on the progress notes. On 6/13/25 at 1146 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON acknowledged the above findings. The DON stated Resident 42's psycho-spiritual needs were met. The DON further stated the non-pharmacological interventions for the use of the Remeron medication were provided to Resident 42, however, was not documented. The DON stated the licensed nurse had to assess the resident's behavior and mood before giving the medication and the licensed nurse needed to listen and give emotional support if the resident expressed their feelings. The DON stated the licensed nurse should document the non-pharmacological intervention on the progress note.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Residents 608) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 608. In addition, the facility failed to ensure the non-pharmacological interventions for Resident 608's pain was consistently documented prior to the administration of the Norco (narcotic pain medication) and failed to document the complete pain assessment for Resident 608's pain prior to the administration of pain medication as per Resident 608's care plan. These failures had the potential to put Resident 608 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Management revised 1/30/25, showed based upon the (pain) evaluation the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Non-pharmacologic interventions will include but are not limited to: environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities, exercise to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility, or cognitive/behavioral interventions. Pharmacologic interventions will follow a systemic approach for selecting medications and doses to treat pain. The facility staff will reassess the resident's pain management regularly for effectiveness and/or adverse consequences. If reassessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If the pain has resolved or there is no longer an indication for pain medication the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion. Medical record review for Resident 608 was initiated on 6/9/25. Resident 608 was admitted to the facility on [DATE]. Review of Resident 608's MDS assessment dated [DATE], showed Resident 608 was cognitively intact. Review of Resident 608's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 5/20/25, for Resident 608's pain evaluation, every shift, - dated 5/20/25, to administer hydrocodone-acetaminophen (narcotic opioid medication) 5-325 mg one tablet by mouth every four hours as needed for severe pain management (pain levels of 7 to 10, on a 0-10 pain scale with 0 = no pain and 10 = worst pain) for 30 days. Do not exceed three grams of acetaminophen per day for all sources, and - dated 5/23/25, to administer morphine sulfate Contin (narcotic opioid medication) extended-release 30 mg, one tablet by mouth every 12 hours for pain management due to breast cancer and metastatic malignant mass. Review of Resident 608's plan of care showed a care plan problem dated 5/21/25, addressing Resident 608's pain related to Resident 608's breast cancer with left mastectomy, metastatic malignant mass on Resident 608's left neck and status-post a laminectomy. The interventions included to administer the analgesia Tylenol, Norco, and morphine sulfate Contin 30 mg as per the physician's orders, to monitor/record the pain characteristics and PRN: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g. continuous, intermittent); aggravating factors; relieving factors; and to provide the non-pharmacological interventions to alleviate pain (Specify: provide warm blanket when cold, provided cool drink when hot, provide extra snack when hungry, provide quiet environment when tired). a. Review of Resident 608's MAR for 5/2025 showed Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10) on the following dates, times, and pain levels: - on 5/21/25 at 1420 hours, for a pain level of 10. - on 5/22/25 at 1443 hours, for a pain level of 10. However, review of Resident 608's medical record failed to show the documentation of the non-pharmacological pain interventions attempted prior to the administration of the hydrocodone-acetaminophen pain medications for the above dates and times. On 6/11/25 at 1332 hours, an interview and concurrent medical record review for Resident 608 was conducted with LVN 1. LVN 1 stated Resident 608 complained of pain in her left chest and her back. LVN 1 stated Resident 608 was administered the morphine pain medication routinely and the Norco and the Tylenol pain medications administered as needed. LVN 1 stated when the resident reported pain, the non-pharmacological interventions were implemented and documented in the nurse's progress notes prior to the administration of the pain medications. LVN 1 further stated if the non-pharmacological pain interventions were effective, the pain medication would not need to be administered. LVN 1 reviewed resident 608's medical record and verified the above findings. b. Review of Resident 608's MARs for May and June 2025 showed Resident 608 was administered the following medications on the following dates, times, and pain levels: * Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg medication one tablet by mouth every four hours as needed for severe pain (pain levels of 7 to 10): - on 5/20/25 at 2305 hours, for a pain level of 10. - on 5/21/25 at 0450 hours, for a pain level of 8; at 0915 hours, for a pain level of 7; at 1420 hours, for a pain level of 10; at 1918 hours, for a pain level of 8; and at 2350 hours, for a pain level of 8. - on 5/22/25 at 0445 hours, for a pain level of 7; at 0934 hours, for a pain level of 7; at 1443 hours, for a pain level of 10; and at 2300 hours, for a pain level of 8. - on 5/23/25 at 0450 hours, for a pain level of 7; at 0900 and 1315 hours, for a pain level of 7. - on 5/24/25 at 0250 hours, for a pain level of 8. - on 5/31/25 at 1000 hours, for a pain level of 7; and at 1518 hours, for a pain level of 7. * Resident 608 was administered the morphine sulfate Contin extended release 30 mg, one tablet by mouth every 12 hours for pain management: - from 5/24 to 5/31/25 at 0900 and 2100 hours, and - from 6/1 to 6/10/25 at 0900 and 2100 hours (except on 6/6/25 at 2100 hours). Review of Resident 608's Monitor Record for May 2025 for the monitoring of Resident 608's pain evaluation every shift, showed the licensed nurses documented Resident 608's pain level as follows for the following dates and shifts (when the hydrocodone-acetaminophen pain medication was administered for severe pain, pain level of 7 to 10): - on 5/20/25 for the 2300 to 0700 hours shift, the pain evaluation was documented as 2, - on 5/21/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0; and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/22/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 0. - on 5/23/25, for the 0700 to 1500 hours shift, the pain evaluation was documented as 1, and for the 2300 to 0700 hours shift, the pain evaluation was documented as 1. - on 5/31/25, for the 0700 to 1500 hours shift and the 1500 to 2300 hours shift, the pain evaluation was documented as 0. Review of Resident 608's medical record failed to show documentation the licensed nurses assessed Resident 608's pain (including the pain location, level, quality, characteristics, and alleviating/aggravating factors) prior to the administration of the morphine sulfate pain medication. On 6/16/25 at 0838 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON stated when the resident had reported pain, the licensed nurse should assess the resident's pain, and implement and document the non-pharmacologic pain interventions and its effectiveness in the nursing progress notes. The DON stated if the non-pharmacologic pain interventions for pain were not effective, the licensed nurse would administer the pharmacological pain intervention, per the physician's order, and evaluate its effectiveness. The DON stated the facility was responsible for the monitoring of the resident's pain, which included the tracking and trending of the resident's pain. The DON stated the monitoring of the resident's pain each shift would assist in determining if there was a pattern for the resident's pain, and would also assist in determining when the pain medications would no longer be needed. The DON stated the licensed nurses were responsible for monitoring and documenting the resident's pain level every shift. The DON stated the pain evaluation should be documented at the end of shift, to accurately reflect the resident's highest level of pain during the shift. The DON further stated, if the PRN pain medications were administered to the resident during the shift for the pain levels of 5 out of 10 and 8 out of 10, when documenting the monitoring of pain for that shift, the licensed nurse was expected to document the pain level of eight for that shift because that was the resident's highest level of pain. The DON reviewed Resident 608's medical record and verified the above findings. The DON stated for the administration of the routine pain medications, the resident's pain should be assessed and documented in the progress notes. c. Review of Resident 608's Progress Notes, showed the following licensed nurses entry documentation: - dated 5/27/25 at 0043 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/28/25 at 0912 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/29/25 at 1007 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 5/30/25 at 0933 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/1/25 at 0556 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/2/25 at 1400 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/3/25 at 1101 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/4/25 at 0913 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/5/25 at 0929 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/6/25 at 1039 hours, the licensed nurse documented Resident 608's pain score was 7, non- medication interventions did not provided relief, PRN medication provided. See MAR for details. - dated 6/7/25 at 1346 hours, the licensed nurse documented Resident 608's pain score was 7, non-medication interventions did not provided relief, PRN medication provided. See MAR for details. However, review of Resident 608's MARs for May and June 2025 failed to show Resident 608 was administered the hydrocodone-acetaminophen 5-325 mg one tablet every four hours as needed for severe pain, pain level of 7 to 10. On 6/16/25 at 1134 hours, an interview and concurrent medical record review for Resident 608 was conducted with the DON. The DON reviewed Resident 608's medical record and verified the above findings. On 6/16/25 at 1350 hours, the Administrator and the DON were informed and acknowledged the above findings.

2. On 6/11/25 at 1116 hours, sn observation and concurrent interview was conducted with the DON. When asked about the facility's process for the disposition of controlled substances, the DON showed a drawer used to store the controlled substances to be destroyed with the pharmacist. According to the DON, the pharmacist and DON conducted disposition of the controlled substances on a monthly basis. During the observation of the drawer containing controlled substances for the disposal, one used patch without a pharmacy label was observed stored inside the drawer. The DON stated the patch was a Fentanyl (opioid) patch. When asked about the patch was missing a pharmacy label, the DON stated she knew who the patch was used for. On 6/13/25 at 1050 hours, a follow-up observation and concurrent interview was conducted with the DON. Two used Fentanyl patches without the pharmacy labels were observed inside the drawer used to store controlled substances to be disposed of. When asked about the facility's process for keeping a record for the accurate reconciliation of the Fentanyl patches stored inside the drawer, at all times, the DON verified she did not have the documentation. The DON stated she would obtain the Controlled Drug Record for the Fentanyl from the licensed staff when the pharmacist came to the facility on a monthly basis to do the medication destruction. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure Resident 12's BP was taken in appropriate time when administering the medications for hypertension. * LVN 1 failed to administer Resident 12's docusate sodium (stool softener) as ordered by the physician. * The facility failed to establish a system of records for Fentanyl patches that were already used and ready to be disposed. These failures had the potential to negatively affect the residents' health condition for possible complications. Findings: 1.a. Review of the facility's P&P titled Medication Administration revised 1/30/25, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section showed to compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. On 6/11/25 at 0846 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 prepared and administered the following medications to Resident 12: - one tablet of amlodipine besylate (medication to treat high blood pressure and chest pain) 2.5 mg; - one tablet of losartan (medication to treat high blood pressure) 50 mg; - one tablet of docusate sodium (stool softener) 100 mg; - two tablets of acetaminophen (pain reliever) 500 mg; - two tablets of cranberry (supplement) 450 mg; - two capsules of Fish Oil (supplement) 500 mg; and - 60 cc of Boost nutritional drink. Medical record review for Resident 12 was initiated on 6/11/25. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 12's Order Summary Report dated 6/11/25, showed the following physician's orders: - dated 12/23/22, to administer amlodipine besylate tablet 2.5 mg. Give one tablet by mouth in the morning for hypertension; and - dated 1/6/22, to administer losartan potassium tablet 50 mg. Give one tablet by mouth one time a day for hypertension. Review of Resident 12's Weights and Vitals Summary dated 6/12/25, showed the resident's blood pressure of 126/76 mmHg was taken on 6/11/25 at 0652 hours. On 6/11/25 at 0901 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified Resident 12's BP was taken at 0652 hours and she administered the amlodipine besylate and losartan potassium medications at 0846 hours. LVN 1 acknowledged she did not take Resident 12's BP just before giving the medications for hypertension. LVN 1 stated Resident 12 had been taking the hypertension medication for a long time and did not need to have the BP taken. On 6/13/25 at 1130 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have taken Resident 12's BP before giving the medication because the BP could change. b. Review of Resident 12's Order Summary Report dated 6/11/25, showed a physician's order dated 12/2/21, to administer docusate sodium (stool softener) capsule 250 mg. Give one capsule by mouth in the morning for bowel management. Hold if with loose stool. On 6/11/25 at 1139 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 verified she administered 100 mg tablet instead of 250 mg capsule of docusate sodium to Resident 12. LVN 1 stated she got confused with the dosage when she gave the docusate sodium medication to Resident 12. On 6/13/25 at 1123 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have checked the physician's order and checked the medication before giving to Resident 12.

Based on observation, interview, facility P&P review, and facility document review: * The facility failed to ensure the food item in the residents' refrigerator was properly labeled, dated, and discarded by the use-by date. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food brought in to the facility. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family and Visitors revised 1/30/25, showed it was the right of the residents to have food brought in by family or other visitors, however the food must be handled in a way to ensure the safety of the residents. All food items brought in that are manufactured and do not require refrigeration may be kept in the resident room inside a lock tight container that is provided by the resident and consumed prior to the expiration date. Any expired food must be discarded. 1. On 6/9/25 at 0848 hours, a concurrent observation and interview was conducted with the Activities Director in the dining room. The refrigerator in the dining room was observed with an opened bottle of coconut water labeled 27-A, without a resident's name or identifier. The manufacturer's label showed best if used by 1/16/25, to refrigerate after opening, and to consume within two days. The Activities Director verified the above findings. When asked, the Activities Director stated she did not know when the coconut water was opened. The Activities Director further stated the bottle should be labeled with the resident's name and the opened date. The Activities Director stated the coconut water should have been discarded. On 6/11/25 at 1045 hours, an interview was conducted with the DSD. The DSD stated the food brought from the outside may be refrigerated if the food was appropriate for the resident's ordered diet. The DSD stated the food would be stored in the refrigerator and should be labeled with the resident's name, room number, and the date the item entered the refrigerator. 2. On 6/11/25 at 1014 hours, an interview was conducted with CNA 3. CNA 3 stated food brought from the outside was stored in the refrigerator in the dining room and labeled with the resident's name, room number, and the date the food was brought in. CNA 3 stated the food would be kept in the refrigerator for three days and reheated for the residents. CNA 3 was asked if she had received any safe-food handling education. CNA 3 stated she did not recall any in-services provided regarding the safe-food handling practices of the food brought from outside. CNA 3 further stated she was only provided with in-services on the storage and labeling of the food brought from the outside. On 6/11/25 at 1020 hours, an interview was conducted with CNA 4. CNA 4 stated food brought from outside for the residents was stored in the refrigerator in the dining room. CNA 4 stated if the food needed to be reheated, she would use the microwave located in the dining room. CNA 4 was asked if she had received any education on safe food handling when reheating and serving the food to the residents. CNA 4 stated no. On 6/11/25 at 1036 hours, an interview was conducted with the IP. The IP stated the food brought from the outside for the residents would be checked for the appropriate diet and texture and stored in the refrigerator in the dining room. The IP further stated the food would be kept in the refrigerator and reheated in the microwave located in the dining room. The IP stated the food would be discarded after three days. The IP stated she did not provide information or education to the residents' family or visitors about the food handling practices when they bring in food from the outside for the residents. On 6/11/25 at 1041 hours, an interview was conducted with LVN 1. LVN 1 was asked if she had received any safe food handling education and if she provided information about safe food handling to the visitors when they bring food from the outside. LVN 1 stated she did not recall receiving any education on safe-food handling and she had only received in-services on ensuring the food brought from the outside were the correct diet and texture, on how to label the food, and where to store the food. On 6/11/25 at 1122 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD reviewed the in-services provided to the facility staff regarding the food brought from the outside and verified the in-services she provided to the facility staff did not cover safe food handling practices of food brought from the outside. On 6/11/25 at 1358 hours, a follow-up interview was conducted with the DSD. The DSD stated the reheating of the food stored in the resident refrigerator was done by the CNAs or licensed nurses. The DSD stated she had not provided any in-services/education to the facility staff about safe food handling practices and the facility did not provide education to the visitors regarding the safe food handling practices of the food brought to the facility. On 6/16/25 at 1325 hours, the Administrator, DON, CDM, and DSS were informed and acknowledged the above findings.