Every finding on record at The Pines at Placerville Healthcare Center

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice when the care plan for use of antibiotics (medications used to treat infections) was not followed for Resident 1. This failure had the potential for Resident 1 to experience adverse drug reaction from the antibiotic without the knowledge of staff. A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including depression (persistent feeling of sadness and loss of interest) and irritable bowel syndrome (chronic condition affecting the digestive system). A review of Resident 1's care plan dated 6/3/26 indicated, [Resident 1] has a Respiratory Infection [pneumonia-an infection/inflammation in the lungs] and was taking antibiotics Levaquin [brand name of antibiotic]. The care plan interventions included, Antibiotic therapy as ordered by the physician .Document response to treatment .Monitor/document breath sounds, document rate, rhythm, and the use of any accessory muscles. A review of Resident 1's Medication Administration Record (MAR) for June 2026 indicated the following: -on 6/3/26, Resident 1 was started on Levaquin 500 milligram (mg, unit of measurement) 1 tablet one time a day for pneumonia for 7 days and the order was discontinued on 6/8/26; and,-on 6/8/26, Resident 1 was started on Amoxicillin-Potassium Clavulanate (antibiotic) 875-125 mg 1 tablet two times a day for pneumonia for 7 days. The last dose was given on 6/15/26; and,-on 6/8/26, Resident 1 was started on Vancomycin (antibiotic, used to treat specific bacterial infection in the intestines) HCl (hydrochloride) 250 mg 1 capsule by mouth two times a day for C. Diff (a germ that causes severe inflammation of the large intestine and watery diarrhea) prophylaxis for 14 days. During a concurrent interview and record review on 7/3/26 at 3:43 p.m. with the Assistant Director of Nursing (ADON), Resident 1's nursing progress was reviewed. The ADON stated it is a standard of practice for nurses to chart/document when a resident is taking an antibiotic. The ADON further stated the nurses are supposed to do progress notes every shift throughout the duration of the antibiotic therapy. The ADON confirmed there were no progress notes from nursing staff when Resident 1 was on antibiotic. The ADON added it was important to document every shift for nursing to be able to monitor the resident for adverse reaction, to monitor for drug interaction, and to monitor how the resident is responding to the antibiotic. A review of the facility's policy and procedure revised December 2016 and titled, Antibiotic Stewardship indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program .The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. A review of the facility's policy and procedure reviewed October 2025 and titled, Care Plans, Comprehensive indicated, .The comprehensive care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Aid in preventing or reducing decline in the resident's functional status .Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident.

Based on observation, interview and record review the facility failed to not employ an individual who has been found guilty of abuse or mistreatment by a court of law for one out of three sampled employees (Employee1), when Employee 1's background check indicated he was convicted of battery in 2019 and the facility was made aware of another violent conviction in 2021.This failure has the potential to risk the safety of all residents residing in the facility.Findings:During an interview on 6/25/26 at 1:51 p.m., the Human Resources Manager (HRM) stated prior to hiring an employee the facility will run a criminal background check to determine if the candidate for employment was appropriate with the role/position they are applying for.During an interview on 6/25/26 at 2:26 p.m., the Director of Staff Development (DSD) stated Employee 1 was hired through the facility's Nurse Aide in Training (NAT) program and Employee 1 worked directly with facility residents. The DSD stated the facility's responsibility was to perform background checks prior to employment and if saw a concerning conviction the facility would rescind the offer of employment. The DSD stated, on 6/20/26 a community member had notified the DSD that Employee 1 was convicted for a violent felony. The DSD stated Employee 1 had misdemeanor for 2019 but no felonies. The DSD stated further that Employee 1 had no issues on the job and worked well with residents.During a concurrent observation and interview on 6/25/26 at 2:35 p.m., Employee 1 was seen in the facility hallway wearing scrubs (uniforms worn by healthcare professionals). The DSD stated, Employee 1 was working a scheduled shift with residents.During a concurrent interview and record review on 6/25/26 at 2:51 p.m., with the HRM, Employee 1's Background Screening Report, dated 2/9/26 was reviewed. The HRM stated the background report indicated Employee 1 had a conviction in 2019 for battery (the intentional and unlawful use of physical force or unwanted offensive contact against another person without their consent). The HRM stated battery was consistent with physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, pain, or mental anguish). HRM confirmed Employee 1 admitted to having two convictions for violent crimes prior to hire.During an interview on 6/25/26 at 3:12 p.m., Employee 1 stated he had been working in the facility directly caring for facility residents since March 2026, including today. Employee 1 stated he had a conviction for battery in 2019 when he assaulted a man. Employee 1 also stated that in 2021, he also had used a weapon against a man, the man was sent to the hospital, and Employee 1 was convicted of assault with a deadly weapon.During a concurrent interview and record review on 6/25/26 at 3:45 p.m. with the HRM, facility policy and procedure titled, Background Screening Investigations, undated, was reviewed. The HRM stated Employee 1 's background report was completed on 2/9/26 and was hired on 2/10/26. The HRM stated, the facility's Background Screening Investigation policy indicated, .Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse. mistreatment of individuals. the applicant will not be employed and/or will be terminated from employment. The HRM stated, we should not have hired [Employee 1].During an interview on 6/25/26 at 3:48 p.m. with the Assistant Director of Nursing (ADON) stated it was important not to hire those with a violent history for safety to the residents.A review of facility document titled, Procedures and Guidelines, undated, indicated, .To ensure that employees of the Company continue to be qualified and to ensure that the Company maintains a safe and productive work environment free of any form of violence.the Company reserves the right to conduct background screening on all of its employees. We conduct extensive background checks upon hire and as needed during employment.

Based on observation, interview, and record review the facility failed to maintain infection control practices for a census of 89 when:The tip of Resident 6's enteral feeding tube (a medical device used to deliver nutrition, fluids, and medications directly to the stomach) was observed hanging from the IV pole without a protective cap;Staff did not follow infection prevention protocols when entering the resident's room; andStaff touched the lunches of Resident 52 and Resident 17 with their bare hands.These failures placed residents at risk for spread of infections, disease outbreaks, increased hospitalization and serious health complications for the residents.Findings: 1.Resident 6 was admitted to the facility in early 2026 with diagnoses that included gastrostomy (a surgical opening fitted with a device that allowed feedings to be administered directly into the stomach, commonly used for people with swallowing problems) and quadriplegia ( a condition where a person cannot move both arms and both legs). A review of Resident 6's Order Summary Report (OSR) dated 1/26/26 indicated an order to change the enteral feeding tubing every 24 hours during the evening shift. During an observation on 3/2/26 at 10:28 a.m. in Resident 6's room, the tip of the enteral feeding tube, which was not connected to the resident but remained connected to the formula line, was observed hanging from the pole without a protective cap. During an interview on 3/2/26 at 10:31 a.m. with Licensed Nurse (LN) 1, LN 1 stated that the tip of the enteral feeding tube should have had a protective cover to maintain a closed system for the formula and reduce the risk of infection. During an interview on 3/4/26 at 3:40 p.m. with the Director of Nursing (DON), the DON stated that the tip of the enteral feeding tube should have had a sterile cap when not in use. The DON further stated that if the tip did not have a cover, the enteral feeding tube had to be discarded and replaced entirely because using an uncovered tip could lead to infection. A review of the facility's policy and procedure (P&P) titled Enteral Feedings – Safety Precautions, dated 10/25, indicated, Preventing contamination: 1. Maintain aseptic technique at all times when working with enteral nutrition systems and formulas.c. Use closed enteral nutrition systems. A review of the facility's P&P titled Infection Prevention and Control Program, dated 10/25, the P&P indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During a concurrent observation and interview with the Nurse Aide in Training (NAT) on 3/4/26 at 3:47 p.m., the NAT was observed inside a resident's room wearing gloves only and without the required gown while handing snacks to residents, despite posted signage indicated STOP.Contact Plus.Please Report to Nurse Before Entering. The NAT then exited the room, retrieved an item from the snack cart without changing gloves and handed it to another resident. When asked, the NAT stated she had not noticed the signage and acknowledged she should have fully donned a gown and checked with the nurse before entering. The NAT later confirmed with a nurse that a resident in the room is on C. difficile (a bacteria that causes life-threatening diarrhea) precaution and stated it was important to fully follow PPE protocols to prevent transmission when going room to room. During an interview with the Director of Staff Development (DSD) on 3/4/26 at 3:52 p.m., the DSD stated that Contact Plus Precaution were used for residents on heightened levels of precaution such as those with C. difficile. The DSD further stated that staff were required to fully gown and glove before entering a room under Contact Plus and must wash hands with soap and water before entering and after exiting. The DSD further stated that staff were expected to follow all posted signs and warnings to protect themselves and residents and to prevent the spread of infection. During a concurrent observation and interview on 3/5/26 at 9:32 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 was observed entering a resident's room where a sign posted near the door indicated Enhanced Standard Precautions. CNA 7 was observed to be wearing gloves but did not don a gown before entering and proceeded to assist the resident in emptying the urinal. When questioned about the observation, CNA 7 stated that according to their infection prevention training he should have followed protocol and worn a gown prior to entering the room and emptying the urinal. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 3/5/26 at 9:35 a.m. outside the above mentioned resident room, the ADON and the Department observed CNA 7 inside the room assisting a resident with emptying a urinal. The ADON confirmed the observation and stated that staff were expected to fully comply with precautionary signage posted at the entrance of rooms and to follow all required protective measures when assisting residents. A review of the facility P&P, titled Infection Prevention and Control revised 6/22 indicated, .prevent the development and transmission of communicable diseases and infections.Prevention of Infection.education staff and ensuring that they adhere to proper techniques and procedures.preventing the spread to other residents. 3. Resident 52 was admitted to the facility in late 2023 with diagnosis which included a decline in memory, and difficulty swallowing. During a review of Resident 52's Order Summary Report [OSR], order date 1/16/26, the OSR indicated Resident 52 required assistance with eating meals. Resident 17 was admitted to the facility in late 2024 with diagnosis which included progressive brain disorder that causes problems with movement and muscle control, communication deficit, and difficulty swallowing. During a review of Resident 17's OSR, order date 1/16/26, the OSR indicated Resident 17 required assistance with eating meals. During a concurrent observation and interview on 3/2/26 at 12:26 p.m. of Resident 52's lunch (hamburger and French fries) with Certified Nursing Assistant (CNA 3) in the dining room, CNA 3 touched both the burger and fries with her bare hands while she assisted Resident 52 to eat her meal. CNA 3 confirmed she touched the food items with her hands. During a concurrent observation and interview on 3/2/26 at 12:27 p.m. of Resident 17's lunch (hamburger and French fries) with Rehab Aide (RA 1) in the dining room, RA 1 touched both the burger and fries with her bare hands while she assisted Resident 17 to eat his meal. RA 1 confirmed she touched the food items with her hands. During an interview on 3/2/26 at 1:51 p.m. with the Director of Staff Development (DSD), the DSD stated staff should not touch resident food with bare hands for infection control reasons, They could get sick from that. The DSD further stated she would expect staff to use some type of barrier or a fork to pick up the food. During a review of the facility's policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 10/25, the P&P indicated, An infection prevention and control program (ICPC) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's P&P titled, Assistance with Meals/Mealtime Policy, undated, the P&P indicated, .All employees who provide resident assistance with meals will comply with infection control practices.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for a census of 89 when:1. Staff did not assess for and treat Resident 12's shortness of breath;2. Staff administered the wrong dose of morphine sulfate for Resident 60; and3. Staff did not accurately complete the weekly summary for Resident 92.These findings had the potential to delay care for Resident 12 and Resident 92, cause inadequate pain control for Resident 60, lead to adverse reactions from medications for Resident 60, and compromise resident safety for Resident 92. Findings: 1. Resident 12 was admitted to the facility in February of 2024 with diagnoses that included asthma (a chronic condition that inflames and narrows the airways in the lungs) and chronic obstructive pulmonary disease (COPD) (a progressive, irreversible lung disease). A review of Resident 12's Physician Orders (PO), dated 2/10/26, indicated, Morphine Sulfate (Concentrate) [a medication used to treat pain and alleviate shortness of breath] Oral Solution 100MG [milligrams, a unit of measurement]/5ML [milliliter, a unit of measurement] (Morphine Sulfate) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Mild Pain (1-3) or Shortness of Breath A review of Resident 12's Care Plan (CP), dated 2/12/26, indicated, HOSPICE/PALLIATIVE [comfort and symptom management for serious illnesses] CARE PLAN.Administer medication as ordered. A review of Resident 12's CP, dated 2/29/26, indicated, PSYCHOSOCIAL/WELL BEING CARE PLAN.Observe for clinical changes: pain, respiratory distress, GI [gastrointestinal] distress, edema, change in LOC [level of consciousness]. During an observation on 3/4/26 at 8:23 a.m., Resident 12 was observed to have a respiration rate of about 36 breaths per minute. Resident 12 also displayed signs of shortness of breath such as accessory muscle use and opening her mouth to breath. During an observation on 3/4/26 at 9:19 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 entered Resident 12's room to prepare Resident 12 for a bed bath. After completing the bed bath and leaving the room, CNA 2 failed to report Resident 12's increased respiratory rate and shortness of breath to her supervising licensed nurse (LN). During a concurrent observation and interview on 3/4/26 at 9:48 a.m. with LN 2, LN 2 entered Resident 12's room to change her scopolamine patch (a medication used in hospice care to manage excessive secretions or nausea). After replacing the scopolamine patch, LN 2 left the room without assessing Resident 12's respiratory rate or shortness of breath. Resident 12's PO for morphine sulfate were then reviewed with LN 2, who confirmed that the last dose was given on 3/2/26 and indicated that morphine sulfate should currently be administered for Resident 12's respiratory symptoms. During an interview on 3/5/26 at 9:33 a.m. with the Director of Nursing (DON), the DON indicated that shortness of breath should be managed if it was outlined in the CP or PO. The DON further indicated that she expected staff to correctly assess residents' vital signs [blood pressure, temperature, heart rate, respiratory rate, and pain level] and report any changes or irregularities to the interdisciplinary team. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/17, the P&P indicated, In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include.Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. 2.Resident 60 was admitted to the facility in December of 2023 with diagnoses which included dementia (a condition characterized by persistent loss of intellectual functioning) and type 2 diabetes mellitus (a condition when the body cannot use insulin correctly and sugar builds up in the blood). A review of Resident 60's Order Summary Report (ORS), indicated, Morphine Sulfate Oral Solution 10mg [milligrams, a unit of measurement]/5ml [milliliters, a unit of measurement].Give 2.5 ml by mouth every 6 hours as needed for moderate (4-7) to severe (8-10) pain Hold for RR [respiratory rate] < 12. A review of Resident 60's Care Plan (CP), dated 12/18/25, indicated **COGNITIVE CARE PLAN** [Resident 60's name] has altered Cognition R/T [related to]: Dementia M/B [manifested by] Changes in skills for daily decision making.Administered meds as ordered A Review of Resident 60's CP, dated 12/18/25, indicated PAIN [Resident 60's name] Resident at risk for pain .will remain adequate level of comfort .Administer pain medication as ordered. A review of Resident 60's electronic medication administration record (EMAR) indicated that 2.5 ml of Morphine Sulfate Oral Solution was administered on 2/26/26 at 10:37 a.m. for a reported pain level of 5/10, indicating moderate pain. A review of the Resident 60's EMAR – Medication Administration Note dated 2/26/26 at 10:37 a.m., indicated, .1 ml given. During a concurrent interview and record review with Licensed Nurse (LN) 7 on 3/4/26 at 10:55 a.m., regarding the medication administration from 2/26/26 during the morning medication pass, LN 7 stated that the resident was experiencing pain and had a documented pain score of 5/10, indicating moderate pain. LN 7 confirmed that Resident 60 had an active order for Morphine Sulfate Oral Solution, 2.5 ml every six hours as needed. After reviewing the progress note, LN 7 acknowledged that the documentation reflected administration of only 1 ml and stated that she administered 1 ml instead of the ordered 2.5 ml. LN 7 confirmed this constituted a medication error and stated that no medication error report had been completed. LN 7 further stated that the physician should have been notified of the error. During an interview with the Director of Nursing (DON) on 3/4/26 at 11:45 a.m., the DON stated that licensed nurses were required to follow physician orders and confirmed that a medication error occurred when only 1 ml of Morphine Sulfate was administered by LN 7 instead of the ordered 2.5 ml. The DON further stated that no medication error report had been submitted at the time the variance occurred. A review of the facility's policies and procedures (P&P) titled, Physician Order, revised 10/25 indicated, Prescribed medications and treatment orders will be carried out in accordance with the physician/nurse practitioner's order.The licensed staff shall carry out physicians/nurse practitioner's orders as prescribed. A review of the facility's P&P titled, Medication Error, revised 10/25, indicated, The safety of the residents is the goal of care during medication passes.Whenever a medication error occurs, the nurse responsible for the error or the staff who caught the medication error will:.Inform the DNS [DON].the nurse will immediately contact the physician.The nurse involved will be involved with filling out the Medication Error Report. 3. Resident 92 was admitted to the facility in late 2022 with diagnosis which included stroke with right side weakness, inability to urinate, urinary retention and urinary tract infections. During a review of resident 92, Order Summary Report, [OSR] order date 4/10/25, the OSR indicated Resident 92 had an order for an indwelling catheter (a thin flexible tube inserted into the bladder to drain urine). During a review of Resident 92's Care Plan Report [CP], date initiated 4/10/25, the CP indicated, INDWELLING URINARY CATH CARE PLAN [Resident 92] requires an indwelling urinary catheter R/T [related to].At risk for Chronic UTIs [urinary tract infections].Monitor urine for sediments, cloudy, odor, blood.Monitor I&O [intake and output, record of fluid that enter the body and fluid that leaves the body] as indicated. During a review of Resident 92's Weekly Summary Notes [WSN], dated 1/15/26 and 1/22/26, the WSN indicated, Is Resident on I&O? No.Average 24-hour Intake: [question not answered], Average 24-hour Output: [question not answered], Urine Color: [question not answered], Consistency: [question not answered], Urine Color: [question not answered], Urine Odor: [question not answered], Clarity: [question not answered], Skin Turgor: [question not answered], Edema: [question not answered], Mucous Membrane: [question not answered]. During a review of Resident 92's hospital records dated 1/28/26, the hospital records indicated Urinary tract infection associated with indwelling catheter. During a concurrent interview and record review on 3/5/26 at 9:30 a.m. with the Director of Nursing (DON), the DON stated all residents were on I&O monitoring and the question in the WSN, Is Resident on I&O? should have been marked Yes. The DON confirmed Resident 92's WSN dated 1/15/26 and 1/22/26 indicated an answer of No for I&O monitoring. The DON confirmed the WSN was not accurate which created a missed opportunity to assess the urine for Resident 92 and stated the documentation should have been accurate for a resident who had an indwelling catheter and was at risk for urinary tract infections. During a review of the facility's policy and procedure (P&P) titled, Weekly Summary Documentation, dated 10/25, the P&P indicated, It is the policy of this facility to provide a weekly summary documentation.The assigned nurse shall complete a weekly summary. During a review of the facility's P&P titled, Intake and Output Measuring and Recording, dated 10/25, the P&P indicated, .Intake and output monitoring is indicated for residents with.Indwelling catheter. During a review of the facility's P&P titled, Catheter Care, Urinary, dated 10/25, the P&P indicated, .The following information should be recorded into the resident's medical record.Character of urine such as color.clarity.and odor.

Based on observation, interviews, and record review the facility failed to ensure that the physical environment was maintained in a clean, safe, and homelike condition. One of five corridors containing15 resident rooms, a hole was observed in the ceiling. The ceiling around the hole showed visible water damage including staining and deterioration consistent with a leak from a pipe above the celling. This failure to maintain the building structure in good repair has the potential to lead to mold growth, further structural damage and safety hazards for residents.Findings:During an observation on 3/4/26 at 10:03 a.m., in the resident corridor, the Department observed a hole in the ceiling surrounded by black and white substance, with visible water marks and water damage consistent with moisture intrusion.During a concurrent observation and interview with Licensed Nurse (LN 7) in the resident corridor on 3/4/26 at 10:19 a.m., LN 7 confirmed the findings described above and acknowledged that the ceiling hole had water marks and was surrounded by black and white substance. LN 7 further stated that the condition should have been reported to the maintenance department and that such issues should not be present as they may pose potential health concerns for residents.During a concurrent interview and record review with LN 7 on 3/4/26 at 10:24 a.m., LN 7 confirmed that the above noted findings had not been reported in the facility's maintenance log.During a concurrent observation and interview with the Director of Plant Operations (DPO) on 3/4/26 at 10:38 a.m., the DPO stated that the finding had not been reported. The DPO confirmed that the hole was surrounded by black and white substance and stated that the damage was caused by water intrusion. The DPO indicated that the facility had recently experienced roof leaks and stated that he was responsible for ensuring the facility remained in good repair and condition. The DPO acknowledged the environment should be maintained in a homelike manner for the residents.During a concurrent observation and interview with the DPO on 3/4/26 at 4:07 p.m., the DPO confirmed that there had been a leaking water pipe in the ceiling and that it had caused water damage to a portion of the ceiling.During a concurrent interview with the facility Administrator (ADM), on 3/4/26 at 12:55 p.m., the ADM confirmed the findings described above and stated that the facility should be maintained in good repair and condition. The ADM further stated that the facility should provide a homelike, comfortable, and safe environment for the residents. The ADM added that staff should have reported the findings promptly so the issue could have been addressed and corrected sooner.A review of the facility's Policy and Procedures (P&P) titled, Homelike Environment, revised10/26, the P&P indicated, Residents are provided with a safe, comfortable, and homelike environment.A review for the facility's P&P titled, Maintenance Service, revised 10/25, The P&P indicated, The maintenance Department is responsible for maintaining the buildings.safe and operable manner.Maintaining the building in good repair.plumbing fixtures.

Based on observation, interview, and record review, the facility did not ensure the medication error rate did not exceed 5% for a census of 89 when: Resident 95's pantoprazole (a medication used to treat heartburn) was crushed;Resident 95's liquid fluconazole (a medication used to treat fungal diseases) was not shaken prior to administration; andResident 60 did not receive the ordered dose of her liquid morphine. These failures resulted in a medication error rate of 10.34% with three medication errors observed out of 29 medication administration opportunities. Findings: 1. Resident 95 was admitted to the facility in February of 2026 with diagnoses that included candidal esophagitis (a fungal infection of the esophagus) and gastroesophageal reflux disease (GERD, a chronic condition where stomach acid frequently flows back into the esophagus, causing symptoms like heartburn, regurgitation, chest pain, and difficulty swallowing). A review of Resident 95's fluconazole pharmacy label indicated, Give 10ml [milliliters, a unit measurement for liquids] via G-Tube [a tube inserted into the stomach to administer nutrition] one time a day for ESOPHAGEAL CONDIDIASIS [a type of fungal infection] UNTIL 3/04/26.SHAKE WELL. During a concurrent observation and interview on 3/2/26 at 8:38 a.m. with Licensed Nurse 3 (LN 3), LN 3 prepared and administered 10ml of fluconazole to Resident 95 without shaking the medication bottle and ensuring the contents of the bottle were adequately mixed. After the medication administration, LN 3 confirmed that fluconazole should be shaken prior to being administered. 2. A review of Resident 95's Physician Orders (PO) for pantoprazole, dated 2/21/26, indicated, Pantoprazole Sodium Oral Tablet Delayed Release 40 MG [milligrams, a unit of measurement] (Pantoprazole Sodium) Give 1 tablet by mouth two times a day for GI [gastrointestinal] bleeding Do Not Crush. During a concurrent observation and interview on 3/2/26 at 3:24 p.m. with LN 4 and LN 5, LN 5 was observed crushing Resident 95's pantoprazole tablet prior to being administered. LN 5 then administered the crushed tablet to Resident 95. After the medication was administered, Resident 95's PO for pantoprazole were reviewed with LN 4 and LN 5, and both LN 4 and LN 5 confirmed pantoprazole should not be crushed prior to administration. During an interview on 3/5/26 at 9:33 a.m. with the Director of Nursing (DON), the DON indicated that staff should administer medications to residents according to the PO. The DON further indicated that staff should call pharmacy and double check if medications can be crushed prior to doing so. During a review of the facility Policy and Procedure (P&P) titled, Crushing Medications, revised 10/25, the P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.When such a medication is administered, the facility staff will observe the resident for pertinent adverse effects. During a review of the facility PNP titled, Physician Orders, revised 8/24, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. 3.Resident 60 was admitted to the facility in December of 2023 with diagnoses which included dementia (a condition characterized by persistent loss of intellectual functioning) and type 2 diabetes mellitus (a condition when the body cannot use insulin correctly and sugar builds up in the blood). A review of Resident 60's Order Summary Report (ORS), indicated, Morphine Sulfate Oral Solution 10mg [milligrams, a unit of measurement]/5ml [milliliters, a unit of measurement].Give 2.5 ml by mouth every 6 hours as needed for moderate (4-7) to severe (8-10) pain Hold for RR [respiratory rate] < 12. A review of Resident 60's Care Plan (CP), dated 12/18/25, indicated **COGNITIVE CARE PLAN** [Resident 60's name] has altered Cognition R/T [related to]: Dementia M/B [manifested by] Changes in skills for daily decision making.Administered meds as ordered A Review of Resident 60's CP, dated 12/18/25, indicated PAIN [Resident 60's name] Resident at risk for pain .will remain adequate level of comfort .Administer pain medication as ordered. A review of Resident 60's electronic medication administration record (EMAR) indicated that 2.5 ml of Morphine Sulfate Oral Solution was administered on 2/26/26 at 10:37 a.m. for a reported pain level of 5/10, indicating moderate pain. A review of the Resident 60's EMAR – Medication Administration Note dated 2/26/26 at 10:37 a.m., indicated, .1 ml given. During a concurrent interview and record review with Licensed Nurse (LN) 7 on 3/4/26 at 10:55 a.m., regarding the medication administration from 2/26/26 during the morning medication pass, LN 7 stated that the resident was experiencing pain and had a documented pain score of 5/10, indicating moderate pain. LN 7 confirmed that Resident 60 had an active order for Morphine Sulfate Oral Solution, 2.5 ml every six hours as needed. After reviewing the progress note, LN 7 acknowledged that the documentation reflected administration of only 1 ml and stated that she administered 1 ml instead of the ordered 2.5 ml. LN 7confirmed this constituted a medication error and stated that no medication error report had been completed. LN 7 further stated that the physician should have been notified of the error. During an interview with the Director of Nursing (DON) on 3/4/26 at 11:45 a.m., the DON stated that licensed nurses were required to follow physician orders and confirmed that a medication error occurred when only 1 ml of Morphine Sulfate was administered by LN 7 instead of the ordered 2.5 ml. The DON further stated that no medication error report had been submitted at the time the variance occurred. A review of the facility's policies and procedures (P&P) titled, Physician Order, revised 10/25 indicated, Prescribed medications and treatment orders will be carried out in accordance with the physician/nurse practitioner's order.The licensed staff shall carry out physicians/nurse practitioner's orders as prescribed. A review of the facility's P&P titled, Medication Error, revised 10/25, indicated, The safety of the residents is the goal of care during medication passes.Whenever a medication error occurs, the nurse responsible for the error or the staff who caught the medication error will:.Inform the DNS [DON].the nurse will immediately contact the physician.The nurse involved will be involved with filling out the Medication Error Report.

Based on observation, interview, and record review, the facility failed to implement their medication storage policy for a census of 89 when expired medications were not disposed of.These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date.Findings:A review of the fluticasone propionate/salmeterol (drugs to aide in breathing) 250mcg/50mcg (micrograms, a unit of measurement) inhaler manufacturer box indicated to discard the product one month after opening.During a concurrent observation and interview on 3/2/26 at 1:35 p.m. with Licensed Nurse 2 (LN 2), medication cart two contained an expired propionate/salmeterol 250mcg/50mcg inhaler with an open date of 1/4/26. The inhaler was being stored with other inhaled medications. LN 2 confirmed the inhaler was expired and indicated that using an inhaler past its expiration date could lead to a loss of effectiveness.During a concurrent observation and interview on 3/3/26 at 9 a.m. with Licensed Nurse 6 (LN 6), the following medications were found to be expired and available for use in the wound treatment cart: two diclofenac sodium 1% gel (a medication used to treat pain and other symptoms of arthritis of the joints) tubes, a triamcinolone 0.1% cream (a medication used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions), and a bottle of ketoconazole 2% shampoo (a medication used to treat infections caused by a fungus). LN 6 confirmed the medications were expired and being stored in the cart. LN 6 then indicated that expired medications should be disposed of.During an interview on 3/5/26 at 9:33 a.m. with the Director of Nursing (DON), the DON indicated that nursing staff should not store expired medications in the medication carts and expects nursing staff to dispose of expired medications.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling, revised 8/24, the P&P indicated, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.Follow the manufacturer's expiration date for inhalers.

Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for two of 21 sampled residents (Resident 25 and Resident 54) when:1. Resident 25's breakfast tray left within reach without staff present; and2. Resident 54's call light was not within reach.These deficiencies had the potential to place Resident 25 at risk for aspiration and resulted in delayed staff response for Resident 54's needs. Findings: 1. A review of Resident 25's admission records indicated the resident was admitted in late 2025 with diagnoses including dysphagia (difficulty swallowing) and pneumonitis (swelling of lung tissue) due to the inhalation of food and vomit. A review of Resident 25's Minimum Data Set (MDS) dated [DATE] indicated the Brief Interview for Mental Status (BIMS) could not be conducted and the resident was rarely/never understood. Section C of the MDS further indicated that Resident 25's cognitive skills for daily decision making score was 2 (moderately impaired—decisions poor; cues/supervision required). A review of Resident 25's Order Summary Report (OSR) dated 3/2/26, the OSR indicated, .Pureed texture .Mildly Thick consistency, Feed assist for breakfast . During an observation on 3/3/26 at 8:16 a.m., Resident 25's breakfast tray was noted uncovered and within reach without staff present. During an interview on 3/3/26 at 8:24 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 25 could eat independently with supervision, but she had left the Resident 25 to assist another resident. During an interview on 3/3/26 at 8:45 a.m. with Licensed Nurse (LN) 1, LN1 stated Resident 25 required both supervision and assistance during meals due to the risk of aspiration and was undergoing a feeding trial. During a concurrent interview and record review on 3/4/26 at 9:46 a.m. with the Speech Language Pathologist (SLP), the SLP stated staff were required to supervise Resident 25 during meals. The SLP further stated the resident's diet was downgraded recently from minced and moist to pureed and that she had educated staff, including Restorative Nursing Assistants (RNAs) and CNAs, regarding diet and swallow precautions. A review of the facility's undated policy titled Assistance with Meals/Mealtime Policy indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. A review of the facility's policy titled Accommodation of Needs, dated 10/25, indicated, .staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. 2. Resident 54 was admitted to the facility in Spring of 2025 with diagnoses which included cerebral infraction (stroke, due to a blockage in the blood vessels supplying blood to the brain) and aphasia (a language disorder that affects how you communicate). A review of Resident 54's Order Summary Report (ORS) indicated, Resident capable of making own decisions A review of Resident 54's Care Plan (CP), dated 1/12/26, indicated **PAIN** [Resident 54's name] is at risk for pain related to.CVA/Post Stroke Syndrome. A review of Resident 54's CP, dated 1/12/26, indicated **FALL CARE PLAN** [Resident 54's name].Approach: Keep call light within reach. A review of Resident 54's Weekly Summary Notes (WSN) dated 2/25/26, indicated Resident 54 was dependent on basic activities of daily living (ADL's) and mobility. During an initial tour of the facility on 3/2/26 at 9:47 a.m., Resident 54 was observed lying on bed crying and grimacing. The Department asked Resident 54 if she needed help, and the resident nodded. When asked whether she had attempted to use the call light to request help, Resident 54 attempted to reach for the call light cord, which was observed to be looped around the bed rails. The resident tried to pull the call light cord but she was unable to. When asked if it was stuck, Resident 54 nodded. The Department confirmed that the call light button was lodged between the mattress and the bed frame, making the call light system inaccessible to the resident. During a concurrent observation and interview with Certified Nurse Assistant (CNA) 4 on 3/2/26 at 10 a.m., in the Resident 54's room, CNA 4 confirmed the findings above and stated that the call light was difficult for Resident 54 to reach because it was stuck between the mattress and the bed frame, and that it should have been positioned closer to the resident. CNA 4 further stated, I could check more often. During a concurrent observation and interview with Licensed Nurse (LN) 2 on 3/2/26 at 11:13 a.m., LN 2 stated that call lights should not be wrapped around bed rails and should instead be clipped or placed across the resident's lap or otherwise within reach. LN 2 further stated that if residents were unable to use their call light to request staff assistance, staff would not be able to assess or respond to the resident's needs. LN 2 added that it was especially important for Resident 54 to have the call light within reach because the resident was choking risk. During an interview with the Assistant Director of Nursing (ADON) on 3/5/26 at 9:32 a.m., the ADON stated that staff should check on residents in their rooms as much as possible, inquire about any specific needs, and scan the rooms for potential hazards. The ADON confirmed that staff receive training on proper call light placement and were expected to ensure call lights were within the resident's reach before leaving the room. The ADON further stated that if call lights were not positioned properly, residents would be unable to call for help or request medications. A review of the facility's Policy and Procedures (P&P) titled, Answering Call Light revised 9/2025, the P&P indicated Residents, when in their rooms.will have the ability to call for assistance.When the resident is in bed.be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure 9 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9,15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents occupancy or 76.2 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 27 residents residing in these rooms for a census of 89 residents.Findings:The observations were made throughout the survey in rooms 3, 4, 5, 6, 7, 8, 9, 15 and 16. The rooms had enough space to store assistive devices, like wheelchairs and walkers, and staff were able to provide care.During an interview on 3/2/26 at 1:04 p.m. with Licensed Nurse (LN) 1, LN 1 stated they were able to give resident care in the rooms without any problems.During a concurrent observation and interview on 3/3/26 at 11:30 a.m. Certified Nursing Assistant (CNA) 1, CNA 1 was seen using a sit to stand device to move Resident 16 from the resident's room to the shower room. CNA 1 stated she did not need to move any items in the room to use the device safely.During an interview on 3/3/26 at 1:15 p.m. with the Director of Plant Operations (DPO), the DPO stated no changes had been made to the size or layout of any of the resident rooms.During an observation on 3/4/26 at 10:51 in Resident 7's room, Resident 7 walked from the bed to the closet, took out clothing, and prepared for a shower without any difficulty.Interviews conducted during the survey process with available residents living in the affected rooms showed that the residents felt they had sufficient space to receive care.During a concurrent interview and record review on 3/5/26 at 1 p.m. with the Administrator (ADM), the rooms' dimension were reviewed. the ADM confirmed that Rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 measured 228.55 square feet for three residents. The ADM confirmed that each resident should have 80 square feet.The Department recommends continuation of the waiver for the above-mentioned rooms.

Based on the interview and record review, the facility failed to protect one of three sampled residents (Resident 2) to be free from physical abuse when Resident 1 swung his arms several times at Resident 2, contacting Resident 2's upper body.This failure resulted in Resident 2 with pain from being hit.During a review of Resident 1's admission record (AR), dated 9/23/25 (print date), the AR indicated that Resident 1 was admitted to the facility in mid-2025 with diagnoses which included dementia (memory loss that gets worse over time), anxiety (fear, worry), depression (a serious mood disorder causing prolonged feelings of sadness or loss of interest that interfere with daily life), restlessness and agitation.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/21/25, the MDS indicated Resident 1 had severely impaired cognition.During a review of Resident 1's care plan (CP) titled, COMBATIVE/PHYSICAL CARE PLAN initiated on 8/16/25, the CP indicated that Resident 1 had a history of being physically combative and abusive and was striking out and grabbing. The care plan further indicated, [Resident 1] Will not harm self and/or others secondary to socially inappropriate and/or disruptive combative behavior.During a review of Resident 1's nursing note (NN), dated 8/17/25, the NN indicated, [Resident 1] Disoriented, delusional, unaware of social distance, aggressive later in evening shift. Unable to be redirected. Going into other rooms and being resistive when told to leave. Touching med carts and things at the ns' [Nurse's] station. DON [Director of Nursing] and ADON [Assistant Director of Nursing] informed of concerns via telephone call.During a review of Resident 1's NN, dated 9/18/25 at 8:53 p.m., the NN indicated, [Resident 1] noted with attempt elopement at 2000 [8:00 p.m.]. Redirected into facility. Resident noted wandering off to side one as usual. This writer continued with medication administration when I heard a loud commotion. [Resident 1] seen attempting to assault another [Resident 2] while 3 staff members were separating both parties. [Resident 1] was unable to calm down and continue to resist staff then became combative with staff. PA [Physician Assistant] notified with orders to send out to acute. 911 arrived then transferred resident to acute care [hospital].During a review of Resident 1's NN, dated 09/18/25 at 22:31, the NN indicated, Behaviors: Restless, angry, combative and agitated. Resident is out of facility in acute care at this time. [Resident 1] attempted to elope with constant redirecting. requires wander guard [a monitoring device] due to elopement risk and poor safety awareness. [Resident 1] became angry then attempted to assault another resident. Both parties separated. This resident couldn't calm down and had to be restrained until PPD [police] arrived.During a review of Resident 2's AR, dated 9/23/25 (print date), the AR indicated that Resident 2 was admitted to the facility at the end of 2024 with diagnoses which included cerebral edema (a brain swelling caused by excess fluid buildup in brain tissue), dementia, and depression.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition.During a review of Resident 2's CP titled, DEMENTIA CARE PLAN, initiated on 12/5/24, the CP indicated that Resident 2 has memory impairment with short and long term problem. risk for behavioral problems.During a review of Resident 2's NN dated 9/18/25 at 9:46 p.m. indicated, Resident noted involved in attempted physical altercation with another resident. Both parties separated immediately and kept apart.During a review of Resident 3's AR, dated 9/23/25 (print date), the AR indicated that Resident 3 was admitted to the facility in late 2022 with diagnoses which included low back pain and depression.During a review of Resident 3's MDS, dated [DATE], the MDS indicated that Resident 3 had intact cognitive abilities.During a review of the facility's security camera footage video titled Hall 2 (Man Cave) time stamped yesterday [9/18/25] 8:43-8:45 p.m., the video recording showed Resident 2 sitting on the wheelchair in the hallway. Resident 2 extended her right arm, blocking Resident 1's passage as he walked down the hallway and grabbed Resident 1 on his right hand, and Resident 1 reacted and pulled back his right hand and reached for Resident 2's neck not completely making contact with the neck as his hand moved down to Resident 2's upper chest area. Resident 1 swung his arms around, contacting Resident 2's arms a few times before the staff were able to pull both residents apart.During a concurrent observation and interview on 9/23/25 at 2:50 p.m. with Certified Nurse Assistant (CNA 1) in the facility's hallway, CNA 1 pointed out facility locations and described an incident that happened between Resident 1 and Resident 2 on 9/18/25. CNA 1 stated that initially, she was in room [ROOM NUMBER] as Resident 1 wandered into the room (room [ROOM NUMBER]), and she had to ask him to get out of the room because it was not his room. CNA 1 further stated that Resident 1 became agitated and responded with foul language and went out walking down the adjacent hallway towards the area close to room [ROOM NUMBER] and room [ROOM NUMBER], where Resident 1 was sitting on the w/c in the hallway. CNA 1 further stated that she saw how Resident 1 hit Resident 2 in the chest area.During an interview on 9/23/25 at 3:19 p.m. with Resident 2, Resident 2 stated that there was a guy in the hallway who twisted her hand and hit her on the chest, and it did hurt.During an interview on 9/23/25 at 4:39 p.m. with Resident 3, Resident 3 stated that few days ago she was in the hallway next to Resident 2 as she saw how Resident 1 approached Resident 2. Resident 3 further stated that during the incident, Resident 2 moved her arm out, blocking the passage to Resident 1, and Resident 1 pushed back on her and then hit her on the arm and chest. Resident 3 stated it was an audible hard hit by Resident 1.During a video call interview on 9/24/25 at 11:30 a.m. with the Director of Nursing (DON), the DON confirmed that she expected facility residents to be free from abuse, including physical abuse and undesirable touching.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/20/21, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility -wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents.

Based on observation, interview and record review, the facility failed to ensure the medical record for one of four sampled residents (Resident 1's) was accurate, consistent and timely when the clinical assessments were contradictory and inconsistent among healthcare professionals.This failure had the potential to lead to incorrect clinical decisions, delays in care and an increased risk of misdiagnosis and inappropriate treatment for Resident 1. Findings: Resident 1 was admitted to the facility in March of 2025 with diagnoses which included heart failure and heart disease from plaque (fat, cholesterol, calcium and other substance inside the walls of the arteries that could cause a blood clot or limit blood flow) buildup. A review of Resident 1's Order Summary Report (ORS), 4/1/25, indicated, Resident has capacity to make his decisions related to. A review of Resident 1's Progress Notes (PN), dated 6/10/25, indicated, Type: IDT [Interdisciplinary Team] NOTE. He [Resident 1] has been observed independently walking throughout facility and is not a risk for contractures; appropriate for D/C [discharge] form [from] RNA [Restorative Nursing Assistant] program at this time. A review of Resident 1's PN dated, dated 6/20/25, The PN indicated, Type: IDT NOTE. OT [Occupational Therapy] conducted AE [Adverse Event] audit; met with resident to assure that they were able to independently and efficiently feed themselves with/without AE. [Resident 1's name] is independent with feeding with/without AE.A review of Resident 1's Nursing - Weekly Summary (NWS), dated 6/29/25, indicated Resident 1 was independent with ADL's (Activities of Daily Living) which included: Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. A review of Resident 1's NWS, dated 7/27/25, indicated that Resident 1 was independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's NWS, dated 8/3/25, indicated that Resident 1 remains independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's Care Plan (CP), dated 8/1/24, indicated, Expresses/indicates a preference to: Return home with part time caregiver.Projected stay is expected to be of short durationA review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 8/2/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating a normal cognitive function and indicated Resident 1 was independent in all Functional Abilities which included eating, toileting, showering, transferring and walking. A review of Resident 1's PN, dated 8/13/25, indicated, Type: Social Service Note.It is noted that this res [Resident 1] does not need or require SNF [Skilled Nursing Facility] level of care, it has been determined he no longer meets the Medicare or Medicaid guidelines for continued nursing home care.During an interview on 8/20/25 at 12:20 p.m., with the License Nurse (LN) 1, LN 1 stated that Resident 1 was independent in performing all ADLs and required assistance only with medication administration. LN 1 further stated that the resident was consistently compliant with his medications.During an interview on 8/20/25 at 12:30 p.m., with the License Nurse Supervisor (LNS), LNS stated that Resident 1 was, Extremely independent and he has his own primary care doctor. During an interview on 8/20/25 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated that Resident 1 was fully independent and did not require SNF level of care. The SSD also stated, He does everything on his own. I explained to them that he does not need this level of care and there are other options that fit his needs. The SSD further described Resident 1 as high functioning. During an interview on 8/20/25 at 1:35 p.m., with Director of Nursing (DON), the DON stated, [Complainant] came to me a couple of months ago and began questioning why the patient does not have physician assessments in his chart. I explained to her that he has a doctor outside of the facility and that he is in total care of [Resident 1's name]. The DON stated, He [Resident 1's primary care physician (PCP)] would call me after hours and explain to me that he will get information to me the next business day, that did not happen. The DON further stated that [Complainant] requested justification for the patient's need for SNF level care. During a telephone interview on 8/21/25 at 2:40 p.m. with the DON, the DON confirmed that Resident 1 was stable and independent, and based on facility documentation and assessments, the resident did not require a SNF level of care. The DON further stated, The facility was also investigating this incident involving his stay since last May without any clinical justifications.A review of the facility document from the Medical Director (MD), dated 8/22/25, the document indicated, I have been asked to review this patient's medical history and functional status in order to assist with the determination of the patient's medical necessity to be in skilled nursing setting. There has not been any documented functional decline observed by staff here at the nursing facility. It has been recommended that he transition to a lower level of care as he is too high functioning for the nursing home setting. In contrast to the facility's assessments and staff interviews of Resident 1, Resident 1's PCP's email to the DON on 8/21/25 indicated, Patient is forgetful and poses a safety risk with regards to medication management and IADLs [sic]. will need constant supervision. This letter is being written for the purpose of recommendations for the continued SNF stay for the patient. During a follow-up phone interview on 8/21/25 at 4:50 p.m. with the DON, The DON stated that after receiving an email from Resident 1's PCP containing justification for the resident's continued need for SNF level of care, the facility reviewed the information and did not agree with the PCP's justification. The DON also confirmed that there were communication issues between the facility and Residents 1's PCP and inconsistencies regarding Resident 1's assessments for SNF level of care.During a phone interview on 8/26/25 at 3:08 p.m. with the MD, the MD acknowledged that there was communication and documentation issues between Resident 1's PCP and the facility. The MD confirmed that Resident 1 did not require skilled nursing SNF level of care.During a telephone interview on 8/28/25 at 3:12 p.m., the DON stated that she had obtained documents from Resident 1's PCP for the resident's past assessments. The DON confirmed that those documents had not been entered into the resident's medical record prior to their receipt. On 8/28/25, the DON provided via secured email the PCP's past assessments, TYPE: Physician Progress Notes (Narrative) for Resident 1 which she obtained that day, included those dates 08/14/25, 07/18/25, 06/20/25, 05/02/25, 04/18/25, 03/5/25, 02/07/25, 01/08/25, 12/20/24, and 11/20/24.Review of the facility's policies and procedures (P&P) titled, Charting and Documentation, dated 7/17, the P&P indicated, All services provided to the resident. shall be documented in the resident's medical record. Documentation in the medical record will be. complete, and accurate.A Review of the facility P&P titled, Charting Errors and/or Omissions, dated, 12/06, the P&P indicated, Accurate medical records shall be maintained by this facility.

Based on observations, interviews, and record review, the facility failed to ensure Medical Director provided oversight and coordination of care for one of four sampled residents (Resident 1) when the MD did not step in and resolve differing clinical opinions about whether Resident 1 was ready for discharge.This failure placed the resident at risk for being discharged prematurely or kept unnecessarily in Skilled Nursing level of care and raised concerns for care coordination, accountability and patient safety. Findings: Resident 1 was admitted to the facility in March of 2025 with diagnoses which included heart failure and heart disease from plaque (fat, cholesterol, calcium and other substance inside the walls of the arteries that could cause a blood clot or limit blood flow) buildup. A review of Resident 1's Order Summary Report (ORS), 4/1/25, indicated, Resident has capacity to make his decisions related to. A review of Resident 1's Progress Notes (PN), dated 6/10/25, indicated, Type: IDT [Interdisciplinary Team] NOTE. He [Resident 1] has been observed independently walking throughout facility and is not a risk for contractures; appropriate for D/C [discharge] form [from] RNA [Restorative Nursing Assistant] program at this time. A review of Resident 1's PN dated, dated 6/20/25, The PN indicated, Type: IDT NOTE. OT [Occupational Therapy] conducted AE [Adverse Event] audit; met with resident to assure that they were able to independently and efficiently feed themselves with/without AE. [Resident 1's name] is independent with feeding with/without AE. A review of Resident 1's Nursing - Weekly Summary (NWS), dated 6/29/25, indicated Resident 1 was independent with ADL's (Activities of Daily Living) which included: Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. A review of Resident 1's NWS, dated 7/27/25, indicated that Resident 1 was independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's NWS, dated 8/3/25, indicated that Resident 1 remained independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's Care Plan (CP), dated 8/1/24, indicated, Expresses/indicates a preference to: Return home with part time caregiver.Projected stay is expected to be of short duration A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 8/2/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating a normal cognitive function and indicated Resident 1 was independent in all Functional Abilities which included eating, toileting, showering, transferring and walking. A review of Resident 1's PN, dated 8/13/25, indicated, Type: Social Service Note.It is noted that this res [Resident 1] does not need or require SNF [Skilled Nursing Facility] level of care, it has been determined he no longer meets the Medicare or Medicaid guidelines for continued nursing home care. During an interview on 8/20/25 at 12:20 p.m., with the License Nurse (LN) 1, LN 1 stated that Resident 1 was independent in performing all ADLs and required assistance only with medication administration. LN 1 further stated that the resident was consistently compliant with his medications. During an interview on 8/20/25 at 12:30 p.m., with the License Nurse Supervisor (LNS), LNS stated that Resident 1 was, Extremely independent and he has his own primary care doctor. During an interview on 8/20/25 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated that Resident 1 was fully independent and did not require SNF level of care. The SSD also stated, He does everything on his own. I explained to them that he does not need this level of care and there are other options that fit his needs. The SSD further described Resident 1 as high functioning. During an interview on 8/20/25 at 1:35 p.m., with Director of Nursing (DON), the DON stated, [Complainant] came to me a couple of months ago and began questioning why the patient does not have physician assessments in his chart. I explained to her that he has a doctor outside of the facility and that he is in total care of [Resident 1's name]. The DON stated, He [Resident 1's primary care physician (PCP)] would call me after hours and explain to me that he will get information to me the next business day, that did not happen. The DON further stated that [Complainant] requested justification for the patient's need for SNF level care. During a telephone interview on 8/21/25 at 2:40 p.m. with the DON, the DON confirmed that Resident 1 was stable and independent, and based on facility documentation and assessments, the resident did not require a SNF level of care. The DON further stated, The facility was also investigating this incident involving his stay since last May without any clinical justifications. A review of the facility document from the Medical Director (MD), dated 8/22/25, the document indicated, I have been asked to review this patient's medical history and functional status in order to assist with the determination of the patient's medical necessity to be in skilled nursing setting. There has not been any documented functional decline observed by staff here at the nursing facility. It has been recommended that he transition to a lower level of care as he is too high functioning for the nursing home setting. In contrast to the facility's assessments and staff interviews of Resident 1, Resident 1's PCP's email to the DON on 8/21/25 indicated, Patient is forgetful and poses a safety risk with regards to medication management and IADLs [sic]. will need constant supervision. This letter is being written for the purpose of recommendations for the continued SNF stay for the patient. During a follow-up phone interview on 8/21/25 at 4:50 p.m. with the DON, The DON stated that after receiving an email from Resident 1's PCP containing justification for the resident's continued need for SNF level of care, the facility reviewed the information and did not agree with the PCP's justification. The DON also confirmed that there were communication issues between the facility and Residents 1's PCP and inconsistencies regarding Resident 1's assessments for SNF level of care. During a phone interview on 8/26/25 at 3:08 p.m. with the MD, the MD stated, I have not worked with Resident 1's PCP, and I do not have a professional relationship with him. I cannot discharge a patient that is not mine. She further stated, I am not his PCP; I am just the Medical Director for the whole building. The MD also acknowledged that there were communication and documentation issues between Resident 1's PCP and the facility. Additionally, the MD confirmed that Resident 1 does not require skilled nursing facility (SNF) level of care and stated, everyone in the facility believes he is ready but [PCP name]. During a phone interview on 9/2/25, at 3:21 p.m. with the DON, when asked about the Medical Director's role in relation to discrepancy with assessments, the DON stated that considering the MD had already provided her opinion on the matter, The DON cannot force Resident 1 to be followed by the MD. The DON further stated that based on observations and the information available to the MD, The MD has expressed her professional judgment. The DON further stated that the situation ultimately falls within the ethical boundaries and discretion of the physicians involved. A review of the facility Policy and Procedures (P&P) titled, Medical Director, dated 4/25, the P&P indicated, The medical director is responsible for implementation of resident care policies and coordination of medical care in the facility. Coordination of medical care in the facility includes: actively participating in the facility assessments. implementing and supervising resident care policies and practices . intervening with a health care practitioner regarding medical care. A review of the facility document titled, MEDICAL DIRECTORSHIP AGREEMENT, the agreement indicated, Medical Director Roles.The medical director is involved in all levels of individualized patient care and supervision, and for all persons served by the facility. Role 1 - Physician Leadership. The medical director helps serve as the physician responsible for overall care and clinical practices carried out at the facility. Other Expectations. Developing a liaison with attending staff physicians to ensure that the patients in the Facility receive effective and prompt medical care.

Based on observation, interview, and record review, the facility failed to maintain room temperature at a comfortable and safe level for four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) out of a census of 88, when: 1. Resident 1 ' s, Resident 2 ' s, Resident 3 ' s, and Resident 4 ' s room temperatures were below 71 degrees Fahrenheit ( F; a unit of measure); and 2. The maintenance department did not provide alternative heat sources after the heating, ventilation, and air conditioning (HVAC) system broke. These failures increased the residents ' potential for discomfort and loss of body heat. Findings: 1. During an observation on 12/10/24 at 9:59 a.m., rooms [ROOM NUMBER] were located in the facility ' s back hallway. The rooms and hallway were cold. During a concurrent observation and interview on 12/10/24 at 11:30 a.m. with the Maintenance Director (MD), room temperatures were checked in rooms 33-35. MD stated the room temperatures were too low for the residents ' comfort and confirmed the following: -room [ROOM NUMBER] ' s temperature was 70.2 F; -room [ROOM NUMBER] ' s temperature was 68.1 F; -room [ROOM NUMBER] ' s temperature was 67.1 F; and -The hall thermostat outside room [ROOM NUMBER] indicated a 67 F. A review of Resident 1's Admission Record, indicated he was readmitted to the facility on [DATE] with multiple diagnoses including heart failure and cerebral infarction (stroke; loss of blood flow to a part of the brain). A review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), indicated on 11/22/24 his brief interview for mental status (BIMS) score was 15 out of 15 with intact memory. During a concurrent observation and interview on 12/10/24 at 11:05 a.m. with Resident 1, in room [ROOM NUMBER], Resident 1 was wearing a hospital robe and covered with a sheet, coverlet, and velour blanket. Resident 1 stated the extra blankets were offered by staff and did not help. Resident 1 also stated he felt cold most of the time since Thanksgiving weekend and his daily requests for a floor heater had gone unanswered. A Review of Resident 2s Admission Record, indicated he was readmitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident 2 ' s MDS, indicated on 11/26/24 his BIMS score was 15 out of 15 with intact memory. During an interview on 12/10/24 at 11:11 a.m. with Resident 2, Resident 2 stated I have been begging them for a floor heater every day since the (main) heater quit working. They only bring me more blankets. Resident 2 also stated he constantly had a cold nose and ears and that was uncomfortable for him. A review of Resident 3's Admission Record, indicated she was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident 3 ' s MDS, indicated on 11/22/24 her BIMS score was 15 out of 15 with intact memory. During a concurrent observation and interview on 12/10/24 at 11:17 a.m. with Resident 3, in room [ROOM NUMBER], Resident 3 was wearing a winter robe and sitting in her wheelchair by her bed. Resident 3 stated she had been freezing nonstop since the heater broke, and she was very upset about the issue. Staff offered her extra blankets for her bed - she already had three blankets and got two more from the Certified Nursing Assistants (CNAs). Resident 3 also stated, At nighttime, I get really cold. It ' s terrible. They tell us every day it ' s (heater) being fixed, but it never changes. A review of Resident 4 ' s Admission Record, indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including heart failure and cirrhosis of the liver (a condition where the liver is permanently scarred and replaced with regenerative nodules and scar tissue). A review of Resident 4 ' s MDS, indicated on 11/4/24 his BIMS score was 14 out of 15 with intact memory. During a concurrent observation and interview on 12/10/24 at 12:14 p.m. with Resident 4, in room [ROOM NUMBER], Resident 4 was sitting in his wheelchair, wearing a jacket, and had a heavy plaid blanket on his bed. Resident 4 stated the heat had been out since he returned to the facility, staff had been offering him more blankets, and since readmission the nightly cold temperatures kept him awake for long hours almost every night. Resident 4 also stated the bathroom window was left slightly open for days and cold air was getting in, so he closed it. He also tried to warm himself at nighttime by placing his legs in front of his bedside oxygen compressor (was on oxygen therapy 20 hours per day), as it gave off heat while operating. During an interview on 12/10/24 at 12:22 p.m. with CNA 1, CNA 1 stated several residents from rooms 33-38 expressed their discomfort due to cold and she offered them extra blankets; however she was unable to find heavy blankets, and the only blankets she could find were small, flimsy, and looked more like sofa throws. CNA 1 further stated the blankets did not provide residents extra warmth and residents told her they were still feeling cold. During an interview on 12/10/24 at 12:37 p.m. with Licensed Nurse (LN), LN stated residents complained about the cold in the back hallway and had extra blankets wrapped around them when they were sitting in their wheelchairs. 2. During an interview on 12/10/24 at 10:39 a.m. with the MD, MD stated he was notified on 12/2/24 by a CNA that the heat had quit working during the Thanksgiving holiday weekend in the south west corner of the building. MD also stated the HVAC heating element for rooms 33-38 was broken and he ordered floor heaters on 12/2/24. During an interview on 12/10/24 at 1:50 p.m. with the MD, MD stated he could not find a purchase order indicating the floor heaters were ordered on 12/2/24. During an observation on 12/10/24 at 1:43 p.m. beside the maintenance office, the MD ' s assistant was taking 18 floor heaters out of boxes and setting them on a cart. A review of a receipt, dated 12/10/24 at 10:18 a.m., indicated the floor heaters were ordered on 12/10/24 and purchased at the self-checkout lane. During an interview on 12/10/24 at 1 p.m. with the Director of Nursing (DON), DON stated she was made aware around 12/2/24 about the broken HVAC in the back hallway and noticed drastic differences in temperatures in areas of the building. DON confirmed she offered residents extra blankets and discussed ordering floor heaters with supervisory staff. During an interview on 12/10/24 at 2:05 p.m. with the Administrator (ADM) and DON, both ADM and DON stated the residents ' room temperatures should have been between 71 F to 81 F. DON also stated continuous cold interior temperatures could cause residents ' arthritis (joint inflammation) to flare up and they might also have hypothermia (when body temperature drops below 95 F). A review of the facility ' s undated policy titled, Physical Environment and Accommodations Policy, indicated, . A comfortable temperature for residents shall be maintained at all times .The facility shall heat rooms that residents occupy to a minimum of 68-degrees F .The facility shall cool rooms to a comfortable range, between 71 degrees F and 81degrees F . Temperatures in resident rooms are checked monthly or as needed and are logged in the maintenance binder at the facility. A review of the facility ' s undated policy titled, Physical Environment and Accommodations Policy, indicated, The facility shall be . in good repair at all times . The policy further indicated, Maintenance shall include provision of maintenance services . for the safety and well-being of residents .

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety, when: 1. Two dietary staff had facial hair were not covered; 2. Juice machine was not clean; 3. Several various sizes of kitchen utensils were stacked wet stored at the clean and ready-to-use storage areas; 4. The raw shelled eggs were not pasteurized in the walk-in refrigerator; and 5. One dietary aide was not able to demonstrate and verbalize the correct process of manual dishwashing by using three-compartment sink. These failures had the potential to cause food borne illness in a medically vulnerable 88 out of 91 residents who consumed food in the facility. Findings: 1. During the initial tour in the kitchen on [DATE] at 8:42 p.m., observed Dietary Aide (DA) with beard but was not covered with any restraint. A follow up observation was conducted at 10:04 a.m., observed Dietary Supervisor (DS) with beard and side burn hair without any restraint. During a concurrent interview with DS, he confirmed DA and himself did not have restraint to cover the facial hair. DS stated they should have the beard guard on to cover the facial hair. During an interview on [DATE] at 11:52 p.m. with Registered Dietitian (RD), RD stated the kitchen staff had facial hair and should have covered them with restraint or beard guard. A review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, indicated, . Proper Dress . beards and mustaches (any facial hair) must wear beard restraint . According to Food and Drug Administration (FDA) Food Code 2022, Section ,d+[DATE].11 Hair Restraint, . (B) The food employees shall wear hair restraints such as . beard restraints . that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils . 2. During a concurrent initial kitchen tour observation and interview on [DATE] at 8:52 a.m. with DS, the juice dispense machine was not clean with dry and sticky juice spilled at the interior upon opening the door panel where the juice concentrate bottles could be replaced and the removable juice dispenser nozzles. During further observation of the exterior of the machine, the vent on the side of the machine had significant amount of dust. DS confirmed and stated it was not clean and the vent was dusty. DS also stated the juice machine should usually be cleaned and sanitized daily. He further stated the kitchen staff needed to pay attention when they clean and sanitize the machine and as well as the vent. A review of the written instructions on the side panel of the juice dispenser machine indicated the machine should be cleaned daily and the interior and exterior should be wiped down daily. A review of the facility's P&P titled, Dispenser Beverage Machine Cleaning, dated 2023, indicated the maintenance and cleaning procedure of the juice machine was to follow the manufacturer's guidelines. A review of the facility's P&P titled, Sanitation, dated 2023, indicated, . All . equipment shall be kept clean, maintained in good repair . 3. During a concurrent initial kitchen tour observation and interview on [DATE] at 8:56 a.m. with DS, there were following food serving items/utensils found stacked wet and stored away at the clean and ready-to-use storage areas: -Seven of half sheet metal pans; -21 of full sheet metal pans; -Six of one-third (,d+[DATE]) sheet metal pans; -Nine of one-sixth (,d+[DATE]) sheet metal pans; -Two of eight quart (qt. - a measurement of fluid volume) of plastic containers; -Two of four qt. of plastic containers; -Five of two qt. of plastic containers; and -Two of plastic container lids. DS confirmed and stated all the dishes, pans and pots should be air-dried completely before stored away. During an interview on [DATE] at 11:52 a.m. with RD, RD stated her expectation for the dishes, pans, and pots should be fully dried before stored away. A review of the facility's P&P titled, Dishwashing, dated 2023, indicated, . Dishes are to be air dried in racks before stacking and storing . According to 2022 FDA Food Code, under section ,d+[DATE].11 Equipment and Utensils, Air-Drying Required, it stated, . Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . 4. During an observation of the walk-in refrigerator on [DATE] at 9:27 a.m., there was a box of raw shelled eggs found and noted the eggs were not pasteurized stored on the rack. A concurrent interview with DS, he confirmed the eggs were unpasteurized. DS checked the invoice of the eggs and was delivered on [DATE]. DS stated he always order pasteurized eggs but not aware the vendor send them unpasteurized eggs for the order. He stated the staff who was responsible for receiving the eggs should pay more attention and checked. DS further stated the raw shelled eggs usually serve for breakfast and the eggs usually were fully cooked without running yolk even using the pasteurized eggs. During an observation of the breakfast for Resident 39 on [DATE] at 8:37 a.m., observed Resident 39 received over-easy egg with running yolk. During a follow up interview with Resident 39 at 10:30 a.m., Resident 39 stated he ate over-easy eggs with running yolks for breakfast usually every day. During an interview on [DATE] at 10:19 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she usually worked at morning shift and served breakfast to the residents. She stated she observed some residents got over-easy eggs for breakfast with running yolks sometimes. During an interview on [DATE] at 10:23 a.m. with Resident 38, Resident 38 stated he usually got over-easy eggs for breakfast with running yolk. During an interview on [DATE] at 10:31 a.m. with CNA 2, CNA 2 stated she usually worked at morning shift and served breakfast to the residents. She stated she sometimes saw residents getting over-easy eggs with running yolks. During an interview on [DATE] at 10:33 a.m. with Resident 53, Resident 53 stated he had over-easy eggs with running yolk with breakfast every day. During an interview on [DATE] at 10:40 a.m. with [NAME] (CK), CK acknowledged the photo of Resident 39's breakfast on [DATE] and confirmed Resident 39 received the over-easy eggs with running yolk. CK further stated he cooked the over-easy eggs on [DATE], [DATE] and [DATE]. During an interview on [DATE] at 10:45 a.m. with DS, DS stated he got the pasteurized eggs on [DATE] and started using them after they were delivered. He stated CK usually cooked the eggs fully cook and no running yolk even though for pasteurized eggs. Then he changed his answer to the pasteurized eggs could be cooked with running yolk. During an interview on [DATE] at 11:52 a.m. with RD, RD stated the kitchen needed to use pasteurized eggs and the eggs should be fully cooked, and the internal temperature of the eggs should be at least 165 degrees Fahrenheit (F; a unit of measure) without running yolk even though for pasteurized eggs. She further stated it was because the kitchen served the older population who were more susceptible for food borne illness. A review of the facility's P&P titled, Procedure for Refrigerated Storage, dated 2023, indicated raw eggs must be pasteurized. According to FDA Food Code 2022, Section ,d+[DATE].13 Pasteurized Eggs, showed, . pasteurized eggs or egg products must be substituted for raw eggs in the preparation of food . 5. During a concurrent observation for the manual dishwashing with three-compartment sink and interview on [DATE] at 9:35 a.m. with DA and DS, DA explained the process and stated the sequence of the steps started with washing, sanitizing, rinsing and air-dried. He stated he did not know the wash and rinse water temperatures and as well as the sanitizer solution temperature. DS confirmed and stated DA's answer was not correct. DS stated the correct sequence should be wash, rinse, sanitize, and air-dried. He further stated the wash and rinse water temperature should be 120 degrees F and the sanitizer solution temperature should be around 75 degrees F. During a concurrent observation of the three-compartment sink and interview on [DATE] at 10:09 a.m. with DS, it was noted three sinks were filled above the fill lines indicated on the sinks, and the wash water (with detergent), rinse water and sanitizer solution were overflowed, and all fused together. DS stated DA filled up the three-compartment sink and confirmed the water and solutions of the three compartments should not fill above the fill line as indicated and should not be overflowed. During an interview on [DATE] at 11:52 p.m. with RD, RD stated the dishwasher and dietary aides should have good knowledge for the manual dishwashing in case the dishwashing machine was not in working condition like on Monday ([DATE]) when the water heater was not working. A review of the facility's document titled, Dietary In-Service, Topic: 3-Compartment Sink, completed on [DATE], given by DS and RD, included the process of manual dishwashing with using of three-compartment sink and the policy and procedure, and the attendance for the in-service. During a concurrent interview with DS, DS stated the attendance showed DA did not attend the in-service for the three-compartment sink. A review of the facility's document titled, Job Description: Dietary Aide, dated ,d+[DATE], indicated the dietary aide should know the process of dishwashing and participate in on-going in-services. It also stated the job required to obtain and maintain the food handler's certificate. During a concurrent interview on [DATE] at 3:15 p.m. with DS, DS stated DA had a food handler's certificate but was expired. DS stated the employee file of DA did not have the copy of the certificate and DA could not provide the certificate for review. A review of the facility's P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the washing water temperature should be at ,d+[DATE] degrees F, the rinse water temperature should be at ,d+[DATE] degrees F. The sanitizer should be tested with test strip with concentration of ,d+[DATE] parts per million (ppm; a unit of measure) and the dishes would immerse in the sanitizer solution for 60 seconds. The last step was to let the dishes air-dried. A review of the facility's P&P titled, Sanitation, dated 2023, indicated the DS is responsible for instructing the kitchen staff in the use of equipment, and each kitchen staff must know how to operate and clean all equipment in their specific work area.

Based on observation, interview, and record review, the facility failed to ensure 10 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 14, 15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two residents occupancy or 79.7 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 29 residents residing in these rooms for a census of 91 residents. Findings: The observations were made throughout the survey in rooms 3, 4, 5, 6, 7, 8, 9, 14, 15 and 16. The space was adequate to store assistive devices in the rooms (such as wheelchair and/or walker) and to facilitate provision of care and needs. During a concurrent interview and record review on 10/23/24 at 12:15 p.m. with the Administrator (ADM), the rooms' dimension were reviewed. ADM confirmed rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents' occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two residents' occupancy or 79.7 sq. ft. per resident. ADM confirmed each room should get 80 sq. ft. per resident. Interviews were conducted with available residents currently residing in the affected rooms. The residents verbalized the space was adequate for the provision of care. The Department recommends continuation of the waiver for the above-mentioned rooms.

Based on interview and record review, the facility failed to ensure controlled substance medications (medications that the use and possession of are controlled by the federal government) for four residents (Resident 33, Resident 37, Resident 51, and Resident 73) of a census of 91 were accurately accounted on the Medication Administration Record (MAR) and Controlled Drug Record (CDR). This failure decreased the facility's potential to ensure accurate accountability for residents' controlled medications and prevent its misuse. Findings: A review of an admission record indicated, Resident 33 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome. A review of Resident 33's Order Summary Report, dated 10/22/24, indicated an order for hydrocodone-acetaminophen (an opioid medication used to treat pain) 5/325 milligrams (mg; a unit of measurement), two tablets every four hours as needed for severe pain and one tablet every four hours as needed for moderate pain. A review of Resident 33's CDR and MAR, dated 10/24, indicated hydrocodone-acetaminophen was given on 10/19/24 at 3:34 p.m. and 6:34 p.m. in the CDR and not noted as given in the MAR. The MAR also indicated the drug was given on 10/19/24 at 8 p.m., but it was not listed as administered in the CDR. A review of an admission record indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis (a chronic disease that breaks down cartilage and tissues in joints, causing pain and stiffness) and chronic pain. A review of Resident 51's Order Summary Report, dated 10/22/24, indicated there was an order for hydrocodone-acetaminophen 5/325 mg, one tablet every 24 hours as needed for moderate to severe pain and one tablet three times a day for pain. A review of Resident 51's CDR and MAR, dated 10/24, indicated hydrocodone-acetaminophen was given on 10/19/24 at 12 a.m. in the MAR, but not listed as administered in the CDR. The CDR also indicated the medication was given on 10/16/24 at 4 a.m. and 10/17/24 at 4 a.m. and was not listed as given in the MAR. A review of an admission record indicated, Resident 37 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (PVD-a slow and progressive disorder of the blood vessels causing pain) and abnormal posture. A review of Resident 37's Order Summary Report, dated 10/22/24, indicated there was an order for hydrocodone-acetaminophen 5/325 mg, one tablet every six hours as needed for moderate to severe pain. A review of Resident 37's CDR and MAR, dated July-October 2024, indicated hydrocodone-acetaminophen doses were documented in the CDR and not in the MAR on the following dates: 7/17/24 at 8 p.m., 9/13/24 at 3:02 p.m. and 9:02 p.m., and 9/20/24 at 3 p.m. A review of an admission record indicated, Resident 73 was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis of hip and malignant neoplasm (cancerous tumor) of bladder. A review of Resident 73's Order Summary Report, dated 10/22/24, indicated there was an order for lorazepam (a medication to treat anxiety) one mg tablet every eight hours as needed for anxiety and agitation, two mg tablet three times a day for behavior, and two mg tablet at bedtime for anxiety, hallucinations, and restlessness. The report also indicated lorazepam one mg, two tablets by mouth every four hours as needed for moderate to severe anxiety and agitation and one tablet every four hours as needed for mild anxiety and agitation. A review of Resident 73's CDR and MAR, dated August-September-October 2024, indicated lorazepam doses were documented in the CDR, but not in the MAR on 8/17/24 at 12:30 a.m., 8/23/24 at 8 a.m., 8/29/24 at 1:20 p.m., 8/30/24 at 4 p.m., 9/11/24 at 1 p.m. and 9 p.m. Lorazepam doses were also documented in the MAR, but not in the CDR on 8/31/24 at 6 a.m. and 2 p.m., 9/8/24 at 6 a.m., 9/9/24 at 2 p.m., 9/25/24 at 2 p.m., 10/1/24 at 2 p.m., and 10/2/24 at 2 p.m. During a concurrent interview and record review on 10/22/24 at 10:05 a.m. with the Director of Nursing (DON), Resident 33's, 37's, 51's, and 73's CDRs and MARs were reviewed. DON stated the times the medications were given must be within the same timeframe for both the CDR and the MAR and nurses should have documented administration times in the CDR and MAR at the same time after they obtained the controlled drug from the bubble pack (a form of medication packaging where individually sealed pills are pushed through foil). DON also stated correct documentation was important for accountability and for nurses to know when to give the next dose. A review of the facility's policy and procedure titled, Controlled Medications, revised 8/24, indicated, When a controlled medication is administered, the licensed nurse administering the medication enters the following information on the accountability record and the medication administration record . Date and time of administration . Amount administered . Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%) for four residents (Resident 3, Resident 38, Resident 55, and Resident 67) of a census of 91, when seven medication errors out of 39 opportunities were observed during medication pass. This failure resulted in medication error rate of 17.95% for the facility. Findings: A review of an admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD-a condition in which stomach acid flows back into the tube connecting the mouth and stomach) and glaucoma (increased eye pressure that can cause blindness). During a medication pass observation on 10/21/24 at 8:24 a.m., Licensed Nurse 1 (LN 1) was observed administering the following medications to Resident 3: 1. One capsule of delayed release omeprazole (a medication used to treat conditions with too much acid in the stomach) 20 milligrams (mg-unit of measurement); 2. One tablet of vitamin D3, 25 micrograms (mcg-unit of measurement); and 3. Dorzolamide/timolol (eye drops used to treat increased eye pressure) 22.3/6.8 mg/ml (milligram-a unit of weight; milliliter-a unit of volume) eye drops. LN 1 asked Resident 3 to look up toward the ceiling and then administered one drop right below each eyeball. No medication contacted the eyes. A review of Resident 3's Order Summary Report, dated 10/22/24, indicated the physician orders were omeprazole delayed release 20 mg, one capsule by mouth two times a day for reduced stomach acid, vitamin D3 50 mcg, one tablet by mouth one time a day, and dorzolamide hydrochloride-timolol maleate 2-0.5 %, to instill one drop in each eye two times a day. A review of Resident 3's Medication Administration Record (MAR), dated 10/22/24, indicated omeprazole was given on 10/21/24 at 8:27 a.m. During an interview on 10/21/24 at 11:38 a.m. with LN 1, LN 1 stated she was supposed to administer omeprazole to Resident 3 between 6 a.m. and 7 a.m. LN 1 further stated, I was late on that one. During an interview and record review on 10/21/24 at 11:44 a.m. with LN 1, Resident 3's MAR was reviewed. LN 1 stated she might have administered 25 mcg of vitamin D3 to Resident 3. During an interview on 10/21/24 at 11:45 a.m. with LN 1, LN 1 stated Resident 3 sometimes pulled down his lower eyelid to make administering the eye drops easier and she thought she got the eye drops into Resident 3's eyes. During an interview on 10/22/24 at 9:46 a.m. with the Director of Nursing (DON), DON stated nurses should have given medications like omeprazole 30 minutes before eating or two hours after a meal. DON also stated omeprazole was usually given at 6 a.m. or 7 a.m. before the breakfast meal. A review of the facility's procedure titled, Administering Ophthalmic Medications, revised 8/24, indicated, Pull the lower eyelid down and away from the eyeball to form a pocket . Hold the dropper tip directly over the eye . A review of an admission record indicated, Resident 38 was admitted to the facility on [DATE] with diagnoses including atherosclerosis (the build-up of fats on the artery walls) of arteries on the left leg and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a medication pass observation on 10/21/24 at 9:11 a.m., LN 1 was observed administering one tablet of cilostazol (a medication that improves blood flow through the blood vessels) 100 mg to Resident 38. A review of Resident 38's Order Summary Report, dated 10/22/24, indicated, cilostazol 100 mg, one tablet 30 minutes before or two hours after a meal. During an interview on 10/21/24 at 11:49 a.m. with LN 1, LN 1 confirmed cilostazol was given within a meal timeframe. During an interview on 10/22/24 at 9:48 a.m. with the DON, DON stated nurses should have administered medications like cilostazol either 30 minutes before eating or two hours after eating. DON also stated residents were usually given these medications before meals between 6 a.m. and 7 a.m. A review of an admission record indicated, Resident 55 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition in which blood flow to the brain is blocked, causing brain tissue to die). During a medication pass observation on 10/21/24 at 9:23 a.m. with LN 2, LN 2 was observed administering one tablet of enteric coated acetylsalicylic acid-aspirin (ASA, a drug that reduces pain, fever, inflammation, and blood clotting) 81 mg to Resident 55. LN 2 crushed the medication along with other medications, poured them into a medication cup, and mixed them with a table spoonful of chocolate pudding. A review of Resident 55's Order Summary Report, dated 10/22/24, indicated to give 81 mg of chewable aspirin tablet by mouth in the morning for stroke prevention. During an interview on 10/21/24 at 11:57 a.m. with LN 2, LN 2 confirmed as per order, aspirin was chewable and stated the enteric coated aspirin was not crushable. A review of an admission record indicated, Resident 67 was admitted to the facility on [DATE] with diagnoses including atrophy (wasting away of an organ) of the kidney and hydronephrosis (a condition where kidneys swell due to buildup of urine). During a medication pass observation and interview on 10/21/24 at 9:23 a.m. with LN 2, LN 2 administered one capsule of omeprazole 20 mg to Resident 67 at 9:41 a.m. LN 2 stated Resident 67 was to receive phenazopyridine (an analgesic pain reliever used to treat increased urination, and increased urge to urinate) 100 mg as ordered, but it was not given because it was not available in the medication cart. A review of Resident 67's Order Summary Report, dated 10/22/24, indicated, omeprazole delayed release 20 mg: Give 1 capsule by mouth one time a day for GERD. Take on an empty stomach . The report further indicated one tablet of phenazopyridine 100 mg to be given by mouth two times a day for dysuria (painful urination) for three days. A review of Resident 67's MAR, dated 10/24, indicated omeprazole to be given daily at 7:30 a.m. During an interview and record review on 10/21/24 at 12 p.m. with LN 2, Resident 67's MAR was reviewed. LN 2 confirmed Resident 67 did not receive omeprazole before her meal and stated Resident 67 usually got this medication around 8 a.m. LN 2 confirmed giving Resident 67 phenazopyridine at 11:13 a.m. on 10/21/24 and stated, I think she's supposed to not take it with meals. During an interview on 10/22/24 at 9:46 a.m. with the DON, DON stated omeprazole should have been given at 7:30 a.m. before breakfast and confirmed it was given late. During an interview on 10/22/24 at 9:57 a.m. with the DON, DON stated Resident 67 should have eaten food while taking phenazopyridine and if she just ate, then she could take phenazopyridine, or she could take it with a snack. DON also stated medication administration directions should be on the MAR and if an unfamiliar drug was ordered for a resident, then nurses needed to check the administration directions in a drug manual or ask another nurse. A review of an undated drug manufacturer prescription titled, Pyridium-phenazopyridine tablet, film coated/Amneal Pharmaceuticals LLC, indicated, Dosage and Administration: 100 mg Tablets: Average adult dosage is two tablets 3 times a day after meals. A review of the facility's policy titled, Administering Medications, revised 8/24, indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet during the lunch meals on 10/21/23 and 10/22/23 when: A. Dining observation on 10/21/24: 1. Two residents (Resident 18 and 58) with consistent or controlled carbohydrate (CCHO) diet (diet for people need to control their blood sugar or to manage diabetes) received one slice of garlic bread instead of half (1/2) slice; 2. Resident 35 with dysphagia mechanical (DM) texture diet (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) with thin liquids (regular liquid consistency) received pudding instead of ice-cream as dessert, and 3. Resident 54 with finger food (FF) diet (diet that provides food in appropriate size and shape to be eaten without utensils but rather with fingers, it allows residents to maintain independence, dignity, and quality of life) received spaghetti instead of bowtie or twister pasta and did not receive dessert. B. Meal service distribution on 10/22/24: 1. Three residents (Resident 8, 35, and 62) with DM texture diet received regular rice and bean instead of puree rice and bean, and puree apple bread pudding instead of soaked chopped bread pudding; 2. Two residents (Resident 6 and 72) with renal diet (diet is for people to manage chronic kidney disease) and CCHO diet received white rice and regular dessert instead of brown rice and diet dessert, and 3. Two residents (Resident 16 and 54) with FF diet received pork cut in slices, penne pasta and diced pear dessert, instead of port cut in bite size, diced potato with margarine and apple bread pudding cut in four pieces. These failures had the potential to result in compromising the medical and nutritional status of nine out of 88 residents who received meals from the facility kitchen. Findings: A. During a dining observation for lunch meal on 10/21/24, beginning at 12:54 p.m., it was noted as followed: 1. Resident 18 and 58 with CCHO diet received one slice of garlic bread. A concurrent review of facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Fall Menus, Week 4 Monday, indicated CCHO diet should have received 1/2 slice of garlic bread. 2. Resident 35 with DM texture diet with thin liquid received pudding as dessert. A concurrent review of facility spreadsheet titled, Fall Menus, Week 4 Monday, indicated DM texture diet with thin liquid should have received ice-cream as dessert. 3. Resident 54 with FF diet received spaghetti and no dessert. A concurrent review of facility spreadsheet titled, Fall Menus, Week 4 Monday, indicated FF diet should have received bowtie, [NAME], or twisties pasta with the entree and popsicle or ice-cream bar as dessert. B. During the lunch meal distribution on 10/22/24, beginning at 12:21 p.m., it was noted as followed: 1. Resident 8, 35 and 62 with DM texture diet received regular texture rice and bean with entree dish and puree apple bread pudding as dessert. A concurrent review of facility spreadsheet titled, Fall Menus, Week 4 Tuesday, indicated DM texture diet should have received puree rice and bean and soaked chopped bread pudding. 2. Resident 6 and 72 with Renal and CCHO diet received white rice and regular apple bread pudding. A concurrent review of facility spreadsheet titled, Fall Menus, Week 4 Tuesday, indicated Renal and CCHO diet should have received brown rice and diet sliced apples with cinnamon. 3. Resident 16 and 54 with FF diet received pork roast in slices, penne pasta, and diced pear dessert. A concurrent review of facility spreadsheet titled, Fall Menus, Week 4 Tuesday, indicated FF diet should have received pork roast cut in bite (cube) size, diced potato with margarine and apple bread pudding cut in four pieces. During an interview on 10/22/24 at 2:09 p.m. with Dietary Supervisor (DS), DS acknowledged and confirmed the observation findings for lunch meals on 10/21/24 and 10/22/24. He stated his expectation for the kitchen staff should provide accurate food items on the meal distribution and follow the menu or spreadsheet. He added the staff needed to pay more attention to put together the meal before delivery. During an interview on 10/23/24 at 11:52 a.m. with Registered Dietitian (RD), RD stated the kitchen staff needed to follow the menu or spreadsheet during the meal distribution. She added the kitchen staff needed to make the meal right to match the therapeutic diets with their nutrition analysis. RD further stated if staff gave more starch to resident with CCHO diet then that might lead to increased blood sugar level. RD added if staff gave incorrect food texture then that might put the residents at risk for choking or aspiration. A review of the facility's policy and procedure titled, Menu Planning, dated 2023, indicated, . menus are planned to meet nutritional needs of residents in accordance with established national guidelines . the facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility . menus are written for regular and therapeutic diets in compliance with the diet manual . A review of the facility's document titled, Job Description: Cook, dated 2/2024, indicated, . essential duties . to follow prepared menus . to prepare special diets accurately . A review of the facility's document titled, Job Description: Dietary Supervisor, dated 2/2024, indicated, . essential duties . check trays for accuracy before they are delivered .

Based on observation, interview, and record review, the facility failed to accommodate the food preferences (food items under the standing order) on the meal tickets (tickets including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) for five residents (Resident 1, 2, 4, 8, and 81) out of 88 residents who received meals from the facility's kitchen. These deficient practices had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of the residents. Findings: During an observation of lunch meal service distribution with concurrent review of residents' meal tickets on 10/22/24, beginning at 12:21 p.m., it was noted as followed: 1. Resident 1 with Regular diet did not receive cottage cheese when the meal ticket indicated Resident 1 should have received cottage cheese as standing order; 2. Resident 2 with Regular, two grams (g; a unit of measurement) Na (sodium) diet (diet with consumption of limited amount of sodium to 2,000 milligrams (mg; a unit of measurement) per day, usually to manage variety of health condition, such as heart disease or kidney disease) did not receive side salad with blue cheese dressing when the meal ticket indicated Resident 2 should have received side salad with blue cheese dressing as standing order; 3. Resident 4 with Regular mechanical soft texture diet (diet with modified texture by chopping or grinding to be soft that allows people who experience chewing or swallowing limitations) did not receive cottage cheese, half (1/2) of tuna salad sandwich, and chicken noodle soup when the meal ticket indicated Resident 4 should have received those food items as standing order; 4. Resident 8 with Regular dysphagia mechanical texture diet (diet is for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) did not receive ice-cream when the meal ticket indicated Resident 2 should have received ice-cream as standing order, and 5. Resident 81 with regular no added salt (NAS) fortified (added calories and/or protein) diet did not receive cottage cheese when the meal ticket indicated Resident 81 should have received cottage cheese as standing order. During an interview on 10/22/24 at 2:09 p.m. and 10/23/24 at 8:28 a.m. with Dietary Supervisor (DS), DS acknowledged and confirmed the findings above. DS stated the food items under the standing order on the meal tickets meant the kitchen needed to provide those food items to the residents. He stated he expected for the kitchen staff to follow and provide the food preferences (standing orders on the meal tickets) for the residents. During an interview on 10/23/24 at 11:52 a.m. with Registered Dietitian (RD), RD stated and verified standing orders on the meal tickets meant food preferences for the residents. RD further stated the kitchen staff needed to provide those food items and honored residents' food preferences. A review of the facility's policy and procedure titled, Food Preferences, dated 2023, indicated, . Resident's food preferences will be adhered . A review of the facility's document titled, Job Description: Dietary Supervisor, dated 2/2024, indicated, . essential duties . assess resident food preferences . check trays for accuracy before they are delivered .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for a census of 91 when: 1. Nursing staff did not sanitize and disinfect medical equipment between resident use and did not change gloves after resident care and when cleaning equipment; 2. Nail care was not provided for Resident 8, Resident 14, Resident 38, Resident 39, and Resident 73; and 3. Certified Nurse Assistant 5 (CNA 5) did not wear the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) upon entering Resident 27's room who was on neutropenic precautions (a set of action to take to prevent infection if there's a low count of white blood cell in the blood that helps fight infection). These practices decreased the facility's potential to prevent the spread of infection among residents. Findings: 1. During a medication pass observation on 10/21/24 at 8:40 a.m., Licensed Nurse 1 (LN 1) used a blood pressure (BP) cuff and stethoscope to measure a resident's BP in a room with Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms using gowns and gloves during high contact resident care). After the resident's BP was taken, LN 1 removed the BP cuff and stethoscope and placed them on top of the medication cart without sanitizing and disinfecting them. At 9:02 a.m., LN 1 was then observed taking the BP of the resident's roommate with the same equipment. During an interview on 10/21/24 at 11:14 a.m. with LN 1, LN 1 confirmed she did not sanitize and disinfect the BP cuff and stethoscope and stated it should have been sanitized and disinfected between resident use. During a medication pass observation on 10/21/24 at 9:23 a.m., LN 2 used a BP cuff and stethoscope to measure a resident's BP. A pulse oximeter (a medical instrument used to measure oxygen saturation level - a measurement of how much oxygen the blood is carrying) was also placed on the resident's finger. After the resident's BP was taken, LN 2 removed the BP cuff and oximeter and placed them on top of the medication cart. She sanitized and disinfected the equipment without changing her gloves. During an interview on 10/21/24 at 11:40 a.m. with LN 2., LN 2 stated she should have removed her gloves after resident care and donned new gloves before cleansing the medical equipment. During an interview on 10/22/24 at 9:46 a.m. with Director of Nursing (DON), DON stated the expectation of nursing staff was to sanitize and disinfect equipment between each use if used for multiple residents. DON added nursing staff needed to use hospital-quality bleach wipes and wait for time recommended by the wipes' manufacturer before using on the next resident. DON also stated nursing staff were expected to remove used gloves and replace them with new gloves before cleansing equipment used to take vital signs for multiple residents. A review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces, revised 8/2024, indicated, Reusable items, including environmental surfaces, and Durable Medical Equipment (DME) will be cleaned and/or disinfected between residents according to manufacturer's instructions. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/24, indicated, Hand hygiene is indicated . after touching a resident . after touching the resident's environment . immediately after glove removal. 36624 2. A review of Resident 8's Admission Record (AR), indicated Resident 8 had diagnoses which included dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During an observation on 10/21/24 at 9:04 a.m. and 10/22/24 at 1:44 p.m., Resident 8's fingernails were long, with jagged edges and black substance underneath the nailbeds. A review of Resident 14's AR indicated Resident 14 had diagnoses which included muscle weakness and left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During an observation on 10/21/24 at 9:07 a.m. and 10/23/24 at 9:51 a.m., Resident 14's fingernails were long, with jagged edges and black substance underneath the nailbeds. During an interview on 10/23/24 at 9:51 a.m. with Resident 14, Resident 14 stated he wanted his fingernails trimmed. A review of Resident 38's AR indicated Resident 38 had diagnoses which included hemiplegia and aphasia (a disorder that makes it difficult to speak). During an observation on 10/21/24 at 11:27 a.m. and 10/22/24 at 11:28 a.m., Resident 38's fingernails were long, with jagged edges and had black substance underneath the nailbeds. A review of Resident 39's AR indicated Resident 39 had diagnoses which included muscle weakness and cognitive communication deficit. During an observation on 10/23/24 at 11:10 a.m., Resident 39 had long fingernails, with jagged edges and black substance underneath the nailbeds. A review of Resident 73's AR indicated Resident 73 had diagnoses which included bilateral osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip and muscle weakness. During an observation on 10/22/24 at 3 p.m., Resident 73 had long fingernails, with jagged edges and black substance underneath the nailbeds. During an interview on 10/22/24 at 3 p.m. with Resident 73, Resident 73 stated he wanted his fingernails to be trimmed. During a concurrent observation and interview on 9/23/24 at 8:37 a.m. with LN 7, LN 7 confirmed Resident 8's, Resident 14's, Resident 38's, Resident 39's, and Resident 73's fingernails were long, with jagged edges and had black substances underneath the nailbeds. LN 7 stated residents' fingernails had to be cut and trimmed as scheduled to ensure residents would not scratch their skins and not get infected. LN 7 also stated long nails could harbor germs and when residents scratched, it could cut their sensitive skin and germs could go into the skin. During an interview on 10/23/24 at 10:24 a.m. with the DON, DON stated her expectations were residents' fingernails should be cut every Sunday by assigned staff. DON stated CNAs should provide nail care and nail trimming unless residents had diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), then nail trimming should be done by the podiatrist. DON also stated dirty and untrimmed fingernails could be an infection control issue and fingernails with jagged edges could also get stuck or caught on things and residents could scratch themselves. A review of the facility's document titled, Shower Schedule, updated 9/24, indicated, . Sunday: All Rooms: Nail Care . A review of the facility's P&P titled, Activities of daily living, Supporting, revised 5/24, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 45770 3. A review of Resident 27's Admission Record, indicated he was admitted to the facility in September 2024 with a diagnosis of multiple myeloma (a cancer that forms in the plasma cell a type of white blood cell). During an observation on 10/21/24 at 9:05 a.m. Resident 27's room was observed to be closed and had a sign that indicated neutropenic precautions, wear gown and mask, with PPEs neatly stacked on a rack by the door. A review of Resident 27's Order Summary Report, dated 9/21/24, indicated an order for neutropenic precautions due to critically low count of white blood cell and neutrophils (another type of white blood cell that helps fight infection) and staff should wear a gown and a mask before entering the room. During a concurrent observation and interview on 10/21/24 at 10 a.m. with CNA 5, CNA 5 was observed inside Resident 27's room talking with the resident. CNA 5 was not wearing a gown or a mask. CNA 5 confirmed she was not wearing any PPE inside the room and stated she will only wear the PPE when providing care. During an observation on 10/21/24 at 11:20 a.m., a visitor was observed inside Resident 27's room not wearing a gown. During an interview on 10/24/24 at 9:38 a.m. with the Infection Preventionist (IP), IP verified that Resident 27 was on neutropenic precautions due to his cancer diagnosis which made him immune compromised. IP stated all staff and visitors are required to wear a gown and mask every time they enter the room and not only when providing care. IP also stated this practice should be followed by all staff to help protect Resident 27 from infection and minimize his risk of getting ill. During an interview on 10/24/24 at 9:55 a.m. with the IP, IP stated the facility did not have their own specific policy for neutropenic precautions. IP also stated the facility only followed the general guidelines for isolation precautions for the prevention of transmission of infection updated on 7/2019.

Based on interview and record review, the facility failed to implement measures to prevent the development of pressure injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) for one resident (Resident 1) of two sampled residents when the facility was unable to provide documented evidence that preventative measures for skin breakdown were an active part of Resident 1's care and skin was not assessed on a regular basis. This failure resulted in Resident 1 developing eight pressure injuries. Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a skin care plan initiated on 6/26/21, indicated Resident 1 was at high risk for altered skin integrity with the goal of reducing the risk for impaired skin integrity. The skin care plan indicated in order to assist Resident 1 to meet this goal, staff was to monitor for any signs of skin breakdown, including areas that were sore, tender, red or broken. The care plan did not indicate staff was to turn and reposition Resident 1 every two hours. A review of a facility document titled Skin Observation, dated 6/26/21, indicated Resident 1 had blanchable (when skin becomes pale upon pressure) [CONDITION(S)] (a reddening of the skin as a result of injury) on the buttocks measuring 3 inches (in., a unit of measurement) by 6 in. and on the left heel, unmeasured. A review of a progress note dated 6/26/21 at 2 p.m., indicated Resident 1 had blanchable redness on the bilateral (both sides) buttocks and bilateral heels. A review of a progress note dated 6/26/21 at 3:55 p.m. indicated, [Resident 1] Requires extensive assist x 2 [by two staff members] for bed mobility, transfers, and toileting . A review of a Minimum Data Set (MDS, an assessment tool), dated 7/3/21, indicated Resident 1 had no pressure injuries or unstageable pressure injuries present on admission but was at risk of developing pressure injuries. Furthermore, the MDS indicated the facility did not place Resident 1 on a turning/ repositioning program. A review of progress notes and shower sheets dated 6/27/21 through 8/21/21 indicated there was no documented evidence Resident 1 had worsening or new skin issues on the bilateral buttocks, coccyx (area at the bottom of the spine), or feet. The Department requested to review Resident 1's skin assessments and documentation which indicated evidence of staff interventions conducted to prevent the development of pressure injuries. The facility was unable to provide this documentation. A review of a progress note, dated 9/6/21 at 8:03 p.m. indicated, .[Resident 1] was taken to the ER [emergency room ]. A review of the hospital admission documentation, dated 9/7/21 at 6:15 a.m., indicated as below, .wound dressing per order and wound photo obtained. Coccyx is non-blanchable, reddened and discolored. Heels are non-blanchable, reddened, discolored and boggy. Incision/Wound Pressure Injury . Coccyx . Incision/Wound Pressure Injury . Ankle Left;Outer . Incision/Wound Pressure Injury . Ankle Right;Outer . Incision/Wound Pressure Injury . Toe .Anterior;Left . Incision/Wound Pressure Injury . Heel left;Posterior . Incision/Wound Pressure Injury . Foot Left;Outer;Mid . Incision/Wound Pressure Injury . Heel Posterior;Right . Incision/Wound Pressure Injury . Foot Right;Mid;Outer. In a concurrent record review and interview on 7/11/22 at 3:10 p.m., the Assistant Director of Nursing (ADON) stated she expected nurses to complete and document comprehensive skin assessments weekly. The ADON stated she could not provide documented evidence of weekly skin assessments for Resident 1 leading up to her hospitalization on [DATE]. The ADON stated nurses were expected to complete a screening tool if any change in the skin was noted and to evaluate, report, and document the changes in the skin. The ADON was not able to provide nursing documentation to support the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated if nurses had turned and repositioned the resident, the wounds could have been avoided. The ADON confirmed staff had not implemented Resident 1's skin care plan. During an interview on 7/14/22 at 3:28 p.m., the Medical Director (MD), when asked if pressure sores on Resident 1's heels and coccyx were preventable, he stated, Yes if they provided an air mattress and turned and repositioned patient [sic] regularly which they did not. A review of the American Medical Directors Association (AMDA) Clinical Practice Guidelines for Long Term Care Facilities, published 2011, indicated, . Inspect the patient's skin at least once weekly during routine care. Direct caregivers should be aware of the signs and symptoms of pressure ulcers as well as predisposing factors .The cornerstone of pressure ulcer management is prevention . Pressure Ulcer Prevention Measures . Create a turning and positioning schedule that is based on the patient's individual risk factors . Inspect skin during bathing or daily personal care . Use appropriate offloading or pressure-redistribution devices . A review of the facility's policy titled Prevention of Pressure Ulcer/ Injuries, revised July 2017, indicated, . The following information should be recorded in the resident's medical record utilizing facility forms . the type of assessment(s) conducted . The name and title (or initials) of the individual who conducted the assessment . Any change in the resident's condition . The condition of the resident's skin (i.e., the size and location of any red or tender areas) . If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal . Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. Documentation in medical record addressing MD [physician] notification if new skin alteration noted with change of plan of care .

Based on interview and record review, the facility neglected one resident (Resident 1) of two sampled residents when Resident 1 showed signs of [CONDITION(S)] (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death) and staff failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure led to a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS, an assessment tool), dated 7/3/21, indicated Resident 1 had no memory problems. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Initiate the orders below if the patient has two or more of the following symptoms . Respiratory Rate greater than 20 . Acute change in mental status ([Yes or No]) . Systolic Blood Pressure less than 100 mmHg [(millimeters of mercury, a unit of measurement for pressure] . Initiate and document vital signs every 4 hours for 72 hours . Notify physician of symptoms, any interventions carried out and if patient has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Ask if following tests should be ordered and if fluids should be started . Consider transfer to ED [Emergency Department] (after consultation with physician) if patient has two or more of the following symptoms . Systolic Blood Pressure less than 100 mmHg . Acute Change in Mental status ([Yes or No]) . [Assess this] Every shift; [Graveyard shift] . AM, PM. A review of progress notes for Resident 1 indicated the following: A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Appear drowsy today, responding in full sentences, vitals are okay . ER [emergency room ] if symptoms worsen. A progress note dated 9/2/21 at 7:28 p.m., by Licensed Nurse (LN) 8 indicated, . order per [physician] . ciproflaxin [an antibiotic] 250 mg [milligrams, a unit of measure] PO [by mouth for] . 5 days . A progress note dated 9/3/21 at 10:49 p.m., by LN 2 indicated, Monitoring resident on [antibiotic] . showing difficulty to swallow [sic] . There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A progress note, dated 9/4/21 at 2:07 p.m., by LN 9 indicated, Resident continues on [antibiotic] for possible infection . Resident having difficulty taking her medications . There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A progress note, dated 9/5/21 at 10:25 p.m., LN 7 indicated, Resident continues on [antibiotic] for possible infection . Resident having difficulty taking her medications . There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A review of a facsimile (fax) transmittal sheet with a header, To: [Medical Director; MD] From: [LN 7], was in Resident 1's medical record, dated 9/4/21 and 9/5/21, and indicated, Resident continues to decline. Unable to swallow pills whole . Very confused . MD had written and signed a note dated 9/9/21 in the bottom right corner of the document that stated, [A physician service] should have been called for this over the weekend. A review of a facility document titled Vitals Report, indicated the following: 9/05/21 at 17:10 -Blood pressure- 159/78 mmHg (Millimeters of mercury, a unit of measure) . 9/05/21 at 17:11- Pulse- 76/per minute . 9/05/21 at 17:12- Respirations- 18/ per minute . 9/05/21 at 21:46- Blood pressure- 158/78 mmHg . 9/05/21 at 21:46- Pulse- 76/per minute . [Respirations omitted] 9/06/21 at 02:13- Pulse- 74/ per minute . 9/06/21 at 02:13- Respiration- 18/ per minute 9/06/21 at 02:13- Blood pressure- 145/72 mmHg . 9/06/21 at 09:32- Pulse - 57/per minute (with indication alert) acceptable range 60-100 per minute . 9/06/21 at 09:32- Blood pressure- 98/67 mmHg . 9/06/21 at 09:33- Respirations- 20/per minute . 9/06/21 at 17:07- Pulse- 50/per minute (with indication alert) acceptable range 60-100 per minute . 9/06/21 at 17:08- Blood pressure- 95/60 mmHg . 9/06/21 at 19:13- Respirations- 32/ per minute . On 9/6/21 at 5:08 p.m. Resident 1's systolic blood pressure was 95 mmHg, there was no documented respiratory rate, and there was no documented evidence a change of mental status was assessed; and, On 9/6/21 at 7:13 p.m. Resident 1's respiratory rate was 32, a blood pressure was not documented, and a change in mental status was documented. A review of progress notes for Resident 1 indicated the first entry made on 9/6/21 was at 7:28 p.m., by LN 5, and stated, [Resident 1] noted with increased lethargy, resident can barely open her eyes to sternal rub. resident [sic] not responding to verbal command. vitals 94/60 [blood pressure] . [heart rate] 50 . [respiratory rate] 20 . call placed to DR [physician] and left voicemail requesting call. Call placed to [Responsible Person (RP)] and informed her of resident's condition. [RP] stated she wants resident sent to ER. Nursing supervisor informed. A review of a progress note dated 9/6/21, at 8:03 p.m., by LN 4, indicated, .alerted around [5 p.m.] of patients [sic] condition. Upon assessment [Resident 1] would not wake up with a sternal rub. Resident was lethargic and was not able to be arouse [sic], resident is usually alert and oriented. Informed bedside nurse that the doctor needed to be called immediately and possibly sent out. Around [7:30 p.m.] I was made aware of residents [sic] daughter calling and stating she wanted [Resident 1] sent out to the [ED]. Bed side nurse then called and notified the MD via voicemail about the change of condition. Spoke with MD myself and he stated [Resident 1] can be sent out. I then called EMS [Emergency Medical Service] . and [Resident 1] was taken to the ER. A review of a ED to Hosp-Admission . note dated 9/6/21, at 11:24 p.m., by the hospital physician, indicated, Clinical Impression: 1. [CONDITION(S)] with [CONDITION(S)] [a brain disease that alters brain function or structure, commonly caused by infection, tumor, or stroke] and septic shock, due to unspecified organism . In an interview on 6/20/22 at 2 p.m., with the Assistant Director of Nurses (ADON), when asked about the low systolic blood pressure taken on 9/6/21 at 9:32 a.m., ADON stated, I don't think the nurse realized it was a low blood pressure for [Resident 1] . [nurse] unaware of [Resident 1's] baseline. A drop in blood pressure was a sign of [CONDITION(S)]. The patient could go into multisystem failure. The nurse failed to notify the doctor of changes. In an interview on 7/14/22 at 3:28 p.m. the MD stated, I suspected [CONDITION(S)] [Urinary Tract Infection] and started [Resident 1] on antibiotics. I wrote the order if patient deteriorated to transfer to ER. I was pretty upset. We have [a physician service] for [medical insurance] patients which [the] facility had access 24 hours to report any change in patient's condition . It was a long weekend . Friday, Saturday, and Sunday no one called [the physician service]. They just wrote on the paper. It was the weekend . They should have called. They ignored it completely . They called me about 7 p.m. The facility told me they had a lot of registry nurses. This patient could have been saved if they notified the doctor and followed my order to transfer the patient to the ER. The patient should have gone a couple days before. Resident was not taking oral antibiotic. I was never informed. How could a patient improve if the patient was not taking the oral antibiotic? The patient could have been sent to the hospital and received IV [intravenous] antibiotic. She continued to deteriorate because she did not receive the treatment which she needed. The patient could not have gone into [CONDITION(S)] if she received the antibiotic. Low blood pressure and confusion was already a sign of [CONDITION(S)] but neither me nor [the service] was notified. Every hour, every minute counts in [CONDITION(S)] and they missed three days on this patient. Septic shock and death could have been prevented in this instance with timely interventions. A review of the American Medical Directors Association (AMDA) Clinical Practice Guidelines for Long Term Care Facilities, published 2011, indicated, Because frail elderly patients are at a higher risk of death and complications from infectious diseases, prompt recognition, assessment, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)]; unstable pulse or blood pressure; or serious illness, combined with uncertain diagnosis, may warrant a hospital transfer . Direct-care staff should closely monitor each patient who is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The practitioner should be notified promptly if the patient's condition worsens . If the patient's condition shows no improvement . reconsider the treatment strategy . Nurses . should provide practitioners with enough detailed information to allow them to determine the patient's progress and identify possible complications . all direct caregiving staff should be taught to recognize signs and symptoms that may indicate an infection . A review of the facility's policy titled Abuse Prevention Program, revised December 2016, indicated, Our residents have the right to be free from . neglect . As part of the resident abuse prevention, the administration will . Protect our resident from abuse by anyone including . facility staff . staff from other agencies . or any other individual . Develop and implement policies and procedures to aid our facility in preventing . neglect .

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was free from abuse when staff witnessed Resident 2's hand under Resident 1's shirt caressing her breast. This failure resulted in sexual abuse and a negative impact on Resident 1's psychosocial sense and dignity. Findings: Resident 1 was readmitted to the facility in early 2021 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Minimum Data Sheet (MDS - an assessment tool), dated 8/21/21, indicated severe memory problems. Resident 2 was admitted to the facility middle of 2018 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Minimum Data Sheet (MDS - an assessment tool) dated 9/1/21 indicated moderate memory problems. A review of Resident 1's care plan, created on 10/23/21, indicated, .[Resident 1] Experienced alleged/suspected abuse, (Sexual) .[is] At risk for emotional disturbance and or trauma .Goal .Will be free of abuse .Intervention/approach .safeguard resident from .abuse perpetrator. A review of Resident 2's care plan, created on 10/25/21, indicated [Resident 2] has inappropriate sexual actions against the opposite sex .Goal .Other [residents] will remain safe around [Resident 2] .Intervention/approach .Monitor [resident] for inappropriate sexual behavior . A review of Resident 1's Interdisciplinary Team (IDT) note, dated 10/25/21 at 2:11 p.m., indicated, [Resident 1] was the victim of alleged sexual abuse .[Resident 2] reached under her shirt and touched her. A review of Resident 2's IDT note, dated 10/26/21 at 1:02 p.m., indicated, [Resident 2] was found to have hand up .[Resident 1's] shirt. In an interview on 11/8/21 at 2:28 p.m., the Director of Nursing (DON) confirmed there was an inappropriate encounter of sexual nature between Resident 1 and Resident 2. In an interview on 11/8/21 at 2:35 p.m., Resident 2 confirmed he knew Resident 1. When asked why he touched Resident 1 on the chest, Resident 2 stated, I like her. In an interview on 11/8/21 at 2:55 p.m., Certified Nursing Assistant 5 (CNA 5) stated, [Resident 2] .knows what he's doing . In an interview on 11/8/21 at 5:03 p.m., CNA 4 stated, [Resident 2's] hand was inside [Resident 1's] shirt, caressing [Resident 1's] boobs, touching [Resident 1's] breast .[Resident 2] knew what he was doing. A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised December 2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .a dignified existence .be treated with respect .and dignity .be free from abuse .and exploitation . A review of the facility's P&P titled, Abuse Prevention Program, revised December 2016, indicated, Our residents have the right to be free from abuse and .exploitation .by anyone including .other residents .