Every finding on record at Valley Pointe Nursing & Rehabilitation Center

Based on observations, interviews, and record reviews, the facility did not ensure medications were administered in accordance with physician orders for two of two sampled residents (Resident 1 and Resident 5) when licensed nursing staff administered medications, including anticoagulant (commonly known as blood thinners, are substances or medications that prevent or reduce the body's ability to form blood clots) and antiplatelet (medications that prevent blood cells called platelets from sticking together and clumping) medications, approximately 90 minutes earlier than physician-ordered administration times and subsequently documented inaccurate administration times that did not reflect the actual time of medication administration.This failure placed Resident 1 and Resident 5 at risk for clinically significant medication errors, reduced therapeutic effectiveness and adverse drug reactions including bleeding complications.During a record review of Resident 1's admission Record (AR), printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with diagnoses including metabolic encephalopathy (acute brain dysfunction caused by chemical imbalances) and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks) and gastrostomy (a surgical or endoscopic procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube) status.During a record review of Resident 5's AR, printed on 4/28/26, the AR indicated Resident 5 was admitted to the facility in April 2023 with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (a type of stroke caused by a blockage in blood vessels supplying the brain, resulting in tissue death (necrosis) due to lack of oxygen affecting right dominant side) and encounter for attention to gastrostomy.During a record review of Resident 45's AR printed on 4/28/26, the AR indicated Resident 40 was admitted to the facility in March 2026 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.)During an observation and interview on 4/28/26 at 8:11 a.m. with Licensed Vocational Nurse (LVN) 4, in front of another resident's room, LVN 4 stated she had completed medication administration for Resident 1 and Resident 5. When asked whether medications had already been administered to Resident 1 and Resident 5 with a gastrostomy tube (g-tube, a medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly), LVN 4 confirmed Resident 1 and Resident 5 had already received their morning medications. LVN 4 then proceeded toward Resident 45's room with the medication cart.During a medication pass observation on 4/28/26 at 8:16 a.m., LVN 4 entered Resident 45's room and informed Resident 45 she was going to prepare the medications after obtaining vital signs.During continued medication pass observation on 4/28/26 at 8:20 a.m. with LVN 4, LVN 4 prepared Resident 45's oral medications, injectable medication (a sterile liquid drug delivered directly into the body using a needle and syringe), inhalers, eye drops, and lidocaine patch (used to relieve localized pain).During a medication pass observation on 4/28/26 from 8:30 a.m. to 8:51 a.m. with LVN 4 was in Resident 45's room administering medications and treatments.During a medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) record review of Resident 1's Medication Administration Record (MAR) Audit Report dated 4/1/26 to 4/30/26, the MAR indicated Resident 1 had the following physician-ordered medications with scheduled administration times of 9:00 a.m. on 4/28/26, including:clopidogrel bisulfate (antiplatelet) oral tablet 75 mg - give one tablet by mouth one time a day for clot preventionheparin sodium injection solution (a fast-acting blood thinner, anticoagulant) 5000 unit/ml - inject 5000 unit subcutaneously (beneath or under all layers of the skin) every 12 hours for deep vein thrombosis (DVT, a blood clot in deep vein) prophylaxis (prevention)During a medication reconciliation record review of Resident 5's MAR dated 4/1/26 to 4/30/26, the MAR indicated Resident 5 had the following physician-ordered medications with scheduled administration times of 9:00 a.m. on 4/28/26, including:apixaban (anticoagulant) oral tablet 5 mg - give one tablet via PEG-tube(percutaneous endoscopic gastrostomy tube) two times a day for atrial fibrillationDuring a medication reconciliation record review of Resident 1 and Resident 5's MAR, Resident 1's 9:00 a.m. medications were documented as administered at 8:13 a.m. and Resident 5's 9:00 a.m. medications were documented as administered at 8:14 a.m. However, LVN 4 remained under continuous medication pass observation with Resident 45 between 8:11 a.m. and 8:51 a.m., indicating the documented administration times for Resident 1 and Resident 5 were inconsistent with LVN 4's observed medication administration during the same timeframe.During an interview on 4/28/26 at 12:23 p.m. with LVN 4, LVN 4 stated and confirmed that she started administering drugs to Resident 1 and Resident 5 approximately as early as 7:30 a.m., despite the physician-ordered administration time of 9:00 a.m. LVN 4 stated she started medication administration early due to a facility morning staff huddle conducted around 7:00 a.m. to 7:30 a.m. LVN 4 stated the facility's policy required medications to be administered within the prescribed time frame. LVN 4 confirmed Resident 1 and Resident 5's physician-ordered time for the administration was at 9:00 a.m., with an acceptable administration time frame between 8:00 a.m. and 10:00 a.m. LVN 4 further stated medications administered outside the ordered timeframe and documenting inaccurate administration time was considered a medication error. LVN 4 further stated administering medications too early could have placed Resident 1 and Resident 5 at risk for adverse (unexpected, harmful, or undesirable results from a drug) medication effects.During an interview on 4/30/26 at 2:48 p.m. with the Director of Nursing (DON), DON stated medication administration times should have been documented accurately to ensure continuity of care and awareness of the of the next scheduled medication administration time by the incoming nurse. DON stated administering medications outside the prescribed timeframe was not in accordance with the physician's order and could have reduced the effectiveness of the medications administered to Resident 1 and Resident 5.During a record review of the facility's policy and procedure (P&P), titled, Administering Medications, revised in April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required timeframe.5. Medications administration times are determined by resident need and benefit, not staff convenience.a. enhancing optimal therapeutic effect of the medication b. preventing potential medication or food interactions.7. Medications are administered within one(1) hour time of their prescribed time.24. As required or indicated for a medication, the individual administering the medication records in the resident's medical record.a. the date and time the medication was administered.

Based on observation and interview, the facility failed to ensure proper disposal and containment of refuse. The outdoor dumpster located near the facility was observed with its lid propped open due to an overflow of trash inside the container. Additional refuse, including dirty gloves and food waste, were scattered on the ground beneath and around the bin. The recycling area also contained overflowed cardboard boxes and other recyclables placed on the ground next to the recycling container.These deficient practices had the potential to attract rodents and insects and cross-contamination of food.During a concurrent interview and observation on 4/27/26 at 2:33 p.m., of the outdoor dumpster area with the Registered Dietitian (RD), the dumpster lid was observed propped open due to an overflow of trash inside the container, and a strong foul odor was present. Additional refuse, including dirty gloves and food waste were scattered on the ground beneath and around the bin. The recycling dumpster was also observed with an overflow of cardboard boxes and other recyclables placed on the ground next to the container.During an interview on 4/27/26 at 2:40 p.m., the RD stated that bacteria could form in the dumpster, leading to hazardous food conditions, and further stated it was not sanitary to keep the dumpster open as it can attract rodents to the facility, and it would also attract flies and other insects.During a review of the facility's policy and procedure (P&P) titled Sanitization dated 2001 on 4/28/26 at 2:53 p.m., the policy states, Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster/compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats and maintained to prevent pests.

Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when:The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Facial hair was not covered. 3. Meal preparation equipment was not air dried. 4. The food preparation sink did not have backflow prevention. 5. Opened food in resident refrigerator was not labeled and dated. 6. The kitchen environment was not clean or in good working order. 7. The test strips used to monitor cleaning solution levels were expired. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 45 facility residents who received food prepared in the kitchen. 1.During a concurrent observation and interview on 04/27/2026 at 9:42 AM with Registered Dietitian (RD) in the kitchen, tuna salad and egg salad labeled with a preparation date of 04/26/2026 was found in the reach in refrigerator. RD stated the cool down log was in use. The two items were not included on the cool down log. The RD stated that the items should have been monitored and documented on the cool down log.During a review of the USDA Food Code 2022, Section 3-501.14 (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F and (2) Within a total of 6 hours from 35 F to 41 F or less.During a review of the USDA Food Code 2022, Section 3-501.14 Cooling. (B) Time/Temperature Control for Safety Food shall be cooled within 4 (four) hours to 41 degrees Fahrenheit (F) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.2. During an observation on 04/28/2026 at 10:30 PM in the kitchen, [NAME] was observed with a beard guard that was below his chin and not covering his facial hair.During an interview on 04/28/2026 at 10:40 PM with RD, RD stated, staff are expected to wear beard restraints in the kitchen. RD confirmed that [NAME] was not properly wearing a beard restraint.During a review of the facility's policy and procedure titled, Sanitization, dated 2001, indicated, food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.3. During a concurrent observation and interview on 04/27/2026 at 9:42 AM with Registered Dietitian (RD) in the kitchen, four out of four hotel pans were observed stacked and stored wet. RD stated, equipment should be air dried and not stored wet. RD confirmed the pans were stacked and stored wet.During a review of the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air Drying Required, showed 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. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms.4. During an observation on 04/27/2026 at 9:42 AM in the kitchen, the food preparation sink was observed without backflow prevention.During an interview on 04/27/2026 at 2:15 PM with Maintenance Supervisor (MS), MS stated, the food preparation sink does not have backflow prevention.During an interview on 04/29/2026 at 09:18 AM with RD, RD was informed and acknowledged the above findings.During a review of the USDA Food Code 2022 Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.5. During a concurrent observation and interview on 04/28/2026 at 1:00 PM with Registered Dietitian (RD) in the rehabilitation gym, multiple food items were found in the resident refrigerator unlabeled and without dates. RD stated, all items should be labeled with the resident's name and use by date. RD confirmed that the following items were not labeled or dated:- Two containers of canned fruit- Four containers of Jello- One plastic reusable container- Six probiotic cultured drink bottlesDuring a review of the facility's policy and procedure titled, Food Brought by Family/Visitors, dated 2001, indicated, containers are labeled with the resident's name, the item and the use by date.6. During a concurrent observation and interview on 04/27/2026 at 9:42 AM with Registered Dietitian (RD) in the kitchen, the following was observed and confirmed by the RD:- The wall above stored food in dry storage had peeling paint.- The wall above stored hotel pans for food storage had peeling paint.- The floor had multiple chipped and cracked tiles.- Under the food preparation sink and next to the grease trap was a broken tile that was no longer attached to the floor.During a review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch.During a review of the facility's policy and procedure titled, Sanitization, dated 2001, indicated, all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.7.During an observation on 04/28/2026 at 9:22 AM in the kitchen with Dietary Aide (DA). DA demonstrated checking the sanitizing solution for correct concentration. DA observed using test strips that were expired.During an interview on 04/28/2026 at 9:22 AM with RD, RD stated, test strips that are expired should not be used to test the concentration of the sanitizing solution. RD confirmed that the test strips were expired.During a review of the facility's policy and procedure titled, Sanitization, dated 2001, indicated, Chemical sanitizing solutions (e.g. chlorine, iodine, quaternary ammonium compound) are used according to manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to implement their infection prevention and control policies and procedures when:1. For one (Residents 45) of three sampled residents, resident's unbagged continuous positive airway pressure (CPAP, a machine that uses a mask to supply air pressure in keeping the airway open) mask and nebulizer (used to deliver medication in a fine mist over the nose and mouth) mask were left exposed to air.2. For one (Residents 59) of three sampled residents, Resident 59's unbagged nasal cannula was found on the floor.3. For one (Residents 3) of three sampled residents, Licensed Nurse performed direct patient care without wearing the proper personal protective equipment (PPEs, wearable gear to protect workers from illness or infection) upon entrance to a room on Enhanced Barrier Precaution (EBP, an infection control strategy to reduce risk of multidrug-resistant organisms).For Residents 45, 59, and 3, these deficient practices had the potential to result in the spread of infection.4. Housekeeping (Hskg)/Laundry Staff belongings were found stored in the Laundry Area.This deficient practice created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) or spread of infection to the 47 residents who get their laundry serviced in the facility.1. During a record review of Resident 45's admission Record (AR), printed on 4/30/26, Resident 45 was admitted to the facility in March 2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, which refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.) and respiratory syncytial virus (RSV, a respiratory virus that infects the lungs and breathing passages), and obstructive sleep apnea (a sleep disorder in which a person repeatedly stops breathing during sleep because the airway becomes blocked). During a record review of Resident 45's Care Plan dated 3/25/26, the care plan indicated Resident 45 was at risk for complications with the respiratory system due to COPD and asthma (a chronic lung condition that makes it hard to breathe because the airways become swollen and narrow). The care plan further indicated to for facility staff to follow infection control protocol for universal/standard precautions (a set of infection-control practices used to prevent transmission of diseases). During an observation and interview on 4/28/26 at 9:02 a.m. with Resident 45, Resident 45's CPAP mask was left exposed on top of the CPAP machine without a protective bag storage. Resident 45 stated the facility had not provided a bag for storage of the CPAP mask when not in use. Resident 45 further stated the CPAP mask should have been kept in a bag to maintain cleanliness. During a follow-up observation on 4/30/26 at 9:53 a.m. in Resident 45's room, Resident 45's CPAP mask remained exposed on top of the CPAP machine without a protective bag storage. Resident 45's nebulizer mask, disconnected from the nebulizer cup (a small container that holds the liquid medication) was also observed exposed on the tray table without a protective bag storage alongside a water pitcher, soda can, and a bottle of lotion. During an interview on 4/30/26 at 9:59 a.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated the CPAP and nebulizer masks should have been kept in a bag to prevent exposure to dirt, contaminants (a substance, impurity, or foreign matter that makes something dirty, impure, unsafe, or unusable), and insects. CNA further stated environmental services staff may have touched or moved the masks during cleaning, which could have contaminated the equipment. During an interview on 4/30/26 at 10:08 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the licensed nurses were responsible for cleaning the CPAP and nebulizer masks weekly. LVN 3 further stated leaving the CPAP and nebulizer masks exposed increased the risk for Resident 45 to inhale contaminants, which could have resulted in respiratory infection. 2. During a record review of Resident 59's AR, printed on 4/30/26, Resident 59 was admitted to the facility in April 2026 with diagnoses including visual loss in both eyes and giant cell arteritis (inflammation of the big blood vessels in the head). During a record review of Resident 59's Care Plan dated 4/26/26, the care plan indicated Resident 59 was at risk for complications with respiratory system due to episode of desaturation (drop in the oxygen level in the blood). The care plan further indicated for facility staff to follow infection control protocol for universal/standard precautions. During an observation and interview on 4/30/26 at 10:05 a.m. with Resident 59, Resident 59's nasal cannula (a lightweight, plastic device with two prongs placed in the nostrils to deliver supplemental oxygen to people with respiratory conditions) was observed lying on the floor next to the oxygen concentrator machine and Resident 59's pair of black shoes. Resident 59 stated licensed nurses assisted with applying and removing nasal cannula at night because Resident 59 was blind and required assistance. During an observation and interview on 4/30/26 at 10:10 a.m. with LVN 3, in Resident 59's room, LVN 3 was observed checking the nasal cannula on the floor. LVN 3 stated the nasal cannula should have been discarded because it already touched the floor. LVN 3 further stated use of contaminated nasal cannula placed Resident 59 at risk for exposure to infections like pneumonia (lung infection) or sepsis (a life threatening condition where the body has an extreme, harmful reaction to an infection). During an interview on 4/30/26 at 11:48 a.m. with Infection Preventionist (IP), IP stated the nasal cannula found on the floor should have been discarded and replaced with a new one. IP stated if CPAP, nebulizer masks, and nasal cannula were not in use, they should have been placed in a bag to prevent them from getting exposed to germs and developing respiratory infections. 3. During a record review of Resident 3's AR, printed on 4/30/26, the AR indicated Resident 3 was admitted to the facility in January 2026 with diagnoses including hemiplegia (a severe or total paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (reduced blood flow (ischemia) leading to tissue necrosis in the brain)affecting left non-dominant side and gastrostomy status (presence of a surgically created opening (stoma) between the abdominal wall and the stomach) During a record review of Resident 3's Care Plan, dated 3/17/26, the care plan indicated Resident 3 required EBP during high-contact resident care activities due to presence of foley catheter (a thin, flexible tube inserted through the urethra into the bladder to drain urine into a collection bag) and enteral feeding (a method of delivering nutrients directly into the stomach). The care plan further indicated for facility staff to utilize PPE during high-contact care activities including device care, During an observation and interview on 4/30/26 at 12:13 p.m. with LVN 2 in Resident 3's room, an EBP posting was right outside the door. The EBP posting indicated the providers and staff must wear gloves and a gown for high-contact resident care activities, including device care and feeding tube use. LVN 2 stated she was going to flush Resident 3's gastrostomy tube (g-tube) and check Resident 3's blood sugar. LVN 2 entered Resident 3's room carrying supplies in a tray including a cup of water, an empty cup, alcohol swabs, glucometer (a device used to measure blood sugar) and a lancet (a small, sharp, sterile needle used to prick the skin to obtain a drop of blood). LVN 2 entered the room without donning the required PPE prior to initiating high-contact care resident. LVN 2 placed the tray on the bedside table and informed Resident 3 that she was going to perform blood sugar check using Resident 3's right pinky finger. After the blood sugar was completed, LVN 2 turned off Resident 3's tube feeding machine and returned to the medication cart to obtain a stethoscope. LVN 2, while still not wearing the required PPE, exposed Resident 3's abdominal area and disconnected Resident 3's g-tube from the tube feeding machine. LVN 2 then proceeded to check for Resident 3's tube feeding residual (the volume of formula remaining in the stomach) by connecting a syringe to Resident 3's g-tube and slowly aspirating for gastric contents and returning it back to Resident 3. During a follow-up interview on 4/30/26 at 12:28 p.m. with LVN 2, LVN 2 stated the EBP posting was intended for Resident 3. LVN 2 stated she was in a hurry and forgot to wear proper PPE prior to providing care to Resident 3. LVN 2 further stated she should have worn a gown to prevent exposure to bodily fluids and for infection control. During an interview on 4/30/26 at 1:56 p.m., with IP, IP stated residents with g-tubes should have been provided with EBP to prevent transmissions of infections like MDROs. IP further stated all staff should have worn the required PPE when providing care to residents on EBP to reduce the risk of transmission of MDROs between staff and residents. During an interview on 4/30/26 at 2:31 p.m. with the Director of Nursing (DON), DON stated wearing PPE in an EBP room was a way to protect the residents from getting infection. DON further stated the respiratory masks should have been kept in a WikiPouch (a breathable, moisture-wicking, and reusable storage pouch designed to replace plastic bags for storing reusable medical respiratory devices, such as nasal cannulas and masks) for infection prevention. During a record review of facility's policy and procedures (P&P), titled, Departmental (Respiratory Therapy) – Prevention of Infection, revised in November 2011, the P&P indicated, Infection Control Considerations Related to Oxygen Administration.The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment.8. Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use.Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol.7. Store the circuit in plastic bag, marked with date and resident's name, between uses. During a record review of facility's P&P, titled, Enteral Feedings – Safety Precautions, revised in November 2018, the P&P indicated, The facility will remain current in and follow accepted best practices in enteral nutrition. 4. During a concurrent observation and interview on 4/29/26, at 9:10 a.m., with the Hskg/Laundry Staff and Maintenance Director (MD), a black upholstered swivel (a chair with a single central leg base that allows the seat to rotate from left to right) chair was found in a corner inside of the laundry room. Hskg/Laundry Staff stated she kept her belongings on top of the chair when working in the laundry. On top of the chair were a purse, some items inside a green disposable plastic bag, and a black puffy jacket placed over the belongings. Per MD, staff belongings should be stored in the staff lounge to prevent risk of cross-contamination. During an interview on 4/30/26, at 9:45 a.m., with the Infection Preventionist (IP)/Director of Staff Development (DSD), IP/DSD stated staff personal belongings should not be stored in the Laundry Room to prevent contamination or spread of infection. Further, IP/DSD stated lockers were provided in the breakroom for staff use. A review of the facility's Policy and Procedure (P&P) titled, Laundry Storage, dated 2001, indicated, To establish procedures for the safe storage of clean and soiled linens to minimize cross-contamination and ensure a sanitary environment for residents, staff, and visitors. The facility shall ensure that all clean and soiled linens are stored, handled, and transported in a manner that prevents contamination and the spread of infection, in compliance with federal and state regulations.Environmental Conditions.Laundry storage areas shall be clean, sanitary, and well-maintained, free from pest, moisture, and contamination risks.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 47 when:1. Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication refrigerator and Medication Cart #1.2. Four pre-refilled COVID-19 (contagious respiratory illness) vaccine (medication that helps body build immunity against a disease) syringes were stored in the medication refrigerator without the original container and without labeling.These failed practices had the potential for medication identification errors, contamination, improper medication use, and administration errors. During a record review of Resident 1's admission Record (AR) printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with diagnoses including metabolic encephalopathy (acute brain dysfunction caused by chemical imbalances) and glaucoma (an eye condition that damages the optic nerve).During a record review of Resident 2's AR printed on 4/29/26, the AR indicated Resident 2 was admitted to the facility in June 2025 with diagnoses including end stage renal disease (permanent stage of chronic kidney disease) and type 2 diabetes mellitus with retinopathy (a chronic complication of long-term diabetes where high blood sugar levels damage the tiny blood vessels in the retina).During a record review of Resident 3's AR, printed on 4/30/26, the AR indicated Resident 3 was admitted to the facility in January 2026 with diagnoses including hemiplegia (a severe or total paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (reduced blood flow leading to tissue necrosis in the brain)affecting left non-dominant side and gastrostomy status (presence of a surgically created opening (stoma) between the abdominal wall and the stomach).During a record review of Resident 40's AR printed on 4/30/26, the AR indicated Resident 40 was admitted to the facility in May 2024 with diagnoses including lagophthalmos (inability to fully close the eyelids, leading to exposed, dry eyes) of left eye and dry eyes syndrome of bilateral lacrimal glands (a chronic condition where both eyes' tear-producing glands fail to secrete enough watery fluid to keep the eyes lubricated).During a concurrent observation and interview on 4/28/26 at 2:28 p.m. with Licensed Vocational Nurse (LVN)/Nursing Supervisor (NS)1, in the medication room, the medication refrigerator's first-level compartment contained a tray storing medications with different routes of administration together, including four boxes of bisacodyl rectal suppositories (a laxative used to treat constipation administered by rectal route), Residents 1, 2, and 40's ophthalmic solution (sterile liquid medication intended for administration into the eyes) eye drops, an opened box of pre-filled COVID-19 vaccine syringes, an opened box of tuberculin (a medication used for tuberculosis [a bacterial lung infection] screening administered intradermally or under the skin) injectable solution, and Resident 2's two insulin vials (injectable medication used to control blood sugar levels). On the second compartment, four pre-filled COVID-19 vaccine syringes were stored in an opened blister pack (a plastic packaging that holds syringes separately)tray without a labeled container. LVN 1/NS 1 stated the medications should have been stored separately according to their medication administration route for infection control purposes. LVN 1/NS 1 further stated the four pre-filled COVID-19 syringes should have remained stored in a labeled container with the original manufacturer labeling containing instructions and expiration date information. LVN 1/NS 1 stated storing medications without proper labeling increased the potential for medication identification and administration errors.During a concurrent observation and interview on 4/28/26 at 12;27 p.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), in Medication Cart #1, the first drawer's farthest right compartment contained a zip-lock bag with Resident 3's rectal suppositories stored together with multiple oral pill medications. DSD/IP stated the rectal suppositories should have been stored separately from the oral medications. DSD/IP further stated storing medications with different routes of administration together increased the risk of cross-contamination and medication administration errors, including the potential for rectal suppositories to have been administered by wrong route, including orally instead of rectally.During an interview on 4/30/26 at 2:44 p.m. with the Director of Nursing (DON), DON stated all medications must be stored according to their designated route of administration. DON further stated this practice was essential to maintaining infection control standards and preventing medications from being inadvertently mixed or administered to the wrong resident.During a record review of the facility's undated policy and procedures (P&P), titled, Medication Labeling and Storage, the P&P indicated, 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medication Labeling.1. Labeling medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . 2. The medication label includes, at a minimum . a. medication name (generic and slash/brand) b. prescribed dose. c. strength.c. expiration date, when applicable.f. route of administration.g. appropriate instructions and precautions . 7. Medications for external use as well as hazardous drugs and biologicals are clearly marked as such and are stored separately from other medications . 8. If medication containers have missing incomplete improper or incorrect labels contact the dispensing pharmacy for instructions regarding returning or destroying these items .

Based on observation, interview, and record review, the facility failed to ensure water temperatures were maintained within a safe range for five of eight sampled residents (Residents 1, 40, 45, 59, and 60) when two Jack-and-[NAME] bathrooms (shared bathrooms with two separate entrances from two different rooms) had faucet sink water temperatures exceeding 120 (degrees) Fahrenheit (a temperature scale used to measure how cold or hot something is).This failure placed Residents 1, 40, 45, 59, and 60 at risk for scald (type of burn caused by contact with hot liquids or steam) injuries.During a record review of Resident 1's admission Record (AR), printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that destroys memory and cognitive functions)During a record review of Resident 40's AR, printed on 4/30/26, the AR indicated Resident 40 was admitted to the facility in May 2024 with diagnosis of neurofibromatosis (a genetic condition where a person develops small, usually harmless tumors on their nerves.)During a record review of Resident 45's AR, printed on 4/28/26, the AR indicated Resident 40 was admitted to the facility in March 2026 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.)During a record review of Resident 59's AR, printed on 4/30/26, the AR indicated Resident 59 was admitted to the facility in April 2026 with diagnosis of visual loss in both eyes.During a record review of Resident 60's AR, printed on 4/30/26, the AR indicated Resident 60 was admitted to the facility in April 2026 with diagnosis of NSTEMI (non-ST elevation myocardial infarction, a type of heart attack when a blood vessel that feeds the heart gets partially blocked).During an observation on 4/27/26 at 10:26 a.m. in the shared Jack-and-[NAME] bathroom designated to Residents 45,59, and 60, a posting near the sink indicated Water may exceed 120F. When the faucet was turned to the hottest maximum level and tested using a contact thermometer (a device that measures temperature by establishing direct physical contact with an object), the temperature reached 154.1 F in approximately less than 30 seconds.During an interview on 4/27/26 at 10:35 a.m. with Resident 45, Resident 45 stated the water in the bathroom could get very hot and it felt horrible because it required a lot of patience and took about five minutes to cool to a tolerable, non-burning temperature before use. Resident 45 further stated the delay made it difficult to perform hand washing due to excessive time required to obtain safe water. During an interview on 4/27/26 at 11:05 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated she did not know why the water temperature in Resident 45's bathroom could exceed more than 120F. CNA 2 stated the safe water temperature for resident use was between 110 F-120 F. CNA 2 further stated the water temperature in bathroom could cause burns to Resident 45 and other residents using the shared bathroom.During an observation on 4/27/26 at 11:19 a.m., in another shared Jack-and-[NAME] bathroom designated for Resident 1 and Resident 40, there was no Water may exceed 120F posting to alert Resident 1 and Resident 40 regarding the water temperature. When the faucet was turned to the hottest maximum level and tested using a contact thermometer, the temperature reached 153.2 F in approximately less than 30 seconds.During a follow-up observation and interview on 4/30/26 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 3, in the shared Jack-and-[NAME] bathroom designated for Resident 1 and Resident 40, the water temperature was tested. Using a contact thermometer, the water temperature reached 167.4 F in less than 10 seconds. LVN 3 stated the water faucet should have been positioned in the middle setting to prevent excessive heat. When the faucet was adjusted to the middle position and retested, the water temperature measured 155 F. LVN 3 was not aware of the facility's policy regarding safe water temperature levels for resident use.During an observation and interview on 4/30/26 at 10:19 a.m. with Maintenance Director (MD) in Residents 45, 59, and 60's shared bathroom, MD stated the posting on the wall was to alert whoever was using the sink including the CNAs that the water could get too hot. MD stated if the water was too hot, he would have adjusted the water temperature. MD stated the safe hottest maximum level of temperature for the residents to use was between 105 F to 120 F. Using non-contact laser thermometer gun (a device that measures an object's surface temperature from a distance), MD turned the water on to the hottest level and pointed the laser directly at the running water had a reading of 162 F with approximately less than 30 seconds of reading.During another observation and interview on 4/30/26 at 10:23 a.m. with MD in Resident 1 and Resident 40's shared bathroom, using the same non-contact laser thermometer, MD turned on the water to the maximum hottest level, but this time, the laser was pointing towards the drain flange (round silver metal plate inside the sink). The water temperature only reached 112 F. MD was asked to retest the running water temperature and to point the laser directly to the water. During the retest, the running water temperature reached 150 F in less than 30 seconds. MD stated the water temperature for the two Jack-and-[NAME] bathrooms that were tested were not acceptable and not safe for residents' use. MD further stated the residents could have sustained burns if they were unaware of the hot water temperature.During a record review of the facility's policy and procedure (P&P), titled, Water temperatures, Safety of, revised in December 2009, the P&P indicated, Tap water in the Facility shall be kept within a temperature range to prevent scalding of residence. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 F, or the maximum allowable temperature per state regulation. 4. If at any time water temperatures feel excessive to touch (i.e., hot enough to be painful or cost reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor.5. If water is found to be above maximum allowable temperature, a sign must be then present notifying residents that hot water exceeds maximum allowable temperature until the temperature is corrected to be within range, and resident is offered alternative water source . 7. The length of exposure to warm or hot water, the amount of skin exposed and the residence current condition affect whether or not exposure to certain temperatures will cause scalding or burns. Therefore, ongoing resident observation and assessment during prolonged exposure to warm or hot water will help to determine the safety of the situation.

Based on interview and record review, the facility did not demonstrate competency in dialysis care to provide services for four (Resident 22, Resident 32, Resident 66, and Resident 3) of four dialysis-dependent (dialysis, a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys fail) residents in accordance with the facility assessment.This failure did not ensure the licensed nurses' competency and skills were met to provide safe care which could potentially result in dialysis-dependent residents receiving inappropriate care and services.A review of Resident 22's admission Record printed 5/1/26 indicated resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (renal failure), diabetes mellitus (high blood sugar), and dependence on renal dialysis, with a port catheter (Port-a-Cath, a dialysis access site surgically placed fully under the skin that cannot be assessed for bruit [swishing sound] and thrill [a buzzing vibration]) access site to the right (R) upper chest.A review of Resident 2's admission Record printed 5/1/26 indicated resident was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease, diabetes mellitus, and dependence on renal dialysis, with an arterio-venous (AV, surgically connecting an artery and a vein, usually placed in the arm) fistula access site to the left upper arm (LUA).A review of Resident 66's admission Record printed 5/1/26 indicated resident was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease, diabetes mellitus, and dependence on renal dialysis, with an AV fistula access site to the LUA.A review of Resident 32's admission Record printed 5/1/26 indicated resident was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease, diabetes mellitus, and dependence on renal dialysis, with an AV fistula access site to the LUA.During an interview on 4/28/26 at 9:41 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 22, a dialysis-dependent with a port catheter to his R upper chest went for routine dialysis on a Monday-Wednesday-Friday schedule. During another interview on 5/1/26 at 10:56 a.m. with LVN 2, LVN 2 confirmed Resident 22 was routinely assessed before being sent out to the dialysis center. LVN 2's pre-dialysis assessment of the resident included checking the R upper chest port catheter using a stethoscope to hear the swishing sound and to palpate a buzzing vibration on the site. LVN 2 stated she had just started work three months ago today, and has not received competency training on dialysis care and management from the facility.During an interview on 5/1/26 at 11:00 a.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), IP/DSD stated when assessing a dialysis AV fistula site, check the bruit for the swishing sound. IP/DSD was unaware and did not mention checking the access site for the thrill. IP/DSD stated DON was responsible for providing training and competencies to all licensed nurses. IP/DSD was unable to recall when training on dialysis care was last provided by the facility.During an interview on 5/1/26 at 11:08 a.m. with LVN 3, LVN 3 stated she has two dialysis-dependent residents (with AV fistula assess sites) under her care today. LVN 3 stated before sending the resident to dialysis, LVN 3 checked the access site for bruit using a stethoscope. LVN 3 was unaware and did not mention checking the access site for the thrill. Furthermore, LVN 3 stated she could only recall receiving her dialysis care training from nursing school.A review of Resident 22's Pre-hemodialysis Communication Observation/Assessment forms, dated 4/25/26 and 4/29/26, LVN 2 indicated Resident 22 had an access site type of port catheter to the right upper chest and documented a yes reply on the presence of bruit and thrill. Further review of Resident 22's Pre-hemodialysis Communication Observation/Assessment form dated 5/1/26, LVN 2 indicated, Resident General Condition.Catheter port is located at the right upper chest. Bruit and thrill present.During a concurrent interview and record review with Director of Nursing (DON) on 5/1/26 at 11:24 a.m., DON confirmed Resident 22's Pre-hemodialysis Communication Observation/Assessment form, dated 5/1/26 indicated LVN 2 documented resident's dialysis access site to R upper chest was assessed for bruit and thrill. DON confirmed Resident 22 was the only resident out of the four dialysis-dependent residents in the facility to have a Port-a-Cath and Port-a-Cath cannot be assessed for bruit and thrill because it is under the skin. DON stated last competency training provided to the licensed nurses was on 5/5/25. DON added further training will be scheduled soon because of the newly hired licensed nurses, resident population, and characteristics that the facility has.A review of the Facility Assessment, last reviewed 2/20/26, indicated the average number of residents on special treatments and conditions included four residents (Resident 22, Resident 2, Resident 66, and Resident 32) who were dependent on hemodialysis (also known as dialysis). Staff training/education and competencies needed to provide level of requirements were also included in the facility assessment. The nursing staff skill sets that were evaluated annually included specialized care such as dialysis.A review of the facility's Policy and Procedure (P&P) titled, Hemodialysis Catheters - Access and Care of, dated 2001, indicated, Hemodialysis catheters are only accessed by medical personnel who have received training and demonstrated clinical competency regarding use of this catheter.Types of hemodialysis catheters.1. Arterio-venous fistula (AVF, access created by surgically connecting an artery and a vein, usually placed in the arm) .3. Central catheters (inserted in the neck, chest or groin area) .Care of AVFs.Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots).Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating conditions when:The ice machine was not sanitized as per the manufacturer's instructions.The facility failed to follow the manufacturer's required maintenance and operational guidelines for the equipment. This failure had the potential to prevent the equipment from functioning as intended, which could have resulted in the gradual degradation of its internal components and compromised its reliability and safety.During interview and observation on 04/27/2026 at 3:05 PM, the Maintenance Supervisor (MS) was observed utilizing Clorox bleach-type solution for cleaning the ice machine. This method does not align with the manufacturer's recommendations, which specify the use of a Montauk-type descaler solution. While the ice machine appeared to be clean and in good condition following a professional cleaning the day before, the use of an improper cleaning chemical raises concerns about the potential degradation of the machine's internal components over time. Adhering to the manufacturer's guidelines is crucial to maintaining the integrity and longevity of the equipment.During a review of the manufacturer's maintenance protocol and regulatory requirements on 04/27/2026 at 3:15 PM, it was noted that USDA Food Code 2022 (Section 4 601.11) mandates that equipment food-contact surfaces and utensils shall be clean to sight and touch an observation and concurrent interview were conducted with the Maintenance Supervisor (MS). The MS stated he cleaned the ice machine once a month using a Clorox cleaning solution and demonstrated his internal cleaning process, which did not follow the manufacturer's required procedure.During a review of the manufacturer's maintenance guidance for the Manitowoc ice machine on 04/27/2026 at 3:40 PM, it was noted that the manufacturer requires the use of a Manitowoc-approved ice machine cleaner and sanitizer as part of the scheduled cleaning and sanitizing procedure. The manufacturer specifies that only its approved sanitizer is formulated to effectively remove scale, slime, and microbial buildup from internal food-contact surfaces and to ensure the equipment maintains its intended performance and sanitation standards. The required sanitizer is an NSF-listed, no-rinse solution designed specifically for Manitowoc ice machines and must be used at the frequency and dilution directed in the manufacturer's maintenance instructions.During a review of the facility's policy and procedure (P&P) titled Sanitization, dated 2001, the policy states: Ice machines and ice storage containers are drained, cleaned, and sanitized per the manufacturer's instructions.

Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to one sampled resident (Resident 49) to ensure the timely acquisition, dispensing, and administration of routine medications when Resident 49's inhalation medication was not available during medication administration.This failure had the potential to result in delayed or missed medication administration and had the risks for increased exacerbation of respiratory conditions.During a record review of Resident 49's admission Record (AR) printed on 4/30/26, the AR indicated Resident 49 was admitted to the facility in February 2026 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into brain tissue) and cognitive communication deficit (difficulty communicating because of thinking skills).During a record review of Resident 49's Medication Administration Record (MAR) dated 4/1/26 to 4/30/26, the MAR indicated Resident 49 had a physician order dated 2/14/26 for Breo Ellipta (reduces inflammation in the lungs and relaxes and opens the airways to help breathing) Inhalation Aerosol Powder Breath Activated 100-25 mcg(microgram)/act (actuation, meaning one puff or one spray from the inhaler). Give 1 puff inhale orally one time a day for suspected COPD (Chronic Obstructive Pulmonary Disease, which refers to a group of diseases that cause airflow blockage and breathing-related problems). scheduled for administration at 9:00 a.m.During a medication administration pass observation on 4/28/26 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared Resident 49's scheduled medications, however, the Breo Ellipta inhaler was unavailable for administration. LVN 4 stated the inhaler was not available for Resident 49's use. During a follow-up interview and record review on 4/28/26 at 10:48 a.m. with LVN 4, Resident 49's electronic MAR was reviewed. LVN 4 confirmed Breo Ellipta inhaler was unavailable because it had not been reordered in a timely manner. LVN 4 showed Resident 49's MAR that indicated the Breo Ellipta inhaler was reordered on the same day as the medication administration observation. LVN 4 stated the pharmacy should have been notified when the inhaler was running low or when approximately six puffs remained. LVN 4 further stated routine medications should have always been available in the medication cart for Resident 49's use. LVN 4 stated failure to administer a prescribed medication would be considered as a medication error and had a potential for Resident 49 to have wheezing or shortness of breath. During another follow up interview on 4/28/26 at 2:16 p.m. with LVN 4, LVN 4 stated the Breo Ellipta had still not been administered because the medication remained unavailable. During an interview on 4/30/26 at 2:48 p.m. with the Director of Nursing (DON), DON stated licensed nursing staff were expected to reorder medications timely, and follow up with the pharmacy when medication was unavailable or running low. DON further stated Resident 49's unavailable Breo Ellipta inhaler had the potential to cause worsening of respiratory symptoms including airway restrictions that could have been life-threatening.During a record review of the facility's policy and procedure (P&P) titled, Administering Medications revised in April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required timeframe.During a record review of the facility's P&P, titled, Medication Orders, updated in February 2025, the P&P indicated, Medication Supply.1. New medication orders are sent to pharmacy for fulfillment.3. Follow up with Pharmacy on the status of the Medication Order.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services consistent with professional standards for one of five sampled residents (Resident 72) on oxygen (O2, a prescription drug used to treat low blood oxygen level) therapy when the facility did not follow physician orders for oxygen administration. This failure resulted in Resident 72 receiving more oxygen than ordered, which placed the resident at risk for serious harm.A review of Resident 72's admission Records, printed on 4/28/26, indicated resident was admitted to the facility on [DATE] with diagnoses that included multiple rib fractures and history of fall.A review of Resident 72's Care Plan, indicated a focus titled, Oxygen: Resident requires the use of oxygen (continuous) related to shortness of breath due to (d/t) .rib fractures. Interventions included, Administer oxygen at two liters (2L) via nasal cannula.Monitor and report signs of hypoxia (when the body is not getting enough oxygen to function properly) to physician.During a concurrent observation and interview on 4/27/2026 at 12:45 p.m., inside Resident 72's room, resident was lying in bed with head of bed raised up to a slight angle, receiving oxygen therapy, administered through a nasal cannula (a tube placed into the resident's nose held in place by an elastic band placed around the resident's head) affixed to her nose. The oxygen concentrator (a medical device that delivers oxygen to patients with breathing problems) was running continuously at a flow rate of three (3) LPM. Resident stated she has an order for oxygen at two (2) LPM to assist her with breathing related to recent rib fractures.During a concurrent observation and interview (this was a follow-up visit after a review of Resident 72's Physician Order, dated 4/24/26, indicating O2 at 2 LPM via nasal cannula continuously) on 4/28/26 at 9:33 a.m., Resident 72, lying in bed awake, stated she just came back from physical therapy. O2 concentrator was noted to run continuously at three and a half (3.5) LPM via nasal cannula. During a concurrent observation and interview on 4/28/26 at 11:48 a.m. with Physical Therapy Assistant 1 (PTA 1), inside Resident 72's room, PTA 1 stated Resident 72 did well during Occupational Therapy session and indicated an O2 saturation (amount of oxygen in the bloodstream) of 98 percent (%). PTA 1 stated resident was receiving O2 at 2 LPM. Upon observation of the O2 concentrator, PTA confirmed O2 was running at four (4) LPM. PTA stepped out of Resident 72's room to clarify the order and came back stated resident's O2 order was 2-4 LPM.During a concurrent interview and record review on 4/28/26 at 11:55 a.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 72's O2 order was reviewed. LVN 1 stated a new order was given on 4/28/26 for O2 at 2-4 LPM via nasal cannula continuously. When asked what the reason was behind the sudden change of order, LVN 1 was unable to respond.During an interview on 4/28/26 at 2:55 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 72 remained on continuous O2 during provisions of activities of daily living (ADL). CNA 1 stated she would call the charge nurse when oxygen had to be turned on and off for showers, or as needed. A review of Resident 72's Physician Order dated 4/24/26 indicated an admission order of O2 at 2 LPM via nasal cannula continuously. Monitor O2 saturation every shift. Further review of telephone Physician Orders received and transcribed by LVN 1 on 4/28/26 indicated the following change of orders in a span of 12 minutes:11:53 a.m., Discontinue O2 at 2 LPM via nasal cannula continuously. 11:54 a.m., Start O2 at 2-4 LPM via nasal cannula continuously. 12:00 p.m., Start O2 at 2 LPM via nasal cannula continuously.12:01 p.m., Discontinue O2 at 2-4 LPM via nasal cannula continuously. During an interview on 4/30/26 at 11:49 a.m. with the Director of Nursing (DON), DON stated Resident 72 should only be administered the oxygen rate that was ordered by the physician. According to the DON, resident was placed at risk due to increased O2 rate outside of ordered 2 LPM. LVN1 should not have requested a change of order when the resident did not show any change of condition with the current O2 order. DON stated O2 order was returned back to original admission order of 2 LPM. A review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 2001, indicated, Medications are administered in a safe and timely manner, and as prescribed. A review of another facility P&P titled, Oxygen Administration, dated 2001 indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Physician 1 was unavailable for interview when writer phoned and attempted to call for Resident 72's O2 order.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 49) received medications as ordered without an error. The facility's medication pass observation during the survey resulted in two errors out of 31 opportunities and indicated a medication error rate of 6.45 percent (%).This failure placed Resident 49 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in adverse health outcomes including, worsening of respiratory symptoms, increased risk for blood clot (thick, viscous, or semi-solid lump formed when blood thickens) formation and stroke (a medical emergency caused by a sudden interruption of blood flow to the brain or a ruptured blood vessel, leading to rapid brain cell death).During a record review of Resident 49's admission Record (AR) printed on 4/30/26, the AR indicated Resident 49 was admitted to the facility in February 2026 with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracerebral hemorrhage (a type of stroke) affecting right dominant side and cognitive communication deficit (difficulty communicating because of thinking skills).During a medication administration pass observation on 4/28/26 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared Resident 49's scheduled; however, the Breo Ellipta inhaler (reduces inflammation in the lungs and relaxes and opens the airways to help breathing) was unavailable for administration. LVN 4 stated the inhaler was not available for Resident 49's use. LVN 4 then proceeded and prepared the following routine oral medications for Resident 49 and separated each medication into individual cups:One tablet of amlodipine 10 mg(milligrams) (lower blood pressure)One tablet of clopidogrel 75 mg (prevent blood clot)Three tablets of losartan 25mg (lowers blood pressure)Four tablets of vitamin D 25mcg (supplement for bone support)One capsule acidophilus 20mg (probiotic, support digestive health) Prior to crushing the medications, LVN 4 confirmed and stated there were total of 10 oral pills that she prepared for Resident 49. LVN 4 also prepared Resident 49's lidocaine patch 4% (a topical medication used to relieve localized pain). LVN 4 mixed the crushed oral medications with apple sauce. LVN 4 proceeded to administer Resident 49's medications.During a follow-up interview and record review on 4/28/26 at 10:48 a.m. with LVN 4, Resident 49's electronic MAR was reviewed. LVN 4 confirmed Breo Ellipta inhaler was unavailable because it had not been reordered timely. LVN 4 showed Resident 49's MAR that indicated the Breo Ellipta inhaler was reordered on the same day as the medication administration observation. LVN 4 stated the pharmacy should have been notified when the inhaler was running low or when approximately six puffs remained. LVN 4 further stated routine medications should have always been available in the medication cart for Resident 49's use. LVN 4 stated failure to administer a prescribed medication would be considered as a medication error and had a potential for Resident 49 to cause wheezing or shortness of breath.During a medication reconciliation record review of Resident 49's MAR, dated 4/1/26 to 4/30/26, the MAR indicated Resident 49 did not receive the following physician-ordered medications scheduled for administration at 9:00 a.m. during the medication administration observation.Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg(microgram)/act (actuation, meaning one puff or one spray from the inhaler). Give 1 puff inhale orally one time a day for suspected COPD (Chronic Obstructive Pulmonary Disease, which refers to a group of diseases that cause airflow blockage and breathing-related problems)Aspirin 81 oral tablet chewable.Give 1 tablet by mouth one time a day for Cerebro Vascular Accident (CVA, stroke or when blood flow to part of the brain was blocked) ppx (prophylaxis or for prevention).During another follow-up interview on 4/29/26 at 1:35 p.m. with LVN 4, LVN 4 stated she may have become confused during medication preparation and mistakenly believed the aspirin had already been administered. LVN 4 further acknowledged that failure to administer the aspirin dose placed Resident 49 at risk for stroke.During an interview on 4/30/26 at 2:48 p.m. with the Director of Nursing (DON), DON stated licensed nursing staff were expected to timely reorder medications and follow up with the pharmacy when medication was unavailable or running low. DON further stated Resident 49's unavailable Breo Ellipta inhaler had the potential to cause worsening respiratory symptoms including airway restrictions, worsening respiratory symptoms, that could have been life-threatening Resident 49. DON further stated if aspirin was not given as ordered, Resident 49 was at risk for clot formation and recurrent stroke, particularly due to Resident 49's history of stroke.During a record review of the facility's policy and procedure (P&P), titled, Administering Medications, revised in April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review the facility failed to maintain a safe, comfortable and homelike environment when one of four sampled resident room (Resident 102) had dust covering the ceiling air vent, scattered areas of peeling paint on the wall, and task lighting cord was not long enough for resident to reach. This failure had the potential to compromise Resident 102's health by exacerbating (making something that is already bad even worse) the respiratory symptoms and decreasing the resident's autonomy (the capacity to decide for oneself and pursue that course of action) . Findings: A review of Resident 102's face sheet dated 6/17/25, indicated Resident 102 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (a severe condition where the respiratory system cannot adequately oxygenate the blood, leading to low blood oxygen levels and potentially affecting tissue oxygenation), chronic obstructive pulmonary disease with acute exacerbation (COPD, a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitations with a sudden and significant worsening of respiratory symptoms), and asthma ( a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breath). During a review of Resident 102's Minimum Data Sheet (MDS, an assessment tool used to guide care), dated 5/31/25, the MDS indicated that Resident 102's Brief Interview for Mental Status (BIMS, a standardized assessment tool used to screen for cognitive impairment) score was 12 out of 15, indicating moderate cognitive impairment. During a concurrent observation and interview on 6/17/25 at 12:30 p.m. with Maintenance Director (MD), in Resident 102's room, ceiling air vent was covered with dust and there was no string for Resident 102 to turn task light on /off. The paint of the wall between the nightstand and headboard were peeling off. Resident 102 stated she had COPD and asthma which had the potential to flare up when she inhaled the dust and paint particles. She stated she preferred to activate the task light by herself but was unable to reach the cord. During a concurrent interview and record review on 6/17/25 at 12:12 p.m. with MD, the facility's preventive maintenance log binder was reviewed. The MD stated there were no maintenance activities performed for wall patching, and repainting from 2/6/25 until 6/16/25. MD stated he was responsible for finding areas in the physical plant requiring repair, and complete them as soon as possible. During a review of the facility's undated policy and procedure (P&P) titled Homelike Environment, P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment . -The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include comfortable (minimum glare) yet adequate (suitable to the task) lighting. -Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes sufficient general lighting in resident -use areas task lighting as needed . During a review of the facility's P&P titled Maintenance Service revision date 2009, P&P indicated The maintenance department is responsible for maintaining the buildings Function of the maintenance personnel include, .maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines, maintain the building in good repair ., maintain lighting levels that are comfortable .

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. Resident 5's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. Six Retacrit medication vials which belonged to discharged resident 261 were found in medication room refrigerator (Retacrit is a medication used to treat a blood disorder caused by a kidney disease). 3. One opened unlabeled Lispro insulin vial was found in medication room refrigerator (Lispro insulin is a fast-acting injection medication that helps treat high blood sugar in the body). 4. Resident 11 did not have an accurate medication card label for Metoclopramide that matched the physician's order. (Metoclopramide is a medication that helps in nausea and vomiting). 5. Eighteen whole loose pills were found scattered underneath the medication cards in the medication cart. 6. Six Acetaminophen suppositories which belonged to discharged Resident 259 were found in the medication cart (Acetaminophen suppository is a medication given thru the rectum to relieve pain and to reduce a fever). 7. Six Acetaminophen suppositories which belonged to discharged Resident 260 were found in the medication cart. This failure could potentially result in medication error and expose residents to expired medications with questionable potency and efficacy. Findings: 1. During a concurrent observation and interview on 6/17/25 at 10:54 a.m. with the Minimum Data Set Coordinator (MDSC), while inspecting medication cart two, Resident 5 had one opened bottle of Latanoprost eyedrops. The eyedrop bottle had an open date of 4/8/25. The medication box of the eyedrop bottle indicated: to dispose the eyedrops after 42 days from the date opened. MDSC stated, the eyedrop should have been discarded on 5/20/25 as the 42nd day after 4/8/25 would have been 5/20/25. (This observation was conducted on 6/17/25). A review of Resident 5's admission record dated 6/18/25 indicated Resident 5 was admitted on [DATE], with the diagnosis of glaucoma (glaucoma is an eye disorder). A review of Resident 5's Physician Order dated 6/18/25 indicated an order for Latanoprost Ophthalmic Solution 0.005 %, instill 1 drop in both eyes at bedtime for glaucoma. During an interview on 6/17/25 at 11:24 a.m. with Registered Nurse (RN) 3, she stated the Latanoprost eyedrops should have been discarded 42 days after the open date. During an interview on 6/18/25 at 3:21 p.m. with the Director of Nursing (DON), DON stated Latanoprost eyedrops with past use by dates should have been disposed because the risk of giving the eyedrops past their use by date might not be effective in treating the illness due to diminished potency. 2. During a concurrent observation and interview on 6/16/25 at 11:28 a.m. with Licensed Vocational Nurse ( LVN) 1 , while inspecting the medication storage room, six Retacrit medication vials which belonged to discharged Resident 261 were found in the medication room refrigerator. LVN stated Resident 261 has been discharged from the facility. Review of Resident 261's admission record dated 6/18/25 indicated Resident 261was admitted to the facility on [DATE] and was discharged on 6/12/25. The admission record also indicated that the resident was admitted to the facility with diagnoses which included dependence on renal dialysis (a treatment that helps clean the blood when the kidneys aren't working properly). During a review of Resident 261's Physician Order dated 6/12/25, it indicated an order for Retacrit 10,000 unit/ml vial, inject 1.5 ml. subcutaneously every Tuesday, Thursday and Saturday for anemia (ml. is milliliters, unit and ml. are form of measurements; subcutaneously means under the skin; anemia is a blood disorder). During an interview on 6/18/25 at 3:21 p.m. the DON stated medications which belonged to discharged residents should have been disposed on the same day of resident discharge due to the risk of medication error. 3. During a concurrent observation and interview on 6/16/25 at 11:28 a.m. with LVN 1 while inspecting the medication storage room, one opened and unlabeled Lispro insulin vial was found inside the medication room refrigerator. LVN 1 stated the insulin vial should have been labeled with an open date. During an interview on 6/19/25 at 2:08 p.m., with Director of Nursing (DON), DON stated unlabeled vial of lispro insulin in the medication refrigerator should have been labeled with the resident's name and date the vial was opened. 4. During a medication administration observation on 6/16/25 at 1:08 p.m. with Registered Nurse (RN)1, RN 1 gave Resident 11 one tablet of Metoclopramide 10 milligrams (mg., a form of measurement) from Resident 11's medication card with a direction label that indicated to give Metoclopramide 10 mg. one tablet as needed every six hours for nausea and vomiting. A review of Resident 11's physician's orders dated 6/18/25 indicated an order of Metoclopramide 10 milligrams one tablet two times a day. A review of admission record dated 6/18/25 indicated Resident 11 was admitted on [DATE], with the diagnoses which included nausea and vomiting. During an interview on 6/16/25 at 1:08 p.m., RN 1 stated she followed the physician's order for the Metoclopramide and not the directions from the medication card. During an interview on 6/19/25 at 2:08 p.m. with the DON, she stated the medication nurse should have put the change in direction sticker on the Metoclopramide medication card to prevent a medication error. 5. During a concurrent observation and interview on 6/17/25 at 10:54 a.m. with the MDSC while inspecting medication cart two, 18 whole loose tablets were found underneath the medication cards. During a concurrent observation and interview on 6/17/25 11:24 a.m. with RN 3, RN 3 was unable to identify the loose tablets and stated the loose tablets should be disposed according to policy and procedure. During an interview on 6/19/25 at 2:08 p.m. with Director of Nursing (DON), she stated there should be no loose pills in the medication cart due to the risk of medication error. 6. During a concurrent observation and interview on 6/17/25 at 10:54 a.m. with the MDSC, while inspecting medication cart two, six Acetaminophen suppositories which belonged to discharged Resident 259 were found. During an interview on 6/17/25 11:24 a.m. RN 3 stated expired medications and medications which belonged to discharged residents should be disposed right away to prevent medication error and/or diversion. Review of Resident 259's admission record dated 6/18/25 indicated Resident 259 was admitted to the facility on [DATE] and was discharged on 5/12/25. The admission record also indicated the resident had diagnoses which included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 259's physician's orders dated 5/12/25 indicated an order of Acetaminophen suppository 650 mg., insert one suppository rectally as needed for mild pain and fever. During an interview on 6/18/25 at 3:21 p.m. with the DON, she stated medications which belonged to discharged residents should be disposed on the same day of discharge due to the risk of medication error. 7. During a concurrent observation and interview on 6/17/25 at 10:54 a.m. with the MDSC, while inspecting the medication cart two, six Acetaminophen suppositories belonging to discharged Resident 260 were found. During an interview on 6/17/25 11:24 a.m. RN 3 stated expired medications and medications which belonged to discharged residents should be disposed right away to prevent medication error. Review of Resident 260's admission record dated 6/18/25 indicated Resident 260 was admitted to the facility on [DATE] and was discharged on 5/10/25. The admission record also indicated the resident had diagnoses which included chronic pain. A review of Resident 260's physician's orders dated 5/10/25 indicated an order of Acetaminophen suppository 650 mg. insert one suppository rectally as needed every six hours for mild pain and fever. During an interview on 6/18/25 at 3:21 p.m. with the DON, DON stated medications which belonged to discharged residents should have been disposed on the same day of resident discharge due to the risk of medication error. A review of the facility's policy and procedure, titled medication labeling and storage, dated 2001, indicated: .Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes at a minimum: a. medication name .b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions . 12. the nursing staff must inform the pharmacy of any changes in physicians orders for a medication. A review of the facility's policy and procedure, titled Discarding and Destroying Medications dated 2001, indicated: Medications that cannot be returned to the dispensing pharmacy ( . medications refused by the resident and/or medications left by residents upon discharge are disposed of in accordance with federal, state and local regulations .2. Non controlled and scheduled V ( non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of nonhazardous medications . (Controlled medications are substances that have been classified by the government as having the potential for abuse and addiction. Non controlled medications are substances that are not considered to have a significant potential for abuse or dependence, as compared to controlled substances).

Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, when food preparation utensils and equipment were not cleaned and/or maintained in good condition. These failures placed 44 residents who received food from the kitchen at risk for food borne illnesses or illnesses related to use of contaminated utensils. Findings: During an observation and concurrent interview with the Registered Dietitian (RD) on 6/17/25 at 3:21 p.m., the following were observed: 1. A two-slot toaster situated on an open shelf across the stove, had hardened, black, burned particles which resembled bread crumbs on its surface, and had a significant amount of the same substance between its slots and its bottom. 2. A knife stored in a knife rack attached to the wall adjacent to the stove had a silicone coating on its handle which was warped, jagged and dented. 3. An industrial can opener mounted on a kitchen preparation table had black/dark brown sticky substance on its blade and on the crevices of the feed wheel. 4. A plastic container stored under a preparation table contained numerous utensils such as spatulas, scoops, measuring spoons, whisks, ladles and tongs which were supposed to be air drying, but the container was too crowded to allow air to circulate. 5. Newly washed muffin pans, baking trays and baking sheets were stacked while still wet. The baking pans and muffin pans had burnt surfaces, stains, dents and deep scratches. 6. The interior of the industrial oven in the kitchen was soiled and had a build up of burnt grease and burnt food particles. RD stated damaged and old equipment needed to be discarded and replaced. The oven and can opener needed to be cleaned thoroughly, and the staff need to know how to air dry utensils. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. Non food-contact surfaces are to be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of the facility's Policy and Procedure (P&P) titled: Sanitization dated 2001, P&P indicated: 2. All utensils, counters, shelves and equipment are kept clean,maintained in good repair

Based on observation, interview, and record review, the facility failed to follow infection control procedures when the specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the medication storage room. These failures had the potential to contaminate the residents' medications and for the spread of infectious disease. Findings: During a concurrent observation and interview on 6/16/25, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 1 , in the facility medication storage room, the specimen refrigerator was observed to be stored below the medication refrigerator (a medication refrigerator is a specialized appliance specifically designed and used for storing temperature-sensitive medications). Observed inside the specimen refrigerator were a stool specimen in a container and urine specimen samples. LVN 1 stated the specimen refrigerator have been in the medication storage room for a long time, but she could not remember the exact time when the specimen refrigerator was initially stored in the medication storage room. During a concurrent observation and interview on 6/17/25 at 1150 a.m., with the Director of Nursing (DON), in the medication storage room, the specimen refrigerator in the medication room was observed to contain stool specimen in a container and urine specimen samples stored inside. DON acknowledged the risk of storing the specimen refrigerator inside the medication storage room was spread of infection because of the risk of contaminating the medications with the specimen samples of the residents. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, . An infection prevention and control program (IPCP) 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 .4. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff .

Based on observation, interview, and record review, facility failed to provide meal assistance in a dignified manner to Resident 254. This failure resulted in an undignified and disrespectful treatment of Resident 254 which could potentially result in more serious negative outcomes. Findings: During a meal observation on 6/16/25 at 12:29 p.m., in the dining room, Resident 254 was sitting in a wheelchair and Occupational Therapist (OT) 1 was standing beside the resident. OT 1 began to assist and spoon feed Resident 254 her lunch meal. On interview, OT 1 stated, when she fed the residents, she would stand sometimes and would sometimes be seated which depended on the cues that she had to give to the residents while assisting the residents with their meals. A review of Resident 254's admission record, dated 6/18/25, indicated that the resident was admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (paralysis that affects only one side of the body), and dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Physician's orders dated 6/18/25, it indicated an order of 1:1 feeding (means a dedicated staff member provides personalized support to a resident during meals, ensuring they can eat and drink sufficiently). During an interview on 6/18/25 at 3:21 p.m. with the Director of Nursing (DON), the DON stated, staff should be seated at an eye level (positioned at roughly the same height as a person's eyes) with the residents when assisting with meals to preserve the residents' dignity. Further stated, the staff should not be standing while they assisted the residents in eating their meals because the residents could choke while eating. During an interview on 6/19/25 at 1:26 p.m. with the Director of Rehabilitation (DOR), DOR stated, when assisting the residents to eat, the staff should always be sitting beside the resident and should be at an eye level to preserve the resident's dignity. During a review of the facility's policy and procedure, titled Assistance with Meals, Revised March 2022 indicated, . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals .

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 13 sampled residents (Resident 3) who was not assessed for smoking. This deficient practice created a potential risk for burn injury to Resident 3 while smoking and placed other residents' lives in danger. Findings: During a review of Resident 3's admission record, it indicated that resident was admitted on [DATE] with diagnoses that included weakness and need for assistance with personal care. During an interview on 6/17/25 at 3:40 p.m., Resident 3 stated he stepped out of the facility to smoke a cigarette accompanied by staff two times a day every day. During a joint interview on 6/17/25 at 3:28 p.m. with Registered Nurse (RN) 1 and RN 2 , RN 1 and RN 2 both stated that Resident 3 was a cigarette smoker, and the facility did not have a smoking schedule for Resident 3 . RN 1 stated during day shift (7:00 a.m. to 3:30 p.m.) which she worked, Resident 3 went out to smoke in the mornings once a day and RN 2 stated, on the evening shifts (3:00 p.m. to 11:30 p.m.) Resident 3 went outside of the facility to smoke once during the shift. RN 1 and RN 2 both stated Resident 3 did not wear a smoking apron when he smoked (a smoking apron is a durable, fire-resistant cover-up that helps protect wheelchair users from falling ashes and smoking debris). Review of Resident 3's Minimum Data Set (an assessment tool) dated 6/13/25, indicated he had a brief interview for mental status or BIMS of 8 (BIMS score of 8-12 points indicates moderate cognitive impairment). The MDS indicated Resident 3 needed supervision from a helper once sitting in the wheelchair to wheel himself at least 150 feet in a corridor or similar space. During an interview on 6/17/25 at 4:35 p.m., with Certified Nursing Assistant (CNA)1, CNA 1 stated he accompanied Resident 3 during smoke breaks outside of the facility. Resident did not have a smoking apron. The cigarette butts were discarded on the ground because there was no ash tray. During a concurrent interview and record review of Resident 3's departmental notes on 6/17/25 at 3:25 p.m. with Minimum Data Set Coordinator (MDSC), MDSC was unable to find a safe smoking evaluation form and a care plan on smoking (A smoking care plan is a structured approach to help residents who smoke to quit or reduce their smoking, and to ensure their safety while smoking. It involves assessment, education, support, and individualized plans to address both the physical and psychosocial aspects of smoking . A safe smoking evaluation is a comprehensive assessment to determine a resident's ability to smoke safely, either unsupervised or with assistance. It involves evaluating a resident's physical and cognitive abilities, as well as their understanding of smoking policies and safety procedures. The goal is to minimize fire hazards and ensure resident safety while respecting their independence). During an interview on 6/18/25 at 3:21 p.m., with the Director of Nursing (DON), DON stated that because Resident 3 did not have a smoking evaluation and care plan on smoking, the facility had just added Resident 3's smoking evaluation and smoking care plan to prevent the hazards of smoking. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents , dated 2001, the P&P indicated, .2. Smoking is only permitted in designated resident smoking areas which are located outside of the building . 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 9. A resident's ability to smoke safely is reevaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 10. Any smoking related privileges, restrictions and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues .

Based on observation and interview, the facility failed to provide 10 of 45 residents in resident rooms [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in lack of sufficient space for the provision of care by facility staff, and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about safely and without obstruction. The State Agency recommends renewal of waiver. Findings: During an interview with the Maintenance Director (MD) on 6/17/25 at 11:43 a.m., MD confirmed that resident rooms 19, 20 and 21 had four beds each. MD measured all three rooms: room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. Random observations of resident rooms 19, 20 and 21 were done from 6/16/25 to 6/20/25 at various times throughout the day. There were no negative observations related to resident care/provision attributed to the decreased space in rooms [ROOM NUMBER]. There were no safety concerns noted.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to two of 20 sampled residents (Residents 148 and 23) as follows. 1 a). Resident 148, identified as a high risk for falls, was not provided with a sitter after the resident was deemed needing one-one supervision to prevent further falls. This resulted in Resident 148 sustaining another serious fall injuries (a comminuted fracture that is broken in at least two pieces caused by trauma to the right clavicle (collarbone), and a subdural hematoma (condition when a pool of blood develops between the brain and its covering, usually from head trauma). b). Resident 148 eloped on 12/7/23 and was later found in a hospital emergency department (ED). This episode of elopement was not reported by the facility to the department. 2. The facility did not apply the ordered bed pad alarm (alerts staff of position movement out of bed) for Resident 23. For Resident 23, this had the potential for fall injuries. Findings: 1. Review of Resident 148's Facesheet (contains contact details, brief medical history at-a-glance), dated 1/25/24 indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses that included history of falling, abnormalities of gait and mobility, epilepsy (condition that affects the brain and causes frequent seizures), insomnia (trouble sleeping), and need for assistance with personal care. Review of Resident 148's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/12/23 under Section C, indicated Resident 148's cognition was moderately impaired. The Functional Abilities and Goals indicated, Resident 148 needed staff supervision when moving from seated to standing position, walking, turning around, moving on and off toilet and during surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Review of Resident 148's Fall Risk observation/assessments dated 12/11/23 until 1/8/24, the score ranged from 18 to 22 (range of high risk for falls). Review of Resident 148's Departmental Notes indicated that Resident 148 had multiple falls from 12/11/23 through 1/25/24 with revised care plans after each episode. However, on 12/27/23, the resident was sent out to the emergency department (ED) and was diagnosed with a comminuted right clavicle fracture, after an unwitnessed fall, the resident's care plan did not indicate new interventions to prevent future falls. During an interview and concurrent review on 1/25/24 at 9:11 a.m., Resident 148's fall care plan was reviewed with the Minimum Data Set Coordinator (MDSC). MDSC stated, it was her responsibility to update the resident's fall care plan, and acknowledged there were no new fall interventions on 12/27/23. MDSC further stated the care plan should have been reviewed after each fall to evaluate if the interventions were effective in preventing future falls. MDSC stated, consistent and constant one-one supervision should have been considered as a fall prevention intervention for Resident 148. Review of Resident 148's Interdisciplinary Team (IDT, a group of individuals representing different departments of the facility) meeting notes, dated 1/8/24 indicated, Resident 148's new intervention for a witnessed fall incident that happened on 1/5/24, at 5:10 p.m., was to place the resident on one-one supervision. Review of Resident 148's IDT meeting notes, dated 1/12/24, indicated, Resident 148 had an unwitnessed fall on 1/12/24 at 7:59 a.m., in another resident's room, and was found in a supine (back) position, with a big skin tear in her right forearm. Resident was sent out to the hospital. During an interview 01/25/24 at 8:37 a.m., with Director of Nursing (DON), DON stated, the facility was not the one who should provide a one-one sitter to the resident. DON further stated, it was Resident 148's family who was responsible for paying for the resident's one-one sitter. Review of Resident 148's Hospitalist (physician specialist in hospital care) Discharge Summary and Transfer Instruction, dated 1/18/24 indicated, Resident 148 was admitted to the hospital on 1/12/24 and stayed in the hospital until 1/18/24, due to a right subdural hematoma caused by the fall and was discharged . Review of Resident 148's Face Sheet dated 1/25/24 indicated Resident 148 was readmitted to the facility on [DATE]. During an interview on 1/25/24 at 10:35 a.m., with the Director of Rehab (DOR), stated, Resident 148 had no safety awareness, and with one-one supervision, the resident's falls could be avoided. During an interview on 1/25/24 10:56 a.m., with the Medical Doctor (MD), stated, after Resident 148's third fall, the only way to prevent the resident from falling in the facility was one-one supervision which was having someone very closely supervising the resident. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, Based on previous evaluations and current data, staff may identify interventions related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling .Resident centered fall prevention plans should be reviewed and revised as appropriate .If the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions. b). Review of Resident 148's Nurses Notes, dated 12/7/23, indicated, Resident was missing on 12/7/23 at around 6:30 p.m., and was found at a hospital's ED at 8:00 p.m. Resident 148 was brought back to the facility at 11:30 p.m. Review of the resident's Elopement Risk assessment dated [DATE], indicated, a score of 16. The elopement risk assessment indicated a score of more than 10 would be considered at risk for elopement. During an interview on 1/25/24 at 1:03 p.m., with DON, stated Resident 148 eloped on 12/7/23 and ended in the hospital ED. Stated the resident's elopement risk score was 16 and resident had a risk of eloping. DON further stated she did not report the resident's incident of elopement to the department. A review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 2007, the P&P indicated, As part by federal or state regulations, our facility reports unusual occurrences or other reportable [NAME] which affect the health, safety or welfare of our residents .1. Our facility will report the following events to appropriate agencies: .Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions by the facility after the event shall be sent or delivered to the state agency within forty-eight (48) hours of reporting the event or as required by federal and state regulations . 2. Review of Resident 23's Facesheet, dated 1/25/24, indicated, the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), history of falling, dementia (memory loss and impaired decision-making capacity), and weakness. Review of Resident 23's MDS dated [DATE] indicated Resident 23's cognition was moderately impaired. The Functional Abilities and Goals indicated Resident 23 was not steady, and was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and during surface-to-surface transfer (between bed and chair or wheelchair). Review of Resident 23's Fall Risk observation/assessments dated 9/24/23, showed the score was 24. The Fall Risk observation/assessments' score dated 10/11/23 was 26. These scores were in the range of high risk for falls. Review of Resident 23's Situation, Background, Assessment, Recommendation (SBAR) notes indicated, Resident 23 had unwitnessed falls on the dates 7/27/23, 9/24/23, 10/10/23, and 12/20/23. During an interview on 1/22/24 at 11:25 a.m., with Resident 23's responsible party (RP) 2, stated he was concerned about the resident's frequent falls and if the staff were applying the resident's pad alarm. Review of Resident 23's active monthly physician order for January 2024 indicated an order dated 9/22/23, for a bed pressure pad alarm when in bed to alert staff of resident's attempts to rise unassisted. During a concurrent observation and interview on 1/24/24 2:09 p.m., with Certified Nursing Assistant (CNA) 11, confirmed Resident 23 had no bed alarm while lying in bed. Further observation and interview on 1/26/24 at 8:15 a.m., CNA 11 confirmed Resident 23 still had no bed alarm while in bed. During a concurrent observation and interview on 1/26/24 at 8:20 a.m., DON verified Resident 23 was lying in bed with no bed pad alarm. DON stated nursing staff should follow the physician's order to apply the bed alarm to prevent falls and injuries. DON further stated the facility had no policy and procedure on bed alarms.

Based on observation, interview and record review, the facility failed to implement the facility infection control program policy and procedure for 48 of 48 residents (all facility residents) when: 1. The facility did not report an outbreak of Coronavirus Disease (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death.) to the California Department of Public Health (CDPH). This failure had the potential to result in lack of communication and oversight between the facility and CDPH during an infectious disease (COVID-19) outbreak. 2. Four nursing staff: Registered Nurse (RN 2), Certified Nursing Assistants 2, 3, and 5 (CNA 2, CNA 3, and CNA 5) did not use appropriate personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury.) when they entered the posted isolation rooms of residents with COVID-19. These failures had the potential to result in the spread of COVID-19, and COVID-19 related complications, and death. Findings: 1. During an interview on 1/22/24 at 11:29 a.m., with the Infection Preventionist/ Director of Staff Development (IP/DSD), IP/DSD stated the facility had two staff and a total of six residents test positive for COVID-19 at the onset of a COVID-19 outbreak in December. The IP/DSD stated the six residents had tested positive on 12/5/23. IP/DSD stated she did not know if the resident cases of COVID-19 had been reported to CDPH. During a review of the facility line list (a list of residents which indicates their infection status over time) dated 12/5/23, the line list indicated a total of six residents had tested positive for COVID-19. During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility in September 2023 with acute respiratory failure with hypoxia (inadequate breathing which results in insufficient oxygen supply to the body). During a review of the facility COVID-19 test log dated 12/5/23, the test log indicated Resident 30 had tested positive for COVID-19 on 12/5/23. During an interview on 1/22/24 at 10:15 a.m., with Resident 30, Resident 30 stated she was upset because she had caught COVID at the facility and needed to be transferred to the hospital for treatment. During an interview on 1/23/24 at 1:06 p.m., with the Admin, the Admin stated the COVID-19 outbreak had not been reported to the California Department of Public Health because the Admin thought the facility only needed to report the COVID 19 outbreak to the county (local) public health department. During an interview on 1/23/24 at 1:38 p.m., with the DON, the DON stated she thought the facility was only required to report COVID-19 outbreaks to the county public health department. During a review of the facility policy and procedures (PNP) titled, Infection Control Policies and Procedures, revised October 2018, the PNP indicated, The objectives of our infection control policies and practices are to prevent, detect, investigate, and control infections in the facility The facility reports confirmed COVID-19 infections, along with other communicable disease data to the local and state health department as required by state law. 2. During an observation on 1/22/24 at 12:13 p.m., in the hallway of the Red Zone (an area dedicated to quarantined residents with active COVID-19 infections), CNA 2 picked up a meal tray from the lunch tray delivery cart and entered resident Room A without performing hand hygiene, or wearing gloves, gown, or face mask. Posted on the wall adjacent to the entry door of Room A were two signs. One sign indicated, STOP- Contact/Airborne isolation, (Airborne precautions are actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. These infectious particles can remain suspended in the air for prolonged periods of time and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. Contact precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.) the sign indicated visitors/staff upon entering the room, were to don face shield and N95 respirator (N95 respirators are barrier face coverings that offer particle filtration and protection from fluids), perform hand hygiene, and don gown and gloves. The sign indicated visitors/staff exiting the room were to doff gown and gloves and perform hand hygiene. The second sign indicated, Red Zone. You must wear the following PPE when entering this room: N95 respirator, gown, gloves, eye protection (glasses or goggles and face shield). In the hallway adjacent to the entry door of Room A was a cart stocked with gowns, gloves, face shields, and N95s. CNA 2 exited Room A without performing hand hygiene and returned to the meal tray cart area. During an interview on 1/22/24 at 12:13 p.m., with CNA 2, CNA 2 stated the residents in Room A had COVID-19, so gowns, gloves, and a face shield should be worn when entering the residents' room. CNA 2 stated she had forgotten to don the necessary PPE when delivering the meal tray to Room A. 47400 During an observation on 1/24/24 at 7:20 a.m., the entry door was open to the shared room (Room B) of Resident 28 and Resident 149. On the wall adjacent to Room B was a posted sign which indicated, Stop Red Room. During an observation on 1/24/24 at 7:50 a.m., Certified Nursing Assistant 5 (CNA 5), Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) were passing the breakfast meal trays from the meal tray delivery cart to resident rooms. RN 2, CNA 3, and CNA 5 entered the Room B without donning PPE. RN 2, CNA 3, and CNA 5 exited Room B and did not perform hand hygiene. During an interview on 1/24/24 at 7:53 a.m., with Infection Preventionist/Director of Staff Development (IP/DSD), IP/DSD stated the residents in Room B (Resident 28 and Resident 149) both had COVID. IP/DSD stated the door to their shared room should be kept closed at all times. IP/DSD stated when the door was not closed there was a risk for the spread of infection to other residents. The facility policy and procedure titled, Coronavirus Disease (COVID-19), revised 3/1/2023, indicated, For a resident with known or suspected COVID-19: Staff working with symptomatic-exposed and isolated residents must wear eye protection during resident care encounters or procedures. Facility will also follow guidance from County Public Health. Eye protection (face shields, goggles) is required as PPE during all resident care during an outbreak and when caring for symptomatic-exposed and isolated residents. For resident with known or suspected COVID-19 staff wear gloves, isolation gown, face shield and N95 or higher-level respirator.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one (Resident 4) of four sampled residents to prevent elopement from the facility. The facility failed to assess and monitor the resident for elopement risk and this failure resulted in the resident being hospitalized . Definitions: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any supervision to do so. Wander guard is a sensor that alarms when a resident approaches an exit door. Opioids are medications that relieve pain Systolic blood pressure is the top number of the blood pressure reading, normally between 90-120 mm Hg (millimeters of mercury) Findings: Review of the clinical record on 11/21/13 showed that Resident 4 was an alert [AGE] year old with multiple [DIAGNOSES REDACTED]. Review of the EHR (Electronic Health Record) showed the LVN (Licensed Vocational Nurse) 1's nurse's note, titled "Event" dated 10/5/13 at 3:46 p.m. reflected that Resident 4 was found on a walkway to the next building at 2:15 p.m.. The note indicated Resident 4 was monitored frequently and a wander guard was placed on his wheel chair. Orders for this event were, "Monitor for elopement" started 10/5/13 and ended 11/7/13. Review of the Care Conference note, dated 11/13/13, showed Resident 4 was non-compliant and the resident removed the code alert attached to his wheelchair. In an interview, on 11/21/13 at 2:50 p.m., the DON confirmed that Resident 4 had removed the wander guard from his wheelchair in the presence of the nurse and told her that they could not control him. There was no care plan for monitoring the resident for elopement. The facility's investigation report showed that on 11/18/13 at approximately 12:15 p.m. Resident 4 eloped from the facility. The report reflected that the resident was seen in the nurses' station at 6:45 a.m. with his medical chart in his lap. At 11:30 a.m., the resident was seen in the hallway talking with staff and residents. At 12:35 p.m. the nurse went to Resident 4's room and the resident was not there. It was observed that Resident 4's room was located a few feet from the facility's main entrance, approximately midway the distance from the facility's main entrance and the nurses' station. During an interview on 11/21/13 at 1:15 p.m., the ADM (Administrator) stated that Resident 4's chart contained multiple prescriptions written by personal care providers at an outpatient clinic where the resident was being followed. He further stated that Resident 4's PCP (Primary Care Physician) would not approve for the prescriptions to be filled. The ADM stated that it was later discovered that Resident 4 had removed an undetermined number of prescriptions from his chart. The ADM stated that Resident 4 was a drug seeker. Review of the after visit summary report by the Orthopedic Surgeon(OS), dated 11/15/13, reflected that the resident should restart his Soma 350 mg tablet four times daily as needed for muscle spasms. Review of the Physician's Telephone Orders from the resident's PCP, dated 11/15/13, showed "No to Soma recommendation." In a telephone interview on 11/26/13 at 9:55 a.m., the Pharmacist at a local drug store stated a prescription for 120 tablets of Soma (a muscle relaxant) was filled for Resident 4 on 11/18/13. He stated it was the only prescription filled for Resident 4 that day. During an interview on 11/21/13 at 3:05 p.m., CNA (Certified Nurse Assistant) 1 stated that on 11/18/13 around 11:30 a.m., the charge nurse had given Resident 4 medications. CNA 1 stated that Resident 4 frequently asked for pain medication but requested more that day. CNA 1 further stated that the resident would sometimes go out to the patio or to the front of the facility to smoke. In an interview on 11/21/13 at 3:50 p.m., LVN (Licensed Vocational Nurse) 1 stated that Resident 4 asked for pain medication around 11:15 a.m. and five minutes later asked for Ativan (medication given for anxiety). LVN 1 stated she returned to the resident's room at 12:30 p.m. to give scheduled medications and Resident 4 was not there. Review of the MAR (Medication Administration Record) reflected that prior to the elopement on 11/18/13, Resident 4 received the following medications: [REDACTED] Acetaminophen 500 mg 2 tablets (for pain) given at 12 a.m., 6 a.m. and 12 p.m. Lidocaine Adhesive patch 5 % applied topically for 12 hours (pain) at 9 a.m. Lorezepam 3 mg (anxiety/increased agitation) given at 12 a.m., 6 a.m. and 12 p.m. Methadone 10 mg give 10 tablets=100 mg (chronic pain) at 12 a.m. Morphine 30 mg given 2 tablets (breakthrough pain) at 10:55 a.m. During an interview on 11/21/13 at 3:20 p.m., the DON (Director of Nursing) stated that at approximately 12:45 p.m. she was notified by LVN 1 that Resident 4 could not be found. The DON stated that she checked the patio where the resident would go to smoke. She and the DS (Dietary Supervisor) searched the neighborhood and went to a nearby convenience store where she thought the resident might have gone to buy cigarettes. The DON stated she saw the police, fire trucks and an ambulance down the streets from the convenience store and when she approached the area she saw Resident 4 in his wheelchair with an oxygen mask. The DON stated she grabbed a medicine bottle from Resident 4 but the police took the bottle from her. She stated the resident was taken to the ED (Emergency Department) at a nearby acute care hospital. Review of the hospital records, on 1/29/14, showed that Resident 4 arrived in the ED of an acute care hospital on [DATE] at 1:36 p.m. with "Altered mental status- possible OD (overdose) on Soma." The ED Provider notes showed the following: ? Outpatient prescriptions marked as taking Carisoprodol (SOMA) 350 mg tablets ? The patient's systolic blood pressure dipped into the 80's (this could lead to shock, a life threatening condition that occurs when the body is not getting enough blood flow) ? The laboratory urine screen for drug abuse was positive for Barbiturates, Methadone and Opiates. ? Narcan (medication that prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension) 0.4 mg IV (intravenously) was given. ? Critical care time was provided for 30 minutes by the attending physician. This was necessary to treat or prevent further deterioration of the central nervous system or compromise. ? The final [DIAGNOSES REDACTED]. ? The patient was admitted to the hospital. Resident 4 was interviewed, on 11/21/13 at 4:40 p.m., from his hospital bed at an acute care hospital. Resident 4 stated that he asked his PCP to give him the Ketamine (sedative) and Soma, but his PCP refused to give them to him. Resident 4 stated the pain had gotten so bad that he willingly took the prescription for Soma from his chart, "It was my fault. I take full responsibility." Resident 4 stated he left the facility, went to the pharmacy, and had the prescription filled. He took 2 Soma tablets and blacked out. He further stated that he was told 20 pills were missing from the bottle, "No doubt I took them."