Every finding on record at Veterans Home of California - Fresno

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), physician's orders for wound care was followed. This failure placed Resident 1's wound at a potential risk for infection. Findings: During a concurrent observation and interview on 4/9/2026 at 1:42 p.m. in Resident 1's room, RN [Registered Nurse] donned gown and gloves and did a dressing change on Resident 1's left ear wound, assisted by CAN [Certified Nurse Assistant] 1. RN used two small, pink plastic bottles of normal saline, gauze, Vaseline packet and a non-adherent dressing to dress Resident 1's wound. RN 1 stated, We clean the wound site with saline, pat dry and put petroleum on the gauze and secure it with dry dressing. During a review of Resident 1's Monthly Physician Order dated March 20206, the orders indicated, . 2/22/26 . Cleanse non-healing ulcer to LT [left] ear auricle site with mild soap and water, pat dry, apply Vaseline and cover with dry dressing DAILY and PRN [as needed] for soilage or dislodgement . During a concurrent interview and record review on 4/10/2026 at 3:50 p.m. with the Licensed Vocational Nurse (LVN), Resident 1's Nurses Progress Notes was reviewed. The Notes dated 3/23/26 at 2130 (9:30 p.m.) indicated, . Cleaned up with NS [normal saline], pat dry. Apply ABX [antibiotic] cream, Cover [with] . dressing . LVN stated they did not have an order for the antibiotic cream. LVN stated, On the order it says mild soap and water. LVN stated the physician's order was not followed. During an interview on 4/14/2026 at 3:40 p.m. with Supervising Registered Nurse 1 (SRN1), SRN1 stated Resident 1's wound should have been cleaned using mild soap and water according to the physician's order. During an interview on 4/15/2026 at 9 a.m. with the Director of Nursing (DON), the DON stated physician's orders should be followed. DON stated providing wound care according to the physician's orders prevented infections, complications, and worsening of the wound. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Administration dated 10/21/2025 the P&P indicated, . Treatments will be administered as prescribed .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), wound was kept clean and covered. This failure resulted in Resident 1's wound found with maggots.Findings: During a concurrent observation and interview on 4/9/2026 at 1:30 p.m. in Resident 1's room, Resident 1 was lying in bed with head elevated. Certified Nursing Assistant (CNA) 1 donned gown and gloves and positioned Resident 1 on the side. CNA 1 stated Resident 1 had a wound on the left ear. A band aid with gauze was hanging on the back of his left ear. During a review of Resident 1's Medical Oncology Clinic Note, dated 3/6/2025, the Oncology Note indicated, . HPI [History of Present Illness]: . squamous cell carcinoma [abnormal growth of squamous cells] of the left postauricular [behind the ear] skin . past medical history of hypertension [high blood pressure], stroke [occurs when blood flow to the brain is blocked] . During an interview on 4/9/2026 at 2:58 p.m. with CNA 2 stated on 3/23/26 at around 9 p.m., she was doing ADLs (Activities of Daily Living) with Resident 1 when she saw a tiny, white worm (maggot) move by his left neck. CNA 2 stated, 1 worm . I finished doing ADLs and told the nurse . A request for Policy on Wound Care was made on 4/10/2026 at 3:36 p.m. DON stated they do not have a policy. During a concurrent interview and record review on 4/10/2026 at 3:50 p.m. with the Licensed Vocational Nurse (LVN), Resident 1's Clinical Record was reviewed.The Nurses Progress Notes dated 3/23/2026 indicated, Noted maggots on Resident's left back ear wound. LVN stated, I saw some maggots behind the resident's [Resident 1] ear . a lot of tiny maggots Resident 1's Treatment Administration Record (TAR) for the month of March indicated the wound was cleaned and dressed daily. LVN stated wound care was done every day. The Monthly Physician Order for March 20206 indicated, . 2/22/26 Cleanse non-healing ulcer to LT [left] ear auricle site with mild soap and water, pat dry, apply Vaseline and cover with dry dressing DAILY and PRN [as needed]for soilage or dislodgement . LVN 1 stated If the resident's wound was properly cleaned and the dressing applied securely, the fly would not have been able to get to the wound. LVN 1 stated, . there would be no maggots. LVN 1 stated wounds should be properly cleaned and secured with dressing to prevent exposure and infection. During an interview on 4/14/26 at 3:40 p.m. with Supervising Registered Nurse 1 (SRN1), SRN1 stated, There was quite a bit of maggots . it was the size of a half a grain of rice in length and width .the maggots were crawling out of the wound . I would say about 50 maggots . SRN1 stated Resident 1 preferred to lay on the left side which caused the dressing to get dislodged. SRN1 stated there should have been no maggots on the wound if it was kept clean and covered. SRN1 stated wounds needed to be properly cleaned and fully covered to prevent infection and exposure to any particles or flies. During an interview on 4/15/2026 at 9 a.m. with the Director of Nursing (DON), the DON stated there should be no maggots in Resident 1's wound. DON stated if the wound was properly secured with the dressing a fly wound not be able to get to the wound.

Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents when the facility did not employ or obtain the services of a licensed pharmacist.This failure resulted in no pharmacist oversight for required pharmacy services and had the potential risk to affect all residents receiving medications. Findings:During an interview with Supervising Registered Nurse (SRN) 2 on 1/29/26 at 9:32 am, SRN 2 stated there was no pharmacist reviewing medications monthly for residents since October 2025.During an interview with Skilled Nursing Facility Administrator (SNF Admin) on 1/29/26 at 10:34 am, SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. During a review of the facility's policy and procedure titled, Pharmaceutical Services dated 9/25/25, indicated, .Pharmaceutical Services will include, but not limited to, the following: Providing consultative and other services furnished by pharmacists, which assist in the development, coordination, supervision, and review of the pharmaceutical services within the SNF .

Based on interview and record review, the facility failed to ensure a licensed pharmacist conducted monthly drug regimen reviews (DRR) when four sampled residents (Residents 3, 7, 21, and 50) did not have evidence of drug regimen reviews since October 2025.This failure resulted in the potential for unidentified medication-related irregularities due to the absence of required drug regimen reviews.Findings:During a review of Resident 3's admission Face Sheet Record, undated, indicated Resident 3 was admitted to the facility with diagnoses of vascular dementia (a form of memory loss due to impaired supply of blood to the brain), hyperlipidemia (high level of fats in the blood), and diabetes mellitus (high blood sugar).During a review of Resident 7's admission Face Sheet Record, undated, indicated Resident 7 was admitted to the facility with diagnoses of dementia (memory loss), hypertension (high blood pressure), and hyperlipidemia.During a review of Resident 21's admission Face Sheet Record, dated 12/26/25, indicated Resident 21 was admitted to the facility with pain in the left knee, non-rheumatic aortic valve stenosis (heart condition where the aortic valve narrows due to calcium buildup or structural abnormalities, restricting blood flow).During a review of Resident 50's admission Face Sheet Record, undated, indicated Resident 50 was admitted to the facility with diagnoses of dementia, diabetes mellitus, and hypertension.During a concurrent interview and record review on 1/29/26 at 9:14 am with Supervising Registered Nurse (SRN) 4, Resident 21's chart was reviewed. Resident 21 did not have a DRR since his admission on [DATE]. SRN 4 stated the facility had not had a pharmacist since October 2025, and there was no DRR done for Resident 21.During a concurrent interview and record review on 1/29/26 at 9:32 am with SRN 2, the most recent DRR was reviewed. SRN 2 stated the last DRR completed for Residents 3, 7, and 50 was on 10/24/25 by the former pharmacist. SRN 2 stated there was no pharmacist completing the DRR since October 2025. SRN 2 stated there was no developed structure to complete DRR when the pharmacist stopped reviewing the medications. During an interview on 1/29/26 at 11:45 am with Quality Registered Nurse (QRN) 1, QRN 1 stated there were no pharmacy reviews of the residents' medications for a few months because there was no pharmacist on staff to complete them.During an interview with Skilled Nursing Facility Administrator (SNF Admin) on 1/29/26 at 10:34 am, SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. SNF Admin stated pharmacist reports were not completed during this time.During a review of the facility's policy and procedure titled, Drug Regimen Review, dated 4/1/25, indicated, A pharmacist will review the drug regimen of each Resident at least monthly and prepare appropriate reports. The goal is to promote positive outcomes and to minimize adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or any other irregularities.

Based on observation, interview, and record review, the facility did not ensure an effective infection control and prevention program for three of 24 residents (Residents 10, 14, and 21), when nursing staff did not follow the use of PPE (personal protective equipment -specialized gear such as masks, gloves, gowns, and eye protection designed to protect healthcare workers from infectious materials and pathogens) for enhanced barrier precautions (EBP - an infection control strategy for nursing homes, requiring staff to wear gowns and gloves during high-contact resident care to reduce the spread of germs) when providing care to the residents.1. CNA 1 and LVN 1 did not wear a gown while providing care for Resident 102. CNA 2, RN 1, and SRN 1 did not wear a gown while providing care for Resident 143. CNA 3 did not wear a gown while providing care for Resident 21.This failure had the potential to place residents 10, 14, and 21 at risk for acquiring an infectious bacteria through cross contamination which could lead to illness or death.Findings:1.During an observation on 1/26/26 at 3:25 p.m. outside of Resident 10's room, there was a sign on the door indicating Enhanced Barrier Precautions. Resident 10 had an indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to continuously drain urine into an external collection bag). Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 were inside the room assisting Resident 10 transfer from the bed to the wheelchair. CNA 1 moved his catheter bag from the bed to the wheelchair and moved Resident 10's blanket from his bed to the wheelchair. Both CNA 1 and LVN 1 did not have a gown when assisting Resident 10. During an interview on 1/28/26 at 11:14 a.m. with CNA 1, CNA 1 stated when a resident was on EBP, staff needed to wear gowns and gloves during patient care. CNA 1 stated tasks such as transferring the resident, moving a catheter bag would indicate the need to wear a gown. CNA 1 stated she should have worn a gown while providing care for Resident 10. CNA 1 stated the gown was necessary to avoid transferring of any germs to Resident 10.During an interview on 1/28/26 at 3:28 p.m. with LVN 1, LVN 1 stated Resident 10 was on EBP due to having a urinary catheter. LVN 1 stated she should have worn a gown and gloves while assisting Resident 10 to transfer from his bed to the wheelchair. LVN 1 stated a gown would protect Resident 10 from acquiring any possible bacteria that could lead to infection due to the urinary catheter. During a review of Resident 10's Care Plan (CP), dated12/5/25, the CP indicated Resident 10 had an indwelling urinary catheter.2. During an observation on 1/27/26 at 9:31 a.m. near Resident 14's room, there was a sign on the door indicating EBP. Resident 14 was stating he was having difficulty breathing. Supervising Registered Nurse (SRN) 1, Registered Nurse (RN) 1, and CNA 2 were in Resident 14's room providing patient care. The staff checked Resident 14's vital signs. SRN 1 provided a breathing treatment to Resident 14. The staff were not wearing gowns during patient care for Resident 14. During an interview on 1/28/26 at 10:46 a.m. with RN 4, RN 4 stated any time a resident had an indwelling urinary catheter, staff should wear a gown and gloves during high contact activity with the resident. RN 4 stated providing a breathing treatment for Resident 14 would be considered high contact with the resident which would require wearing a gown. During a review of Resident 14's CP, dated 8/13/25, the CP indicated Resident 14 had an indwelling urinary catheter. 3. During a concurrent observation and interview on 1/27/26 at 10:03 a.m. with CNA 3, near Resident 21's room, there was a sign on the door indicating EBP. CNA 3 was in the room grooming Resident 21's hair, and moving linen in his room. CNA 3 stated she was grooming Resident 21's hair and changing his linen. CNA 3 did not have a gown on during patient care. During an interview on 1/28/26 at 3:28 p.m. with LVN 1, LVN 1 stated Resident 21 was on EBP due to having an indwelling urinary catheter. LVN 1 stated any patient care that required contact with the resident required staff to wear a gown such as grooming or changing linen. LVN 1 stated the gown was to prevent Resident 21 from acquiring a bacteria that could lead to infection due to his urinary catheter. LVN 1 stated CNA 3 should have placed a gown on when she was grooming Resident 21 and changing his linen. During a review of Resident 21's CP, dated 1/9/26, the CP indicated Resident 21 had an indwelling urinary catheter.During an interview on 1/29/26 at 11:32 a.m. with the Infection Preventionist (IP), the IP stated EBP was implemented for any residents that had Multidrug - Resistant Organisms (MDRO -bacteria or other microorganisms that have developed resistance to at least three classes of commonly used antimicrobial drugs, making infections difficult to treat), indwelling devices, or wounds that required dressings. The IP stated prevention of infection was the rationale for PPE use. The IP stated wearing gowns and gloves for high contact activities such as dressing, transferring, providing hygiene was important to prevent cross-contamination of bacteria. The IP stated staff providing care to Residents 10, 14, and 21 all needed to wear gowns and gloves for the type of care being provided. During a review of the policy and procedure (P&P) titled Enhanced Barrier Precautions dated 12/30/25, the P&P indicated, .Enhanced Barrier Precautions: Infection control interventions requiring gown and glove use during high-contact resident care activities to reduce the spread of MDROs.High Contact Activities: These include dressing, bathing, transferring, providing hygiene, changing linens, assisting with toileting, caring for indwelling medical devices, and performing wound care.Medical Devices: Identify residents with indwelling medical devices. (e.g., central venous catheters, urinary catheters). Implement EBP for residents with indwelling medical devices, regardless of MDRO status, due to the risk of contracting an MDRO.Focus on the use of gown and gloves during high-contact resident care activities.

Based on observation, interview, and record review, the facility failed to safely store medications when two containers of discarded medications, designated for disposal, was found in Building 1A's soiled utility room and one container of discarded medications, designated for disposal, was found in Building 5A's soiled utility room and were accessible to unlicensed personnel.These failures had the potential for unauthorized access to medications.Findings:During a concurrent observation and interview on [DATE] at 2:08 pm with Registered Nurse (RN) 5 in the medication room in Building 1 A, a blue waste container with a white top was on the counter. RN 5 stated the container held non-controlled resident medications that were no longer in use and were to be disposed of. RN 5 stated the medications in the container were kept in its original pill form and once the container was full, it would be placed in a bigger bin in the soiled utility room, which was located across the hall from the medication room, for pickup and disposal.During a concurrent observation and interview on [DATE] at 2:30 pm with Quality Registered Nurse (QRN) 1, bins labeled for pharmaceutical waste were found in the unlocked soiled utility room. QRN 1 stated the medications were kept in that room and the housekeepers would pick up these disposed medications, along with the other trash bins, to transport them to the facility's building. From that building, an outside contracted company would pick up the medications to destroy.During a concurrent observation and interview on [DATE] at 2:47 pm with Supervising Registered Nurse (SRN) 3 in the Building 5A medication room, a blue container and a black container, with lids open, were sitting on the counter. SRN 3 stated the blue container was for discontinued and expired uncontrolled medications in pill and tablet form. SRN 3 stated the black container was for discontinued and expired uncontrolled medications like inhalers. SRN 3 stated the nurses used plastic bags to bag up the blue and black containers located in the medication room and walked them across the hallway to the soiled utility room to be placed in designated bins. SRN 3 stated the nurses put the black containers into the designated bin in the soiled utility room labeled RCRA [Resource and Conservation Recovery Act- a United States law enacted to govern the disposal of solid waste and hazardous waste] ONLY. SRN 3 stated the nurses put the blue containers into the designated bin in the soiled utility room labeled NON HAZARDOUS PHARMACEUTICAL. SRN 3 stated Environmental Services (EVS) staff picked up the blue and black containers of discontinued and expired uncontrolled medications from the designated bins in the soiled utility room to be taken to another location where a contracted company came to pick them up to destroy them.During an observation on [DATE] at 3:13 pm in the Building 5A soiled utility room, one container of discarded medications was tied in a clear plastic bag in the bottom of a gray-colored bin labeled RCRA ONLY.During an interview on [DATE] at 3:15 pm with SRN 4, SRN 4 stated EVS picked up the bagged black and blue containers containing the discontinued and expired uncontrolled medications from the soiled utility room and took them to a back warehouse to be picked up by a contracted company for disposal. SRN 4 stated the warehouse was accessible by warehouse staff members, EVS staff members, security personnel and supervisors.During an interview on [DATE] at 3:25 pm with SRN 2, SRN 2 stated only licensed nurses and pharmacy techs have access to residents' medications. Unlicensed staff would be supervised by authorized staff if they needed access to the rooms where medications are located. During an interview on [DATE] at 4:04 pm with SRN 4, SRN 4 stated the authorized staff members who handled medications included all Licensed Vocational Nurses (LVN) and RN as well as pharmacy staff. SRN 4 stated all facility staff members have access to enter the hallway in Building 5A that leads to the soiled utility room. SRN 4 stated the soiled utility room was not locked, therefore any staff member could access the soiled utility room. SRN 4 stated the blue and black containers were kept in designated bins in the soiled utility room until removed by EVS staff for disposal. SRN 4 highlighted the risk that staff could access discarded medications from these containers.During a review of the facility's policy and procedure (P&P) titled, Drug Storage dated [DATE], the P&P indicated, .Drugs and biologicals in the Skilled Nursing Facility (SNF) are stored in compliance with applicable State, Federal, and local laws and regulations.To ensure all drugs and biologicals in the SNF are stored in such a manner so as to maintain their security and integrity.Drug storage containers must not be.without secure closures.Drugs will be accessible only to authorized personnel designated in writing by the SNF.Discontinued drug and biological containers.will be stored in a separate location which will be identified solely for this purpose in the medication room.During a review of a list of classifications authorized to access medications dated [DATE], the list indicated that Licensed Vocational Nurses, Registered Nurses, Supervising registered Nurses, Supervising Nurse II, and Pharmacy Technician.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one of 24 residents, when Resident 4's indwelling urinary catheter bag (a bag connected to a tube that drains urine from the resident's bladder) was observed on the floor.This failure had the potential to result in catheter-associated urinary tract infection (CAUTI) [an infection that can occur when germs enter the bladder through the tube].Findings:During an observation on 1/28/26 at 11:11 am in Resident 4's room, Resident 4 was observed lying in bed with the urinary catheter drainage bag resting directly on the floor.During a concurrent observation and interview on 1/28/26 at 11:17 am with Registered Nurse (RN) 2, RN 2 confirmed that the catheter bag was on the floor, acknowledging it posed an infection risk.During an interview on 1/28/26 at 11:33 am with Infection Preventionist (IP) IP confirmed that the urinary catheter bag should not be on the floor. IP stated, It should be hanging above the floor. It should not be sitting on the floor.During an interview on 1/29/26 at 10:22 am with RN Nurse Instructor (NRS ED) 1 and RN Nurse Instructor (NRS ED) 2, NRS ED 1 and NRS ED 2 confirmed the urinary catheter bag should not be on the floor. NRS ED 2 stated, That is not what we teach. NRS ED 2 confirmed the facility does not have a specific policy for urinary catheter maintenance, but they teach and follow the Lippincott Nursing Procedure Manual.During a review of the professional reference titled, Lippincott Nursing Procedure 8th Edition published 2019, page 387 indicated, Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI.

Based on interview and record review, the facility failed to ensure proper discharge notification and documentation were made for one of two closed record sampled residents when:The facility did not notify the State Long Term Care Ombudsman of Resident 113's discharge.The facility did not perform and document a discharge medication reconciliation (process of comparing pre-discharge medications and post-discharge medications) for Resident 113 upon discharge from the facility.These failures had the potential to adversely affect the continuity of care for Resident 113.Findings:1. During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included compression fracture (a bone in the spine collapsed or flatten due to pressure) and hypertension (high blood pressure).During a review of Resident 113 Physician Orders, dated 1/5/26, the Physician Orders indicated, May discharge to RCFE [Residential Care Facilities for the Elderly- non medical residential setting for elderly persons] due to goals met.Review of Resident 113's chart indicated there was no documentation that the ombudsman was notified of Resident 113's discharge.During an interview on 1/29/26 at 11:54 am with Quality Registered Nurse (QRN)1, QRN 1 stated the ombudsman was not notified when residents were discharged from the facility to RCFE.During an interview on 1/29/26 at 4:18 pm with the Standards Compliance Coordinator (SCC), the SCC stated the facility did not send notification of Resident 113's discharge to the ombudsman. SCC also stated the facility did not have policies and procedures on ombudsman notification process.2. During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included compression fracture (a bone in the spine collapsed or flatten due to pressure) and hypertension (high blood pressure).During a review of Resident 113 Physician Orders, dated 1/5/26, the Physician Orders indicated, May discharge to RCFE [Residential Care Facilities for the Elderly- non medical residential setting for elderly persons] due to goals met.During a concurrent interview and record review on 1/29/26 at 10:09 am with Quality Registered Nurse (QRN)1, QRN 1 stated that medication reconciliation was not performed and documented as part of the facility's discharge process when a resident was discharged to the RCFE. QRN1 confirmed that there were no physician orders for Resident 113's discharge medications in the resident's record.During an interview on 1/29/26 at 4:48 pm with Nurse Educator (NRS ED) 2, NRS ED 2 stated upon discharge from the facility, the resident's current medications should be reconciled with the medications the resident will require at discharge. NRS ED 2 further stated the physician should document an order for the resident's discharge medication in the record.During an interview on 1/30/26 at 9:20 am with the Medical Director (MD Director), the MD Director stated that when a resident was discharged from the facility, the nurse should call the physician to ask about medication changes for the resident's discharge; however, a complete medication list was not usually reviewed during call. MD Director stated that the medication reconciliation and discharge medication list was not performed during discharge from the facility to RCFE.Review of Resident 113's chart indicated there was no documentation the medication reconciliation was conducted and no documentation of physician's orders for discharge medications for Resident 113's discharge from the facility.Requested a policy related to discharge medication reconciliation. A policy was not provided during survey.

Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement Plan (QAPI) program when the facility did not utilize the QAPI process to address the known absence of a licensed pharmacist since October 2025.This failure resulted in the potential for continued noncompliance with pharmacy service requirements due to the facility's failure to utilize its QAPI program to identify and correct the issue. Findings:During an interview with Skilled Nursing Facility Administrator (SNF Admin) on 1/29/26 at 10:34 am, SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. During an interview with Standards Compliance Coordinator (SCC) on 1/30/26 at 8:21 am, SCC stated the QAPI meetings occur at least quarterly and as needed. SCC stated the last QAPI meeting was on 10/30/25. SCC stated there were no specific issues that were discussed regarding pharmacy services. There was no plan created for pharmacy services during the meeting. SCC stated communication between leadership and headquarters regarding the termination of pharmacy services with the contracted pharmacy company was not discussed with other members in QAPI during the last meeting.During a review of the facility's QAPI plan dated 2/2025, indicated, .QAPI Purpose: The purpose of QAPI is to take a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.

Based on interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 with the Sara lift (resident mobility lift), alone. This failure had the potential to negatively impact the resident's safety and increased risk for injury. Findings: A review of Resident 1's clinical record titled, admission Face Sheet (record containing resident personal information), indicated Resident 1 was [AGE] years old. Resident 1 had multiple diagnoses which included Left Hemiplegia (paralysis of left side of the body from a stroke), and contracture of left hand (deformity of hand). During an interview on 6/30/25 at 9:58 a.m., Resident 1 stated, I have to use the Sara lift because my left side hand, leg, and ankle were affected by the stroke. Frequently, just one person gets me on the Sara lift but they are required to have two people. I could hear her [CNA] straining to get me up from the bed and I'm in danger because I can't balance. I don't like her pushing me on it. Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) dated 5/20/25, contained a brief interview for mental status which identified a score of 15/15, which indicated his cognition was intact. An assessment of functional abilities of upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) identified a score of 1/15, which indicated very little functional ability. During an interview on 6/30/25 at 1:43 p.m., CNA 1 stated she was behind on shower day (6/17/25) and Resident 1 was ready for his shower. She stated she assisted R1 onto the Sara lift by herself. CNA 1 acknowledged she should not have assisted Resident 1 onto the Sara lift by herself. During an interview on 7/1/25 at 1:10 p.m., Physical Therapist (PT) stated each resident was assessed for height, side weakness, cognition, and weight to determine if the Sara lift is a 1- or 2- person assist for use. PT stated the facility should follow common industry practice of a 2-person assist for all mechanical lifts, for the safety of residents. PT stated Resident 1 should have been a 2-person assist for all transfers. During an interview on 7/1/25 at 1:18 p.m., Occupational Therapist (OT) stated Resident 1 was tall, heavy, and he had no functionality on the left side of his body. OT stated Resident 1 required a 2-person assist for all transfers for resident safety. During a review of the facility's training course titled, Reminders 2-person use of Hoyer and Sara lift for Safety dated September 23, 2024, the Training Course indicated CNA 1 attended the training as evidence by her signature. During a review of Resident 1's Comprehensive Plan of Care (CCP) dated September 26, 2023- July 12, 2025 the CCP indicated Resident 1 had impaired physical and functional mobility .balance problem during transitions requiring assistance with transfers .use of mechanical ([NAME]) lift in transfers .non-ambulatory .ROM (Range of Motion) limitation to LUE (Left Upper Extremity) and LLE (Left Lower Extremity). Review of facility's instructions for use titled, [NAME] Flex dated May 2020 indicated, Safety Instructions . It is the responsibility of the caregiver to determine if a 1- or 2-person transfer is more appropriate, based on the following .Patient's condition, the task, patients' weight, environment, capability . Review of facility's policy and procedure (P&P) titled, Activities of Daily Living, Standards reviewed April 18, 2024 indicated, Mechanical Devices . staff will use approved mechanical devices available for comfort and safety according to [Facility] policies and manufacturers recommendation .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (R3) when the interdisciplinary team (IDT) did not develop a new intervention after R3 fell on [DATE]. This failure has the potential risk for R3 to sustain another fall and possible injuries. Findings: An unannounced visit was made on 3/26/25 to investigate a facility report of a fall R1 had on 3/14/25. Three residents were selected who had an actual fall within 30 days. R3 was sampled for the investigation. During a review of R3 facesheet (demographics) indicated R3 was admitted on [DATE] with diagnoses including heart failure, hypertension, peripheral vascular disease. R3 Minimum Data Set (MDS) dated [DATE] indicated R3 was severely cognitively impaired and had a history of two falls with injuries. During a concurrent observation and interview on 3/26/25 at 1:30 pm with R3 in R3's room, R3 was sitting in a recliner. There was a sign posted in the room indicating Call Don't Fall. R3 stated he did not recall falling in his room. During a concurrent interview with Licensed Vocational Nurse (LVN) and record review of R3 chart on 3/26/25 at 1:40 pm, LVN reviewed the fall risk assessment and stated the last assessment date was 3/14/25. LVN stated R3 scored 21 which indicated a high risk for falls. During a concurrent interview with Quality Assurance Nurse (QAN) and record review of R3 chart on 3/26/25 at 1:54 pm., QAN reviewed the IDT note for the fall on 3/14/25 and care plan for falls and stated IDT recommended to continue the plan of care for R3. QAN stated IDT did not need to develop new interventions every time a fall happens if the current interventions were already in place. QAN reviewed the interventions that were in documented in the current care plan for at risk for falls and stated there were no new interventions developed after the fall on 3/14/25. During a review of R3 post-fall nursing note dated 3/14/25, indicated R3 was found on the floor in his room. Under care plan revision/updates section indicated to continue with the current plan of care. During a review of R3 IDT note dated 3/14/25, indicated under new or revised interventions, the facility had no new interventions added to the fall care plan. During a review of R3 current at risk for falls care plan initiated on 12/12/23, indicated there was no new interventions developed after R3's fall on 3/14/25. During an interview with Director of Nursing (DON) on 3/26/25 at 2:29 pm, DON stated IDT was not expected to develop a new intervention after each resident fall. During a review of the facility policy titled Fall Prevention and Intervention Program dated 5/23/24, indicated .Based upon the Fall Risk Assessment, if the Resident is assessed as a high risk (score of 10 or higher), the RN will: 1. Develop and implement a plan of care based upon the identified risks defined by the Fall Risk Assessment, individual deficits .history of falls, and any other needs that will affect the plan of care .The IDT will .review current interventions and implement new approaches to the care plan upon the IDT findings .

Based on observations, interview, and record review, the facility failed to store and serve food in accordance with professional standards for food service safety when the fryer had a build-up of grease on the wheels and on the compartment underneath. The tile floor in front of the cooking line was missing grout between the tiles and it had a black build-up of food and grease. The floor under the center island of the cooking line had a build-up of black grime and old food. This failure resulted in the potential for food to be contaminated and cause food borne illness in 98 of 98 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on 2/24/2025 at 9:40 a.m., with the Dietary Director (DD), in the main kitchen, the fryer had a build-up of yellow grease on the wheels and in the compartment underneath. The DD stated the fryer should be cleaned more often to prevent grease build-up. In the same area there was a compartment that housed the gas lines and inside this area there was black grease build-up. The DD stated it should be kept clean. On the floor in front of the cooking line (fryer, stove top, griddle), the tiles were missing the white grout and between the tiles was a build-up of grime and grease. The floor under the center island of the cooking area had a build-up of black grime and old food. The DD stated it was difficult for them to keep the floor under this island clean. During an interview on 2/24/2025 at 2:15 p.m. with DD, DD stated maintenance strips and cleans (deep cleaning of flooring) main kitchen floor once a quarter. DD stated deep cleaning should have been done more often. During an interview on 2/24/2025 at 2:30 p.m. with Director Plant Operations II (DPO), DPO stated a contract request had been filed on 12/11/24 for a complete rehaul of the tile flooring in the main kitchen. DPO stated it was a six-month process requiring approval, in the meantime he could have the grout redone in this area where there is build-up of grease in between the tiles but he was not aware it was an issue. The dietary team did not inform him. During an interview on 2/26/2025 at 10:30 a.m., with DD, DD stated her expectation was the fryer should be cleaned daily to prevent build-up. DD stated she should have had the cabinet next to the stove that housed the gas lines on the cleaning schedule. During a review of Cooks Cleaning List AM's, dated 2/16/2025 through 2/23/2025, the Cooks Cleaning List AM's indicated Prep area - wipe down all prep tables and prep sink. Clean stove. Clean floor drains, clean ovens, inside and outside, Sweep and mop floor. During a review of facilities policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated 8/7/2024, the P&P indicated, Kitchen and serving area will be kept clean, free from litter and rubbish . floors . will be kept clean and maintained in good repair (i.e. free from breaks, corrosion, holes, cracks, chips, dirt, and/or grime). During a review of Food Code, U.S. Food and Drug Administration 4-601.11 (C), dated 2022, the Food Code, U.S. Food and Drug Administration 4-601.11 (C) indicated Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . to remove soil from nonfood contact surfaces so that pathogenic microorganisms (disease causing bugs or fungus) will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of Food Code, U.S. Food and Drug Administration 4-602.13, dated 2022, the Food Code, U.S. Food and Drug Administration 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues . Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms.

Based on observation, interview and record review, the facility failed to meet professional standards of quality for three of 26 sampled residents (Residents 77, 51 and 47) when: 1. Resident 77, Diltiazem, Lisinopril and Metoprolol (Treatment for Heart/Blood pressure) medications were administered to the resident without checking the blood pressure/ heart rate as per physician's orders. 2. Resident 51, Alfuzosin (prostate medication) was administered without food as per physician's orders. 3. Resident 47, Novolog insulin (Treatment for blood sugar) was administered via ASPART insulin flexpen without priming the medication as per the manufacturer's instructions . These deficient practices had the potential to adversely affect the residents' medical health condition. Findings: 1. During a review of the clinical record for Resident 77, the physician order dated 10/30/2024, indicated Diltiazem (heart/ blood pressure medication) capsule 360 mg (milligram - unit of measure) ER (extended release), take one (1) tablet by mouth daily, hold for SBP (systolic blood pressure) less than 90. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with Licensed Vocational Nurse (LVN) 2 , LVN 2 administered Diltiazem 360 mg ER to Resident 77 orally without checking Resident 77's blood pressure. There was no evidence to indicate that LVN 2 took the resident's blood pressure prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with Director of Nursing Services (DON), DON stated the licensed nurse should have taken the resident's blood pressure, right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . During a review of the clinical record for Resident 77, the physician order dated 10/30/2024 indicated, Lisinopril (blood pressure medication) tab 10 mg (milligram), take one (1) tablet by mouth daily. Hold if SBP [Systolic Blood pressure] less than 110; or HR [Heart rate] less than 60. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with LVN 2, LVN 2 administered Lisinopril 10 mg orally to Resident 77 without checking Resident 77's blood pressure and heart rate. There was no evidence to indicate that LVN 2 took the resident's blood pressure and heart rate prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with the DON, DON stated the licensed nurse should take the heart rate and blood pressure right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . During a review of the clinical record for Resident 77, the physician order dated 12/1/2024 indicated, Metoprolol suc [succinate] [heart/ blood pressure medication] tablet 25 mg (milligram) ER, take one (1) tablet by mouth daily, HOLD if heart [rate] less than 50. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with LVN 2 , LVN 2 administered Metoprolol 25 mg ER to Resident 77 without checking Resident 77's heart rate. There was no evidence to indicate that LVN 2 took the resident's blood pressure or heart rate prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with the DON, DON stated the licensed nurse should take the heart rate and blood pressure right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . 2. During a review of the clinical record for Resident 51, the physician order dated on 6/20/2024 indicated, Alfuzosin tablet 10 mg (milligram) ER, take one (1) tablet by mouth daily with food for BPH [Benign prostate hypertrophy]. During a medication pass observation on 2/26/2025 at 7:50 a.m. with Registered Nurse (RN) 1, RN 1 administered Alfuzosin 10 mg ER orally to Resident 51 without food. During a review of the facility's policy and procedures (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, Medications that are ordered in relation to meals are administered as follows: . B. WITH MEALS - Administer during meal and up to 30 minutes after meal time. 3. During a medication pass observation on 2/26/2025 at 11:37 a.m. with LVN 3, LVN 3 administered 9 units of Novolog insulin subcutaneously (injection into fat layer under skin) via an ASPART insulin flexpen (device used to inject insulin medication) to Resident 47's abdomen without visualizing a drop from priming the device. During an interview on 2/26/2025 at 4:10 p.m. with DON, DON stated that the insulin flexpen needs to be primed with two units before administration. During a review of the manufacturer's instructions titled Patient Information Insulin Aspart under Giving the Airshot before each injection, it indicated Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing . A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Insulin Aspart Flexpen .

Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (5%) or greater during the medication pass observation for three of 26 sampled residents (Residents 77, 51 and 47) when: 1. Resident 77, Diltiazem, Lisinopril and Metoprolol (Treatment for Heart/Blood pressure) medications were administered to the resident without checking the blood pressure/ heart rate. 2. Resident 51, Alfuzosin (Prostate medication) was administered without food. 3. Resident 47, Novolog insulin (Treatment for blood sugar) was administered via ASPART insulin flexpen without priming the medication. The facility had a cumulative medication error rate of 15.15% consisting of five errors out of 33 opportunities. These deficient practices had the potential to adversely affect the residents' medical health condition. Findings: 1. During a review of the clinical record for Resident 77, the physician order dated 10/30/2024, indicated Diltiazem (heart/ blood pressure medication) capsule 360 mg (milligram - unit of measure) ER (extended release), take one (1) tablet by mouth daily, hold for SBP (systolic blood pressure) less than 90. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with Licensed Vocational Nurse (LVN) 2 , LVN 2 administered Diltiazem 360 mg ER to Resident 77 orally without checking Resident 77's blood pressure. There was no evidence to indicate that LVN 2 took the resident's blood pressure prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with Director of Nursing Services (DON), DON stated the licensed nurse should have taken the resident's blood pressure, right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . During a review of the clinical record for Resident 77, the physician order dated 10/30/2024 indicated, Lisinopril (blood pressure medication) tab 10 mg (milligram), take one (1) tablet by mouth daily. Hold if SBP [Systolic Blood pressure] less than 110; or HR [Heart rate] less than 60. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with LVN 2, LVN 2 administered Lisinopril 10 mg orally to Resident 77 without checking Resident 77's blood pressure and heart rate. There was no evidence to indicate that LVN 2 took the resident's blood pressure and heart rate prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with the DON, DON stated the licensed nurse should take the heart rate and blood pressure right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . During a review of the clinical record for Resident 77, the physician order dated 12/1/2024 indicated, Metoprolol suc [succinate] [heart/ blood pressure medication] tablet 25 mg (milligram) ER, take one (1) tablet by mouth daily, HOLD if heart [rate] less than 50. During a concurrent medication pass observation and interview on 2/26/2025 at 7:11 a.m. with LVN 2 , LVN 2 administered Metoprolol 25 mg ER to Resident 77 without checking Resident 77's heart rate. There was no evidence to indicate that LVN 2 took the resident's blood pressure or heart rate prior to the medication administration during the medication pass observation. During an interview on 2/26/2025 at 2:10 p.m. with the DON, DON stated the licensed nurse should take the heart rate and blood pressure right before the medication administration. During a review of the facility's policy and procedure (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required . 2. During a review of the clinical record for Resident 51, the physician order dated on 6/20/2024 indicated, Alfuzosin tablet 10 mg (milligram) ER, take one (1) tablet by mouth daily with food for BPH [Benign prostate hypertrophy]. During a medication pass observation on 2/26/2025 at 7:50 a.m. with Registered Nurse (RN) 1, RN 1 administered Alfuzosin 10 mg ER orally to Resident 51 without food. During a review of the facility's policy and procedures (P&P) titled, Medication Treatment Administration dated 1/17/2025, P&P indicated, Medications that are ordered in relation to meals are administered as follows: . B. WITH MEALS - Administer during meal and up to 30 minutes after meal time. 3. During a medication pass observation on 2/26/2025 at 11:37 a.m. with LVN 3, LVN 3 administered 9 units of Novolog insulin subcutaneously (injection into fat layer under skin) via an ASPART insulin flexpen (device used to inject insulin medication) to Resident 47's abdomen without visualizing a drop from priming the device. During an interview on 2/26/2025 at 4:10 p.m. with DON, DON stated that the insulin flexpen needs to be primed with two units before administration. During a review of the manufacturer's instructions titled Patient Information Insulin Aspart under Giving the Airshot before each injection, it indicated Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing . A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Insulin Aspart Flexpen .

Based on observation, interview, and record review, the facility failed to enhance one of 26 sampled residents (Resident 68) quality of life, when Resident 68 qualification assessment for power wheelchair request was not provided. This failure resulted in a violation of Resident 68's Rights and had the potential to negatively impact the resident's quality of life. Findings: During a review of the Resident 68's Demographics (Face Sheet), the Face Sheet indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included Parkinson (disorders that affect movement, balance, and coordination). During an interview on 2/25/2025 at 8:55 a.m. with Resident 68, Resident 68 stated he frequently participated in completing the puzzles in the common area, near his room; however, he has had difficulty with movement around puzzle table due to limitations in manual wheelchair. Resident 68 stated he had been requesting an assessment for a power wheelchair, and had not received an assessment. During an interview on 2/26/2025 at 2:22 p.m. with Restorative Nursing Assistant (RNA), RNA stated Resident 68 requested an assessment for power wheelchair approximately one month ago during a session with her. RNA stated she spoke to a staff member in the Physical Therapy department about Resident 68's request, but did not remember who she spoke to. During a concurrent interview and record review on 2/26/2025 at 3:17 p.m. with Occupational Therapist (OT), OT stated Occupational Therapy department performed resident qualification assessments for power wheelchairs. OT stated Occupational Therapy department received referral form with resident's request for assessment from nursing department, and OT arranged for assessment to be performed with the resident. OT confirmed there was no referral form for assessment for power wheelchair for Resident 68. There was no evidence of an assessment conducted by the OT staff found in Resident 68's clinical record. During a concurrent observation and interview on 2/27/2025 at 9:31 a.m. with Resident 68, Resident 68 was observed pushing himself in manual wheelchair with some difficulty and at a very slow pace. Resident 68 stated a power wheelchair would have made it easier, quicker to move around and less of a hassle to attend and participate in activities. During an interview on 2/27/2025 at 12:28 p.m. with Director of Nursing Services (DON), DON stated the RNA should have communicated Resident 68's request to the licensed nurse for a follow up.

Based on observation, interview and record review, the facility failed to provide necessary services for one of 26 sampled residents (Resident 68) to maintain highest practicable physical and psychosocial well-being, when Resident 68 request for qualification assessment for power wheelchair was not fulfilled. This failure had the potential to result in a decline of Resident's 68 physical and psychosocial well-being. Findings: During a review of the Resident 68's Demographics (Face Sheet), the Face Sheet indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included Parkinson (disorders that affect movement, balance, and coordination). During a review of Resident 68's Physician's Monthly Orders, dated February 2025, the physician's orders indicated, Resident 68 had the capacity to make own healthcare decisions. During a review of Resident 68's Minimum Data Set (MDS-an assessment care-planning tool), dated 2/11/2025, the MDS indicated, Resident 68 had the ability to understand others and make himself understood by others. During an interview on 2/25/2025 at 8:55 a.m. with Resident 68, Resident 68 stated he frequently participated in completing the puzzles in the common area near his room; however, he has had difficulty with movement around puzzle table due to limitations in manual wheelchair. Resident 68 stated he had been requesting an assessment for a power wheelchair and had not received an assessment. During an interview on 2/26/2025 at 2:22 p.m. with Restorative Nursing Assistant (RNA), RNA stated Resident 68 requested an assessment for power wheelchair approximately one month ago during a session with her. RNA stated she spoke to a staff member in the Physical Therapy department about Resident 68's request, but did not remember who she spoke to. During a concurrent interview and record review on 2/26/2025 at 3:17 p.m. with Occupational Therapist (OT), OT stated Occupational Therapy department performed resident qualification assessments for power wheelchairs. OT stated Occupational Therapy department received referral form with resident's request for assessment from nursing department, and OT arranged for assessment to be performed with the resident. OT confirmed there was no referral form for assessment for power wheelchair for Resident 68. There was no evidence of an assessment conducted by the OT staff found in Resident 68's clinical record. During a concurrent observation and interview on 2/27/2025 at 9:31 a.m. with Resident 68, Resident 68 was observed pushing himself in manual wheelchair with some difficulty and at a very slow pace. Resident 68 stated a power wheelchair would have made it easier, quicker to move around, and less of a hassle to attend and participate in activities. During an interview on 2/27/2025 at 12:28 p.m. with Director of Nursing Services (DON), DON stated the RNA should have communicated Resident 68's request to the licensed nurse for a follow up.

Based on interview and record review, the facility failed to maintain accurate and systematically organized medical records for two of 26 sampled residents (Resident 68 and Resident 550) when: 1. Resident 68's Restorative Nurses Aid-Weekly Notes documentation had incorrect dates. 2. Resident 550's medical chart contained Physician Progress Notes belonging to another resident. These failures had the potential to result in inaccurate clinical records. Findings: 1. During a concurrent interview and record review on 2/26/2025 at 2:22 p.m. with Restorative Nursing Assistant (RNA), Resident 68's Restorative Nurses Aide-Weekly Notes (RNA-Weekly Notes), dated February 2025, were reviewed. The RNA-Weekly Notes indicated, restorative nursing aide staff notations for February 2025 sessions with the following session dates documented: 1/4/25, 1/6/25, 1/11/25, 1/13/25, 1/17/25, 11/20/25, and 11/23/25. RNA confirmed RNA-Weekly Notes was for February 2025. RNA stated the dates were written incorrectly. During a review of the facility's Policy and Procedure (P&P) titled, Documentation Principles, dated 10/15/2024, the P&P indicated, Staff will follow facility documentation principles and record keeping practices to ensure that resident health records are current and kept in detail consistent with good medical and professional practice . These records will be complete, accurately documented, readily accessible, systematically organized . 2. During a concurrent interview and record review on 2/26/2025 at 4:11 p.m. with Quality Registered Nurse (QRN), Resident's 550's clinical record was reviewed. A progress note belonging to another resident was found in Resident 550's clinical record. The QRN confirmed the progress note was not Resident 550's. During a review of the facility's Policy and Procedure (P&P) titled, Documentation Principles, dated 10/15/2024, the P&P indicated, Staff will follow facility documentation principles and record keeping practices to ensure that resident health records are current and kept in detail consistent with good medical and professional practice . These records will be complete, accurately documented, readily accessible, systematically organized .

Based on observation, interview, and record review, the facility failed to follow their infection control policy for one of seven sampled residents (Resident 65) when staff did not wear gowns prior to high care activity to Resident 65 who had indwelling foley catheter (a thin tube inserted into the bladder to drain urine) and was in Enhanced Barrier Precaution (EBP - an infection control strategy where staff wears gowns and gloves in high care activity). This failure had the potential for Resident 65 to contract further infections. Findings: During a review of Resident 65's face sheet (resident's demographic) indicated that the Resident 65 was admitted to the facility on [DATE] with diagnoses included Alzheimer's Disease, pneumonitis, chronic kidney disease, and retention of urine. During a review of the quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) for Resident 65, dated 12/27/2024, confirmed that Resident 65 had an indwelling foley catheter. During an observation on 2/25/2025 at 3:30 p.m. in the Resident 65's room, Certified Nursing Assistant (CNA) 1 and CNA 2 were observed transferring Resident 65 from wheelchair to bed without wearing gowns. During an interview on 2/25/2025 at 3:38 p.m. at the nursing station, CNA 1 stated, they were not aware of Resident 65's EBP since they were usually not wearing any gown. CNA 1 and CNA 2 confirmed they were not checking the door sign prior to entering Resident 65's room. During an interview on 2/26/2025 at 4:03 p.m. with Director of Nursing (DON), DON stated staff were expected to wear gowns prior to transferring resident in high-contact and in EBP to break the chain of infection. During a review of the facility's Policy and Procedure (P&P) titled, ENHANCED BARRIER PROTECTION, undated, the P&P indicated, EBP are indicated for residents with any of the following, regardless of where they reside in the facility: . indwelling medical devices even if the resident is not known to be infected . Indwelling medical device examples include central lines, urinary catheter . The P&P also stated dressing, transferring, and changing briefs are included in the high-contact resident care activities. During a review of the Centers for Disease Control and Prevention (CDC) titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/2024, CDC indicated transferring resident with urinary catheter was a high-contact care, and the use of gown and gloves was indicated.

Based on observation, interviews, and record review, the facility failed to maintain a safe environment, free from accidents and hazards, for one of the three sampled residents (Resident 1). Resident 1, who was fully dependent and required assistance for all Activities of Daily Living (ADLs), sustained an injury while being repositioned by a Certified Nursing Assistant (CNA). This failure resulted in Resident 1 sustaining a head injury when his head hit the headboard of the bed, resulting in an abrasion on the posterior head, accompanied by a bump and bleeding. Findings: During a review of Resident 1's Admission Face Sheet Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included, vascular dementia (a chronic condition that affect memory, thinking, and behavior), unspecified osteoarthritis (a degenerative joint disease), repeated falls. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level) dated 6/7/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 99- the resident was unable to complete the interview . Section GG (Function Status) indicated . A Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed [was] code 01 Dependent, [required] helper does all of the effort. Resident does none of the effort to complete the activity . During a review of Resident 1's Nurses Progress Notes (NPN), dated 7/4/24, the NPN indicated, CNA reported around 0430 [4:30 a.m.] that resident accidently hit his head against the head board of the bed. Upon assessment, noted 3 x 4 cm abrasion to posterior head with bump and some bleeding . During an interview on 8/21/24 at 9:58 a.m., with Supervising Registered Nurse 2 (SRN 2), SRN 2 confirmed that on 7/4/24 at around 4:30 a.m., a CNA reported that Resident 1 accidentally hit his head against the headboard during repositioning. SRN 2 noted that Resident 1 sustained a 3 x 4 cm (unit of measure) abrasion with a bump and some bleeding. It was also mentioned that the incident could have been prevented. SRN 2 noted that Resident 1 was non-ambulatory and fully dependent on assistance, as indicated in the MDS. During an interview on 8/22/24 at 1:48 p.m., with SRN 1, SRN 1 acknowledged the hospice nurse (a nurse who specializes in providing care for the terminally ill patients in the final stages of their life), as part of a collaborative care approach, informed the RP. During an interview on 8/23/24 at 6:28 a.m., with CNA 1, CNA 1, who assigned to Resident 1 on 7/4/24, confirmed that Resident 1 was totally dependent on care. She stated that while repositioning Resident 1, his head hit the headboard, resulting in a head injury. Upon noticing the injury, CNA 1 immediately sought assistance from a nurse. During an interview on 8/23/24 at 10:15 a.m., with MDS Nurse, MDS Nurse confirmed that Resident 1's quarterly assessment and care screening were completed on 6/7/24. The assessment indicated that Resident 1 was completely dependent on assistance for repositioning, requiring the support of one or more helpers. The nurse emphasized that Resident 1 needed assistance for all activities and was not capable of completing them independently. MDS Nurse stated Resident 1 was not a big person, and he needed 1 staff assistance for positioning. During a review of Resident 1's care plan dated 3/30/23, the care plan indicated .decreased functional mobility .Resident is non-ambulatory .generalized weakness requiring extensive to total assist with ADLs .Provide extensive to total assistance in all his ADLs while promoting independence if able . Reposition resident for comfort, avoid shearing . During a review of the Policy and Procedure (P&P) titled, Accident Prevention, dated 1/22/24, the P&P indicated, The facility will ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. I. The facility will develop a culture of safety and commitment to implement systems that address resident risk and environmental hazards to minimize the likelihood of accident .

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. The ice machine in the satellite kitchen in building five and the ice machine in the satellite kitchen in building one had a build-up of a yellow substance and discoloration on their water tubes. This failure had the potential to contaminate the water and the ice after it was formed. 2. Buildup of dirt and debris were found under kitchen appliances and countertops, and crumbs were found behind an ice machine and on the bottom shelf of a reach-in freezer. This failure had the potential for microorganism growth and to attract pests. 3. The bulk sugar was contaminated with a black substance. This failure had the potential to contaminate the residents' food. 4. Dust, grime (dirt stuck to surface), and food residue were found in toolboxes used to store clean utensils. This failure had the potential for microorganism growth and to attract pests. The kitchen served meals for a population of 99 residents. Findings: 1. During a concurrent observation and interview on 3/18/24 at 3:38 p.m. with the Plant Operations Chief Engineer (PCOE) in Building 5 Satellite Kitchen, there was black discoloration on the tubing where the water was running through the ice machine. PCOE stated the tubing was supposed to be changed as needed. During an observation on 3/18/24 at 3:46 p.m. in Building Five Satellite Kitchen, there was yellow residue wiped with a paper towel from the ice chute. During an interview on 3/18/24 at 3:54 p.m. with the Director of Dietetics (DD), DD stated ice from the ice machines are used for residents' beverages and ice baths (ice placed under food containers to keep food cold) on the snack cart. During an observation on 3/18/24 at 3:56 p.m. in Building One Satellite Kitchen, there was purple discoloration on the tubing where the water was running through in the ice machine. During a concurrent observation and interview on 3/18/24 at 3:57 p.m. with PCOE in Building One Satellite Kitchen, there was yellow residue wiped with a paper towel from the ice chute. PCOE stated his staff did not usually clean the area of the ice chute where the yellow residue was found. During an intervieon 3/20/24 at 2:19 p.m. with DD, DD stated food-contact surfaces should not have any build-up or any discoloration that may be mold (fungus growth on wet surfaces that can look black, blue, red, and/or green) or mildew (white-like growth of fungus on damp surfaces). During an interview on 3/20/24 at 3 p.m. with the Chief of Plant Operations (CPO), CPO stated the ice machine tubing should be replaced if it was discolored. CPO stated anything that might touch the water or ice that the residents consumed should be kept clean. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Sanitizing Ice Machine, dated November 2023, the P&P indicated, Clean all internal and external surfaces of the machine with the disinfecting solution. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated 11/5/23, the P&P indicated, Ice used in connection with food or drink will be from a sanitary source and will be handled and discarded in a sanitary manner. Ice machines will be cleaned according to manufacturer's guidelines. During a review of the ice machine manufacturer's guidelines titled, Modular Crescent Cuber Instruction Manual, dated 12/2/13, the manual indicated, The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. During a review of the Food and Drug Administration's Food Code, dated 2022, Section 4-602.11 indicated, .Ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. In addition, If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. 2. During an observation on 3/18/24 at 9:47 a.m. in the Main Kitchen, there were crumbs scattered on the bottom shelf of the reach-in freezer. During a concurrent observation and interview on 3/18/24 at 10:13 a.m. with the Director of Dietetics (DD) in the Main Kitchen, there was a buildup of dirt, food residue, and black grime under the grill and countertops at the food preparation area. DD stated the area under the kitchen equipment like the grill was hard to clean. During an observation on 3/18/24 at 10:27 a.m. in the Main Kitchen, there was a buildup of dirt and grime behind the ice machine. During an interview on 3/20/24 at 2:13 p.m. with DD, DD stated the freezer shelves were supposed to be wiped out daily. During an interview on 3/20/24 at 2:19 p.m. with DD, DD stated it was hard to clean behind or under large equipment. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated 11/5/2023, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean . During a review of the Food and Drug Administration's Food Code, dated 2022, Section 4-601.11 indicated, Nonfood contact surfaces . shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic (able to cause disease) microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 3. During a concurrent observation and interview on 3/18/24 at 9:47 a.m. with the Director of Dietetics (DD) in the Main Kitchen, the bulk sugar was contaminated with a black substance. DD stated staff must discard the contaminated food item, wash and sanitize the bulk food bin, and then refill. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Storage (All Homes), dated 11/5/2023, the P&P indicated, .Food shall be protected from contamination by storing the food in a clean, dry location . All food should be protected against contamination. Contaminated food shall be discarded immediately upon discovery. During a review of the Food and Drug Administration's Food Code, dated 2022, Section 3-305.11 indicated, Food shall be protected from contamination. 4. During an observation on 3/18/24 at 9:35 a.m. in the Main Kitchen, there were two red [brand name] tool cabinets, with chipped paint and a buildup of dust, grime, and food residue, being used as storage for clean utensils. During an interview on 3/20/24 at 2:08 p.m. with the Director of Dietetics (DD), DD stated the [brand name] tool cabinet drawers should have been kept clean with daily cleanings. DD also stated the [brand name] tool cabinets may not have been food-safe equipment, and storage might have to be changed. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated 11/5/2023, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair (i.e. free from breaks, corrosion, open seams, cracks, and chipped areas). During a review of the Food and Drug Administration's Federal Food Code, dated 2022, Section 4-202.16 indicated, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. In addition, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. Well-designed equipment enhances the ability to keep nonfood-contact surfaces clean.

Based on interview and record review, the facility failed to provide adequate supervision for the prevention of an accident for one of three sampled residents (R 1), when R 1 was not provided staff supervision for toileting. This failure resulted in R 1 falling and sustaining a laceration to the back of his head. Findings: A review of R1's clinical record titled, Admission Face Sheet (record containing resident personal information), indicated Resident 1 was [AGE] years old. R 1 had multiple diagnoses which included [CONDITION(S)] (temporary loss of consciousness caused by fall in blood pressure), wandering and Alzheimer's disease (a disorder that affects memory, judgement, and the ability to communicate). A review of R 1's Minimum Data Set (MDS-a resident's assessment tool used to identify care needs) dated 7/10/2020, indicated a brief interview for mental status (BIMS-an assessment of cognitive status) score of five points out of fifteen which indicated R 1 had severe cognitive impairment. The MDS indicated R 1 required two-person physical assist for toilet use. A review of Fall Risk assessment dated [DATE] indicated a score of 24, .if a score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . A review of Post Fall/Nursing Note dated 8/26/2020, indicated Probable Cause of Fall indicated, .staff not able to respond on time while helping other residents and unable to hear alarm . A review of Post Fall/Nursing Note dated 7/29/2020, indicated 1st Responders Detailed Description of Incident indicated, CNA responded to bed alarm and found resident on the floor .when he ambulated to the toilet unassisted .resident fell near the toilet . During an interview, with Certified Nursing Aide (CNA 1), on 10/6/2020 at 10:20 a.m., she stated R 1 would get up without assistance and will not use the call light. During an interview with CNA 2, on 10/7/2020 at 7:23 a.m., she stated on 8/26/2020 she had been in another resident's room and when she came out she had heard R 1's bed alarm (a device that alarms when it detects a reduction of pressure when a patient gets out of bed). She entered into R 1's room at 5:17 a.m. and saw R 1 exit the bathroom and witnessed him fall backward. She stated R 1 hit his head on the bathroom doorframe. CNA 2 stated she was assisting another Resident and no other staff was present to respond to R 1's alarm. CNA 2 stated R 1 was a high risk for falls and got up frequently without assistance. During an interview with Registered Nurse (RN), on 10/7/2020, at 7:30 a.m., she stated R 1's fall could have been prevented had more staff been present on the unit. She stated the nurses were covering multiple stations and the CNA covers fifteen residents, each station had at least two residents with a high-risk for falls. She stated the staff was running to answer call lights and trying to prevent falls. During an interview with Supervisor Registered Nurse (SRN), on 10/8/2020, at 1:19 p.m., he stated R 1 had a history of falls associated with getting up without staff assistance. The facility policy and procedure titled, Call Light System dated 2/10/2020, indicated D. Residents unable to use the call light system due to physical or mental condition will have alternate safety monitoring .Care staff will be notified of Residents inability to use the call light system and will be monitored more frequently. The facility policy and procedure titled, Fall Prevention and Intervention Program dated 7/24/20 indicated, A. Based upon the fall risk assessment, if the resident is assessed as high risk (score of 10 or higher), RN will: 1. Develop and implement a plan of care based upon the identified risks defined by fall risk assessment, individual deficits, medications, history of falls and any other needs that will affect the plan of care.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when Resident 1 was not provided staff supervision for transfer while toileting. This failure resulted in Resident 1 suffering an unwitnessed fall and sustained a fracture of the ninth rib. Findings: Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) dated 1/2/2020, indicated a brief interview for mental status (BIMS -an assessment of cognitive status) score of seven points out of fifteen which indicated Resident 1 had severe cognitive impairment. MDS indicated Resident 1 required supervision, oversight, encouragement or cueing and for self-performance support one-person physical assist for toilet use. On 2/25/2020 at 9.30 a.m., during an interview, Restorative Nurse Assistant (RNA) stated A review of Resident 1's clinical record titled, Admission Face Sheet (record containing resident personal information), indicated Resident 1 was [AGE] years old. Resident 1 (R1) had multiple diagnoses which included a history of difficulty walking, dementia (a disorder that affects memory, judgement, and the ability to communicate) and hypertension (abnormally high blood pressure). ident 1 was a fall risk and required a wheelchair. RNA stated Resident 1 was sitting on the toilet alone in the bathroom when he delivered Resident 1's breakfast tray. RNA stated he put the breakfast tray in the room and left to give Resident 1 privacy. RNA1 stated the nurse went to Resident 1's room and found the resident on the floor next to the toilet. On 2/25/2020 at 9:55 a.m., during an interview, Certified Nursing Assistant (CNA)1 stated she assisted Resident 1 to the toilet and left the room to go pass breakfast trays. CNA 1 stated Resident 1 required assistance to bathroom and CNA's were supposed to stay with Resident 1 while he was on the toilet. CNA 1 stated Resident 1 refused to use his call light. On 2/25/2020 at 10:07 a.m., during an interview, Licensed Vocational Nurse (LVN) stated Resident 1 had fallen in the bathroom off the toilet and it could have been prevented if staff stayed in the room with Resident 1. A review of Resident 1's clinical record titled, Interdisciplinary Resident Fall Investigation and Intervention dated 2/3/2020, indicated, Analysis of fall .At approximately 0745 CNA [CNA 1] assisted resident [Resident 1] to the toilet and placed wheelchair in front of him [Resident 1] .while CNA [CNA 1] was passing breakfast trays .Floor nurse went to give medications to the resident [Resident 1] and noticed resident [Resident 1] was sitting on the floor between the toilet and wheelchair . On 3/3/2020 at 10:37 a.m., during an interview, Supervisor Registered Nurse (SRN) stated his [Resident 1's] first fall was on 1/23/20. Resident [1] was in the bathroom and refused CNA assistance and fell while staff was on standby in his [Resident 1's] room. Resident [Resident1] had an unwitnessed fall 2/2/20 during breakfast while staff was busy passing out breakfast trays. This was resident's [Resident 1's] second fall and the nurse found him on the floor. SRN stated, staff should stay with him till done toileting, it would have prevented the fall. During a review of Resident 1's clinical record titled, Interdisciplinary Resident Fall Investigation and Intervention dated 1/24/20, indicated, Analysis of Fall .At approximately 2340 on 1/23/20 CNA was assisting resident [Resident 1] from the bathroom to bed resident [Resident 1] refused help and wheel chair .as resident [Resident 1] stepped out of the bathroom door way he stumbled sat down on the floor then laid on his back . On 3/03/2020 at 11:09 a.m., during an interview, CNA 2 stated Resident 1 was not stable to walk or transfer without assistance. CNA 2 stated Resident 1 does not use the wheelchair or call light because Resident 1 does not remember. A review of Resident 1's clinical record titled Radiology Report dated 2/3/2020, indicated, .Conclusion .Fracture left ninth rib. A review of Resident 1's clinical record titled Plan of Care dated 1/28/2020, indicated, [Resident 1] is a high risk for falls R/T [Related to] Dementia .HX of falls, unsteady gait, poor judgment, poor coordination and balance .place w/c [wheelchair] within resident's reach, remind, encourage and assist resident with use of w/c and walker .[Resident 1] is resistant with call light for assistance, attempts to transfer self without assistance .Assist resident with his toileting needs . A review of Resident 1's clinical record titled Plan of care dated 2/2/2020 indicated, .Provide assistance with mobility and transfers and toileting . The facility policy and procedure titled, Fall Prevention and Intervention Program dated 7/24/19, indicated To promote a safe environment, all skilled nursing facility (SNF) Residents will be assessed for fall risk .history of falls, and any individual needs to prevent and/or decrease falls .