Every finding on record at Villa Coronado D/P SNF

Based on interview and record review, the facility failed to post nursing staffing information which reflected the actual working hours of the staff responsible for resident care.As a result, the facility's staffing information reflecting actual hours worked was not posted where the public could view it.Findings:On 7/30/26 at 2:03 P.M., an observation and interview was conducted with the Manager of Staffing and Clinical Support Services (MSCS). The MSCS stated she was responsible for the nursing staffing schedule and posting. The facility's staffing form titled, (Facility's name) Long Term Care Unit Daily Nurse Shift Staffing was posted by the nurses' station for 7/30/26. The posting was reviewed with the MSCS. The MSCS stated the facility posted the projected nursing working hours for each shift and not the actual nursing working hours. The MSCS stated the facility had never posted the actual working hours of nursing staff. The MSCS stated the posting of the facility's staffing hours should have been the actual working hours and the facility should have revised the form used to post the nursing working hours.On 7/30/26 at 3:03 P.M., an interview was conducted with nurse manager (MGR) 1. The MGR 1 stated actual working hours for the nursing staff should have been posted at the start of each shift.On 7/30/26 at 3:26 P.M., the MSCS stated the facility did not have a policy regarding the posting of staffing hours.

Based on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food items were not properly sealed, labeled, and dated, including an open bag of grits, and an open bag of raisins, 2. Food items were not discarded when spoiled or damaged,3. The Kitchen staff (KS) did not consistently document the sanitizing log for the sinks and surface, and, 4. The [NAME] (CK) 1 did not perform hand hygiene consistently during food preparation. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne pathogens to come in contact with the residents' food and may cause food borne illness to the residents. The facility's census was 97. Findings: 1.During the tour of the dry food storage room on 7/27/26 at 7:54 A.M., an observation and an interview with the Food and Nutrition Services Manager (FNSM) was conducted. There was an unsealed opened bag of grit and undated opened bag of raisins. FNSM stated the staff should have sealed the bag once opened and they should have labeled the bag with raisins. On 7/30/26 at 3:03 P.M., an interview with the FNSM and the Area Clinical Manager was conducted. FNSM stated the expectation was for the staff to label, date and seal the opened food items to prevent spillage, maintain freshness and food product quality for resident safety. The facility's policy and procedure titled, Infection Prevention for Food and Nutrition Services, dated 8/2024, indicated, Purpose: To prevent of microorganisms among patients, personnel and visitors and maintain effective infection prevention measures within the kitchen area and outlying areas stocked by food service personnel .Procedure: G. Food Storage/ Disposal, 1. All foods are labeled, covered and dated when stored. 2. During the tour of the refrigerator on 7/27/26 at 7:54 A.M., an observation and an interview with the FNSM was conducted. There was rotten red bell pepper inside a box of red bell peppers. FNSM stated that should have been discarded. The facility's policy and procedure titled, Food and Nutrition Services, dated 3/2026, indicated, Policy: All dry food products shall be stored in a manner that protects them from contamination, deterioration, pest infestation, and damage.Procedural Guidelines.damaged or compromised food items shall be removed from inventory and discarded immediately. 3. During the initial tour of the kitchen on 7/27/26 at 7:54 A.M., a record review of the sanitizing log for the sink and surface and an interview with the FNSM was conducted. There were missing entries of the sanitizing log for the sink and surface on 7/11/26, 7/15/26 and 7/17/26. FNSM stated he will check with the kitchen staff. On 7/30/26 at 3:03 P.M., an interview with the FNSM and the Area Clinical Manager was conducted. FNSM stated the expectation was for the staff should have properly documented the sanitation log to validate that staff did the sanitation of the sink and counter to ensure there was no infestation and for the safety of the residents. The facility's policy and procedure titled, Infection Prevention for Food and Nutrition Services, dated 8/2024, indicated, Purpose: To prevent of microorganisms among patients, personnel and visitors and maintain effective infection prevention measures within the kitchen area and outlying areas stocked by food service personnel .Procedure: E. Equipment/ Sanitation.7. Work areas, food trays.are cleaned with approved sanitizer after each use. 4. A follow-up tour of the kitchen during food preparation was conducted on 7/29/26 at 10:23 A.M. An observation was conducted with [NAME] (CK) 1. CK 1 with his gloves on, took out a blender from under the counter, got a knife and opened the plastic bag with soup content. CK 1 then took out two small metal trays with tomato soup and gravy, then he took the thermometer, cleansed the thermometer with alcohol wipes, pulled out the gray trash bin from under the sink to throw the alcohol swab, pushed back the gray trash bin and he took the temperature of the tomato soup. CK 1 with the same gloves and after handling the trash bin, cleansed the thermometer with alcohol wipes, pulled out the trash bin and pulled it back, then he took the temperature of the gravy. CK 1 did not change his gloves or performed hand hygiene during the entire process. On 7/29/26 at 10:59 A.M, an observation of CK 1 was conducted. CK 1 had a pair of gloves on, put on a potholder on top of the gloves, took a large metal bin with turkey breast out from the oven, removed the potholder from his hands, took the temperature of the turkey breast, put back the potholder, placed back the metal bin to the oven, removed the potholder, took out the garnish from the stove top, and mixed the garnish together. CK 1 did not change his gloves or performed hand hygiene during the process. On 7/29/26 at 11:13 A.M., an observation of CK 1 was conducted. CK 1 with gloves on, put a potholder on top of his gloves, took out the large metal bin with turkey breast from the oven, took out the potholder, sanitized the thermometer with alcohol swab, checked the temperature of the turkey breast, and pulled out the gray trash bin. With the same gloves after handling the trash bin, CK 1 took out a parchment paper, laid the parchment paper into a large metal bin and cut the turkey breast and laid them on the parchment paper. CK 1 did not change his gloves or perform hand hygiene after handling the trash bin. On 7/29/26 at 12:41 P.M., an interview was conducted with CK 1 with the presence of FNSM and Area Clinical Manager. CK 1 stated he was not consistent with performing hand hygiene or removing his gloves during the food preparation. CK 1 stated he should have been because it was important to prevent contamination of the food. On 7/30/26 at 3:03 P.M., an interview with the FNSM and the Area Clinical Manager was conducted. FNSM stated the expectation was for the staff to properly use gloves and perform hand hygiene to prevent contamination and for resident safety. The facility's policy and procedure titled, Infection Prevention for Food and Nutrition Services, dated 8/2024, indicated, Purpose: To prevent of microorganisms among patients, personnel and visitors and maintain effective infection prevention measures within the kitchen area and outlying areas stocked by food service personnel .Procedure, C. Handwashing and glove use.g. Between handling soiled.equipment and handling clean food or utensils.

Based on observation, interview, and record review the facility failed to ensure residents' medical records had complete, accurate, readily accessible, and systemically organized documentation for five of 23 residents (Resident 8, 20, 28, 40, 104) when:Resident 28 and Resident 40 had incomplete and inaccurate tube feeding (liquid food delivered through a tube that was surgically placed in the stomach) intake documentation.Resident 104's care plan related to shingles (contagious rash) and contact precautions (infection prevention measures to prevent the spread of disease) was not readily accessible.Resident 8's daily wound inspection was not documented consistently after care was provided.Resident 20's psychotropic behavior monitoring was inaccurate. These failures resulted in staff not being able to determine what care and treatment was provided to residents, which had the potential to result in compromised continuity of care and delayed clinical- decision making. Findings: 1a. Resident 40 was admitted to the facility on [DATE], per the facility's Face Sheet. On 7/27/26 at 3:23 P.M., observation was conducted of Resident 40 in his room. Resident 40 had a tracheostomy (opening into the windpipe from outside the neck), was connected to oxygen and had gastrostomy tube (G-tube, a thin flexible tube inserted through the abdominal wall and into the stomach) connected to a tube feeding (TF) pump with a bag of Diabetisource (type of formula) around 400 milliliter (ml, metric of measurement) remaining from the TF bag. Resident 40 was awake but did not respond to his name. On 7/28/26 at 11:10 A.M., a review of Resident 40's electronic medical record (EMR) was conducted with Licensed Nurse (LN) 31. Resident 40 had diagnoses which included stroke, dysphagia (difficulty swallowing), per Resident 40's EMR. A review of Resident 40's physician order dated 3/18/26 indicated, Diabetisource via G-tube 75 milliliter per hour (ml/hr.), 1,500 ml per day. On 7/30/26 at 9:38 A.M., a concurrent record review of Resident 40's TF intake and an interview was conducted with LN 32. LN 32 stated Resident 40 was admitted due to stroke, had tracheostomy and had a G-tube. LN 32 stated Resident 40 was to receive Diabetisource for 20 hours and the TF started from 2 P.M. to 10 A.M. the following day. LN 32 stated Resident 40 was scheduled to get 1,500 ml/ day for total amount of TF. LN 32 stated there was missing and inaccurate documentation of TF intake for Resident 40. Resident 40's missing and inaccurate TF intake as follows: 7/23/26 – 7/24/26, 265 ml missing documentation 7/24/26 – 7/25/26, 600 ml missing documentation 7/25/26 – 7/26/26, 1620 ml was documented 7/26/26 – 7/27/26, 1515 ml was documented 7/27/26 – 7/28/26, 1425 ml was documented 7/28/26 – 7/29/26, 675 ml missing documentation LN 32 stated there was documentation gap from the LNs. LN 32 stated LNs should have accurately documented Resident 40's TF intake to ensure Resident 40 was getting the nutritional value for Resident 40's needs and to maintain his current weight. On 7/30/26 at 10:43 A.M., an interview was conducted with the Manager (MGR) 2. MRGR 2 stated the expectation was for the LNs to accurately document Resident 40's TF intake in his EMR to ensure he was receiving the entire amount of TF. A review of the facility's policy and procedure titled, Charting Guidelines, effective date 07/2025, indicated, It is the guideline of this facility that: 1. All documentation will be completed as required for each resident. Procedure.2d Special Focus.1. Assessment of intake. 1b. A review of Resident 28's admission record indicated Resident 28 was admitted to the facility on [DATE]. A review of Resident 28's Clinical Nutrition Follow Up dated 5/11/26, indicated Resident 28 had diagnoses to include dysphagia (difficulty swallowing) and aspiration pneumonia due to gastric secretions (stomach contents are inhaled into the lower airways and lungs). A review of Resident 28's Active Orders indicated, .Dietary Orders. NPO [nothing by mouth] diet (Tube feeding no tray) Diet effective.Start 10/29/25 1446 [2:46 P.M.] Tube feeding no tray [tube feeding formula]. Route of admission: G tube [ feeding tube]; Method of administration: Cyclic Goal rate (ml/hr): 55; Hours/day: 20 [hours]; Cyclic start/stop time: Start at 1400 [2 P.M.], end at 1000 [10 A.M.] or until dose is completed; ML/day: 1,100 [mL]. On 7/28/26 at 8:55 A.M., an observation was conducted in Resident 28's room. The tube feeding container was labeled 1.2 cal [calories] /mL at 55 mL/hour for 20 hours and dated 7/28/26 at 4 A.M. Resident 28's feeding pump was running at 55 mL/hr with a volume infused of 1018 mL. On 7/29/26 at 3:34 P.M., a concurrent interview and record review was conducted with licensed nurse (LN) 5 and LN 4. LN 5 stated Resident 28 should have received 1,100 mL of tube feeding every 24 hours and expected nursing staff to document the total volume administered in the input section under tube feeding in the medical record. LN 5 and LN 4 reviewed the input section under tube feeding for Resident 28. LN 5 and LN 4 confirmed that on 7/25/26 nursing staff documented only 660 mL of tube feeding was administered for Resident 28. LN 4 stated the medical record did not include documentation for the remaining 440 mL of tube feeding. LN 5 and LN 4 confirmed that on 7/26/26 nursing staff documented only 605 mL of tube feeding was administered for Resident 28. LN 4 stated the medical record did not include documentation for the remaining 495 mL of tube feeding. LN 4 further stated that all nurses should have documented the total amount of Resident 28's tube feeding administration during their shift in the input section under tube feeding. LN 4 stated she expected the documentation to clearly and accurately reflect the total volume of tube feeding the resident received each day. LN 4 stated the incomplete documentation could have caused staff to misinterpret how much tube feeding the resident received. LN 5 agreed with LN 4's statements. On 7/30/26 at 3:04 P.M., a concurrent interview and record review was conducted with nursing manager (MGR) 1. MGR 1 reviewed Resident 28's input section under tube feeding in the medical record for 7/25/26 and 7/26/26 and stated the documentation was inconsistent. MGR 1 stated nursing staff should have accurately documented the amount of tube feeding administered because staff relied on that documentation to assess the resident's nutritional intake and make clinical decisions regarding the resident's care. MGR 1 stated the medical record served as the primary method of communication among staff and inaccurate or incomplete documentation could affect the care and treatment provided to the residents. 2. A review of Resident 104's admission record indicated the resident was admitted to the facility on [DATE]. A review of Resident 104's Nursing Orders dated 7/21/26, indicated, . On contact isolation for Shingles. On 7/28/26 at 9 A.M., a concurrent interview and record review was conducted with LN 5. LN 5 reviewed Resident 104's medical record and stated she was unable to locate a care plan addressing Resident 104's shingles and contact precautions in the medical record. LN 5 stated Resident 104 did not have a care plan for shingles and contact precautions and should have had one. LN 5 stated having a care plan for shingles and contact precautions was important because it documented the resident's isolation precautions, treatment interventions, and communicated the plan of care to the staff to ensure consistent implementation of care. On 7/30/26 at 3:04 P.M., a concurrent interview and record review was conducted with nurse manager (MGR) 1. MGR 1 stated the facility had developed a care plan for Resident 104's shingles and contact precautions; however, LN 5 was unable to locate it in the medical record. MGR 1 stated minimum date set (MDS) nurses could locate care plans. MGR 1 stated the facility's documentation system was not systemically organized, which prevented staff from readily accessing the residents' care plan. MGR 1 stated all nurses should have been able to easily locate and access care plans because staff relied on the documentation to provide consistent care. 3. A review of Resident 8's admission record indicated the resident was admitted to the facility on [DATE]. A review of the Resident 8's Report of Resident Fall with Associated Injury dated 07/13/26, indicated, .The resident was returning to the facility after being out on pass with a friend.the resident was seated in her wheelchair while her friend was pushing the wheelchair. The wheelchair reportedly toppled, causing the resident to fall onto the concrete surface.The resident.sustained injuries including acute comminuted and mildly displaced fractures of the distal tibial and fibular metadiaphysis [lower leg bone just above the ankle joint]. A review of the Resident 8's nursing note dated 7/12/26, indicated, .[Resident 8] complained of pain on left ankle, unable to move left foot, with abrasion on top of left foot.No swelling on other part of the body except left ankle. A review of Resident 8's Custodial Progress Note dated 7/15/26, indicated, .Assessment & Plan Acute left comminuted and mildly displace fracture of the distal tibial and fibular metadiaphysis.Physical Exam Musculoskeletal: Comments: Left ankle in splint. On 7/28/26 at 10:14 A.M., a concurrent interview and record review with licensed nurse (LN) 1 was conducted. LN 1 reviewed Resident 8's fall care plan. Resident 8's fall care plan dated 7/12/2026, indicated, .Inspect the foot daily for skin breakdown, pressure sores, or signs of infection. LN 1 then reviewed Resident 8's flowsheet for monitoring of the daily foot inspection. LN 1 stated the documentation was blank on 7/24/26, 7/25/26, 7/26/26, and 7/27/26 for the daily foot inspection. LN 1 stated Resident 8 had a splint on the left foot. LN 1 stated it was important to monitor the left foot for swelling. LN 1 stated it was important to check the circulation in the foot especially since it had a splint. LN 1 stated it was important to also take off the splint to check for skin breakdown. LN 1 stated it was important to monitor the abrasion on the foot to check if it was worsening. LN 1 stated Resident 8's daily inspection of her left foot should have been done and documented in the clinical record. On 07/29/26 at 3:17 P.M., an interview and record review was conducted with nurse manager (MGR) 1. MGR 1 reviewed Resident 8's flowsheet for monitoring of the daily foot inspection. MGR 1 stated there was no documentation that Resident 8's foot was inspected on 7/24/26, 7/25/26, 7/26/26, and 7/27/26. MGR 1 stated that complete documentation should have been done. 4. A review of Resident 20's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses to include G31.9 (unspecified degenerative disease of the nervous system). A review of Resident 20's hospice history and physical indicated the resident had dementia (involves a progressive decline in memory, thinking, and behavior that disrupts daily life) and was legally blind. A review of Resident 20's order sheet for current scheduled medications dated 3/12/26, indicated the resident received Olanzapine (an anti-psychotic/psychotropic medication) 2.5 milligrams (mg) daily. The same order indicated staff were to, .Monitor for agitation AEB [as evidenced by] verbalization of negative thoughts and verbalization that people are talking about her. On 7/30/26 at 11:30 A.M., an interview and record review was conducted with Nurse Manager (MGR) 1. MGR 1 reviewed Resident 20's flowsheet for, .Monitor for agitation AEB verbalization of negative thoughts and verbalization that people are talking about her. MGR 1 stated on 7/18/26, 7/17/26, 7/21/26, 7/20/26, 7/23/26, 7/22/26, 7/24/26, 7/25/26, 7/26/26, 7/27/26, and 7/28/26, Resident 20 had hallucinations documented as being her target behavior. MGR 1 stated hallucinations were not a target behavior for Resident 20. MGR 1 stated the documentation of Resident 20's targeted behavior (hallucinations) was incorrect and inaccurate. MGR 1 stated Resident 20's target behavior should have been a free response entered by the nurse that matched the order for behavior monitoring while on Olanzapine. On 7/30/26 at 2:01 P.M., MGR 1 stated the facility did not have a policy regarding documentation and charting. MGR 1 stated she expected the staff to properly and accurately document.

Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented for three of 33 sampled residents (Resident 40,113 and 101) when:1.A tube feeding pump was observed with yellowish/ brown stained while tube feeding was administered to the resident (40). 2. Certified nursing assistant (CNA) 25 did not follow the enhanced barrier precautions (EBP, an infection control strategy in long-term care facilities to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that resist common medicines and antibiotics resulting in harder to cure illnesses]) for Resident 113 during patient care.3. Licensed nurse (LN) 22 did not adhere to the EBP's hand hygiene and gloving during Resident 101's medication administration. These failures had the residents at risk for exposure to unwanted pathogens (microorganisms that cause disease) and spread of infection among residents, staff and visitors. Findings: 1.Resident 40 was admitted to the facility on [DATE], per the facility's Face Sheet. On 7/27/26 at 3:23 P.M., observation was conducted of Resident 40 in his room. Resident 40 had a tracheostomy (opening into the windpipe from outside the neck), was connected to oxygen and had gastrostomy tube (G-tube, a thin flexible tube inserted through the abdominal wall and into the stomach) connected to a tube feeding (TF) pump with a bag of Diabetisource (type of formula) around 400 milliliter (ml, metric of measurement) remaining from the TF bag. Resident 40 was awake but did not respond to his name. Resident 40's TF pump was observed to have a streak of yellowish/ brown stain. On 7/27/26 at 4:12 P.M., a concurrent observation of Resident 40's TF pump and an interview was conducted with Licensed Nurse (LN) 33. LN 33 stated she was assigned to Resident 40. LN 33 stated the stain could have been a dried formula when the LNs spiked the formula bag with the TF tube and could have leaked to the TF pump. LN 33 stated the expectation was for the LNs to clean and disinfect the TF pump for infection control. On 7/30/26 at 10:43 A.M., an interview was conducted with Manager (MGR) 2. MGR 2 stated the expectation was for the nurses to maintain clean pump and poles to prevent infection. MGR 2 stated the LNs should have cleaned the TF pump in real time. A review of the facility's policy and procedure titled, Cleaning Schedule – Patient Care Equipment, effective date 07/2026, indicated, Purpose: Provide guidelines for cleaning and disinfecting equipment to prevent the spread of infection.Equipment Cleaning Guidelines.Pumps, Feeding.Nursing Services.when visibly soiled. 2. A review of Resident 113's facility provided facesheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of primary osteoarthritis (a joint disease that causes stiffness), left hip. A review of the EBP sign outside Resident 113's room indicated, .Enhanced Barrier Precautions Are in Place.Everyone must clean their hands before entering this room. Gowns and gloves are required for staff.during high-contact activities.assisting with toilet use.transferring to and from bed. On 7/28/26 at 10:08 A.M., an observation was conducted with CNA 25 in Resident 113's room. There was an EBP sign by Resident 113's door. CNA 25 was observed to enter the room with no hand hygiene, gowning and gloving. CNA 25 proceeded to assist the resident to a standing position with a gait belt (a safety and mobility tool). Resident 113 was sitting on his bed, waiting for assistance to go to the bathroom. CNA 25 held on to the gait belt and the resident while Resident 113 ambulated using a front wheel walker (a mobility device) to the bathroom. CNA 25 left the resident in the bathroom, went to Resident 113's bedside area, moved the resident's bedside table and touched items that were in the table. CNA 25 continued to be without any gloves and gown. CNA 25 then stepped out of Resident 113's room without performing hand hygiene. CNA 25 removed a gown from a cart outside of Resident 113's room, then donned the gown, leaned on the wall, put gloves on and entered the room across Resident 113's room. On 7/28/26 at 10:11 A.M., a joint medication administration observation and interview was conducted with LN 26. LN 26 was outside Resident 113's room preparing the resident's medications. LN 26 was waiting for Resident 113 to come back from the bathroom. LN 26 stated he saw CNA 25 transferring Resident 113 to the bathroom without a gown and gloves. LN 26 stated the resident was on EBP due to being treated with antibiotics (medications that fight infections). LN 26 stated CNA 25 should have followed the EBP to ensure the resident's safety. On 7/28/26 at 10:27 A.M., an interview was conducted with CNA 25. CNA 25 stated he was aware of Resident 113's EBP. CNA 25 reviewed the EBP sign by the resident's door. CNA 25 stated he should have donned a gown and put gloves on before entering and assisting Resident 113. CNA 25 stated he should have followed the EBP. CNA 25 stated EBP were for residents who might be sick. CNA 25 stated without him performing hand hygiene and wearing the gown and gloves could have exposed Resident 113 and everyone else in the facility to disease-causing bacteria. On 7/29/26 at 11:48 A.M., an interview was conducted with the infection preventionist nurses (IPN) 1 and 2. IPN 1 stated the all staff annual in-service on infection control was conducted the previous week or two. IPN 1 stated staff should follow the indicated infection control precautions for each resident to prevent cross-contamination and to protect patient and staff from MDROs. IPN 2 stated CNA 25 violated the facility's infection control policy when the CNA did not follow the EBP. On 7/30/26 at 3:30 P.M., an interview was conducted with manager (MGR) 2. MGR 2 stated CNA 25 should have followed the EBP of hand hygiene, donning a gown and gloves before assisting the resident to mitigate possible transmission of MDROs. A review of the facility's policy titled, Hand Hygiene, last revised on 6/2024, indicated, .Performance of hand hygiene is required of all team members. Hand hygiene must be performed.1. Upon entry and exit of a patient room.3. Before and after contact with a patient's intact skin.6. After contact with inanimate objects in the immediate vicinity of the patient. A review of the facility's policy titled, Enhanced Barrier Precautions in the Skilled Nursing Units, 05662, indicated, .Purpose.establish evidence-based infection prevention measures to reduce transmission of multi-drug-resistant organisms (MDROs).This policy applies to all healthcare personnel (HCP) including clinical staff.and any personnel involved in direct resident care or handling of resident care equipment.3. HCP must don gown and gloves when performing high-contact care activities, including.c. Transferring .assisting with toileting.Care should be taken to not cross-contaminate.during ambulation. 3. A review of Resident 101's facility provided Patient Demographics indicated the resident was admitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy (an opening through the skin to the stomach for a feeding tube [a medical device to deliver liquid food and medicine] insertion), tracheostomy (a surgical opening in the neck to the windpipe) and pneumonia (a lung infection). A review of the EBP sign outside Resident 101's room indicated, .Enhanced Barrier Precautions Are in Place.Everyone must clean their hands before entering this room. Gowns and gloves are required for staff.during high-contact activities.device.care. On 7/28/26 at 12 P.M., a joint medication administration observation and interview was conducted with LN 22 in Resident 101's room. There was an EBP sign outside the resident's door. Resident 101 was lying in bed, with eyes closed, was unable to speak, and with a tracheostomy tube (a tube inserted into a surgically created hole in the neck to help with breathing). LN 22 was observed moving items on the resident's bedside table and pulling the table closer to the bedside. LN 22 then proceeded to touch Resident 101's gastrostomy tube (GT, a medical device inserted through the skin of the abdomen to the stomach to deliver food, liquids and medications) wearing the same gloves. LN 22 stated she should have performed hand hygiene and changed gloves after touching items around the resident's bedside and before starting the GT medication administration. LN 22 stated Resident 101 was on EBP. On 7/29/26 at 11:29 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated all staff, including the CNAs, had been trained on transmission of infection and the use of personal protective equipment (PPE, items such as gowns and gloves, which are used to minimize spread of illnesses). The DSD stated the infection preventionist nurse (IPN) conducted an annual all staff in-service on infection control. The DSD stated staff should adhere to EBP to prevent the spread of disease-causing organisms. On 7/29/26 at 11:48 A.M., an interview was conducted with the infection preventionist nurses (IPN) 1 and 2. IPN 1 stated the all staff annual in-service on infection control was conducted the previous week or two. IPN 1 stated staff should follow the indicated infection control precautions for each resident to prevent cross-contamination and protect patient and staff. IPN 1 stated curtains, beds and rails were examples of high contact surfaces. IPN 1 stated staff should remove gloves, perform hand hygiene and put new gloves on if they touched and moved objects around the bedside before touching the GT. On 7/30/26 at 3:30 P.M., an interview was conducted with manager (MGR) 2. MGR 2 stated staff would need to perform hand hygiene and changed their gloves after touching high contact surfaces to mitigate possible transmission of MDROs. A review of the facility's policy titled, Hand Hygiene, last revised on 6/2024, indicated, .Performance of hand hygiene is required of all team members. Hand hygiene must be performed.1. Upon entry and exit of a patient room.3. Before and after contact with a patient's intact skin.6. After contact with inanimate objects in the immediate vicinity of the patient. A review of the facility's policy titled, Enhanced Barrier Precautions in the Skilled Nursing Units, 05662, indicated, .Purpose.establish evidence-based infection prevention measures to reduce transmission of multi-drug-resistant organisms (MDROs).This policy applies to all healthcare personnel (HCP) including clinical staff.and any personnel involved in direct resident care or handling of resident care equipment.3. HCP must don gown and gloves when performing high-contact care activities, including.c. Transferring .assisting with toileting.Care should be taken to not cross-contaminate.during ambulation.

Based on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 20 and 62) were free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when:1. Resident 20's target behavior monitoring was not specific to psychosis.2. Resident 62's target behavior monitoring for two psychotropic medications were not completedThese failures had the potential for residents to receive psychotropic medications inappropriately and in excessive dosage. FINDINGS: 1. A review of Resident 20's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses to include G31.9 (unspecified degenerative disease of the nervous system). A review of Resident 20's hospice history and physical indicated the resident had dementia (involves a progressive decline in memory, thinking, and behavior that disrupts daily life) and was legally blind. A review of Resident 20's Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 7/1/26, indicated her vision was, .4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to follow objects. The same MDS indicated the resident's brief interview for mental status was 6 out of 15 (a score of 6 meant the resident was cognitively impaired). A review of Resident 20's order sheet for current scheduled medications dated 3/12/26, indicated the resident received Olanzapine (an anti-psychotic/psychotropic medication) 2.5 milligrams (mg) daily. The same order indicated staff were to, .Monitor for agitation AEB [as evidenced by] verbalization of negative thoughts and verbalization that people are talking about her. On 7/27/26 at 2:55 P.M., an observation was conducted in the hallway with Resident 20. A certified nursing assistant (CNA) was observed bringing Resident 20 out of her room via wheelchair. Resident 20 stated she wanted to go to the bathroom. The CNA stated that Resident 20 just went to the bathroom. On 7/27/26 at 3:08 P.M., a joint observation and interview was conducted in the hallway with Resident 20. Resident 20 was sitting in a wheelchair and had an overbed table in front of her. Resident 20 was eating chocolate pudding and gelatin. A CNA was guiding the resident's hand that held the spoon and was telling the resident where and what the food was. Resident 20 stated she was blind and she could not see her food. On 7/29/26 at 10:25 A.M., an interview was conducted with CNA 11. CNA 11 stated Resident 20 was confused and blind. CNA 11 stated Resident 20 had a roommate (Resident 27) with a similar sounding name. CNA 11 stated when staff went into the room to talk with Resident 20, the resident would ask if staff were talking to her because her name sounded like the roommate's name. On 7/29/26 at 10:42 A.M., an interview was conducted with CNA 12. CNA 12 stated Resident 20 would get confused if her roommate's name was called because it sounded like her own. CNA 12 stated Resident 20 was not paranoid. On 7/30/26 at 9:37 A.M., an interview and record review was conducted with Licensed Nurse (LN) 13. LN 13 stated Resident 20 was confused and blind. LN 13 stated Resident 20 had a history of yelling and hitting others when agitated. LN 13 stated it was unknown what caused Resident 20 to become agitated. LN 13 stated Resident 20 was very social and wanted someone to be there with her. LN 13 stated Resident 20 would yell I need help, and staff would respond. LN 13 stated Resident 20 would often ask to go to the bathroom even if she did not have to go. LN 13 stated this was an attention-seeking behavior. LN 13 stated Resident 20 often asked if someone was talking about her because she could not see. LN 13 stated Resident 20 would have negative thoughts because she thought staff talking near her were talking about her. LN 13 stated that could also be due to blindness. LN 13 stated she had heard Resident 20 asked staff if they were talking about her when staff were speaking to Resident 20's roommate. LN 13 stated Resident 20 and her roommate's names sounded the same. LN 13 reviewed Resident 20's physician order dated 3/12/26 for Olanzapine and monitoring for the resident's agitation AEB verbalization of negative thoughts and verbalization that people were talking about her. LN 13 stated the target behavior of the monitoring could be attributed to the resident's blindness. LN 13 stated Resident 20's Olanzapine monitoring should have been related to the resident's psychosis which presented as agitation, restlessness and physical aggression. On 7/30/26 at 11 A.M., a telephone interview was conducted with Resident 20's nurse practitioner (NP). LN 5 was also present. The NP stated Resident 20 was his patient since 2025. The NP stated the cause of Resident 20's agitation was unspecified and he was unsure of its origin. The NP stated when Resident 20 became agitated, she was a danger to herself and to others because she got physical. The NP stated Resident 20 was responding well to a daily dose of Olanzapine 2.5 mg. Resident 20's Olanzapine order dated 3/12/26 was read to the NP. The NP acknowledged Resident 20's behavior being monitored could be attributed to blindness and was not appropriate. The NP stated Resident 20's Olanzapine order should indicate for unspecified psychosis with dementia AEB agitation with hitting and throwing items. The NP stated inaccurate target behavior monitoring could result in unnecessary psychotropic medications being given. On 7/30/26 at 11:12 A.M., an interview and record review was conducted with LN 5. LN 5 stated the purpose of behavior monitoring with psychotropic medications was to track the behavior the medication was controlling. LN 5 stated if a resident's behaviors increased, then more psychotropic medication would be recommended. LN 5 stated if a resident's behaviors decreased, it may indicate that a gradual dose reduction should be done. LN 5 stated, It's important to monitor the true target behavior to avoid over medicating. LN 5 reviewed Resident 20's physician order for Olanzapine dated 3/12/26, which indicated behavior monitoring AEB verbalization of negative thoughts and verbalization that people were talking about her. LN 5 stated this was not an appropriate behavior monitoring as Resident 20's blindness impacted her ability to see who was talking to or about her. LN 5 stated Resident 20 questioning if staff were talking about her when she had a roommate with a similar sounding name was not a sign or symptom of psychosis. LN 5 stated she agreed with the NP that Resident 20's target behavior should have been AEB agitation with hitting others and throwing items. On 7/30/26 at 11:30 A.M., an interview was conducted with Nurse Manager (MGR) 1. MGR 1 stated psychotropic behavior monitoring was done to address what the medication was indicated for and to make sure to treat the real signs and symptoms of the illness. MGR 1 stated behavior monitoring, .lets us know if the medication is working based on how often we see the target behavior. MGR 1 stated if the target behavior was seen often, it might necessitate increasing the medication. MGR 1 stated a resident could receive too much medication if the target behavior was inappropriate. MGR 1 stated Resident 20's Olanzapine target behavior was not right. MGR 1 stated, We didn't dig into this enough and take into consideration the resident's blindness and that she had a roommate with a similar name for more than a year. MGR 1 stated Resident 20 could have been fearful as a result of blindness and not knowing who was there or who was talking to her but this was not psychosis. MGR 1 stated, We should have addressed this further. MGR 1 stated Resident 20's target behavior should have been related to psychosis manifested by agitation with throwing things, hitting, and kicking. A review of the facility's policy titled Monitoring of Antipsychotic Medications, 39103 dated 2/2024, indicated, I. Purpose To provide guidelines for the safe and effective use of antipsychotic medications. Residents will receive antipsychotic medications only when medically necessary. Antipsychotic use is monitored to facilitate residents receiving the intended benefit of the medication and to minimize the unwanted effects of the antipsychotic medications.B. When antipsychotic therapy is initiated, the resident is monitored to determine the effectiveness of the medication. Findings: 2. A review of the facility provided facesheet for Resident 62 indicated the resident was admitted to the facility on [DATE]. A review of Resident 62's History and Physical, dated 10/30/25, indicated past medical history of Lewy body dementia (a brain disease affecting thinking, mood and behavior), functional quadriplegia (loss of ability to move all four limbs and trunk) and depression (a mood disorder causing sadness). A review of Resident 62's medical record indicated active medication orders including the following: quetiapine (a medication to treat various psychiatric conditions) 25 milligram (mg, a unit of measure) tablet by mouth nightly, dated 3/11/26. The order included administration instructions to monitor Resident 62 every shift for side effects of quetiapine and for mood disorders with psychotic (loss of contact with reality) features as evidenced by grabbing and pinching staff and throwing self on the floor. sertraline (a medication to treat depression) 100 mg tablet by mouth two times daily, dated 11/26/25, with administration instructions to monitor Resident 62 every shift for side effects of sertraline and for depression as evidenced by withdrawal from activity and refusal to talk or interact. On 7/29/26 at 4:05 P.M., a joint observation and interview with certified nurse (CNA) 27 was conducted in Resident 62's room. Resident 62 was lying in bed and awake. Resident 62 maintained eye contact but remained quiet when greeted. CNA 27 stated he had worked with Resident 62 for about two years. CNA 27 stated the resident was quiet most of the time and would only talk when hungry and that the resident loved food. CNA 27 stated the resident would randomly call out for his wife who visited him regularly. CNA 27 stated Resident 62 was cooperative, well-mannered and was pretty chill. CNA 27 stated he had not observed the resident grab and pinch staff or throw himself on the floor. CNA 27 added Resident 62 participated in his scheduled morning activities. CNA 27 stated Resident 62, though mostly quiet, would smile and wave at staff the resident recognized. On 7/29/26 at 4:20 P.M., a joint interview and record review was conducted with licensed nurse (LN) 29. LN 29 stated he had taken care of Resident 62 for two years. LN 29 stated Resident 62 had been very sweet. LN 29 stated the resident would refuse care a year ago, but was chill now and at times liked to be left alone. When LN 29 was asked if Resident 62 had any side-effects from quetiapine and sertraline, LN 29 responded, not that I know of. On 7/30/26 at 10:03 A.M., a joint interview and record review with LN 2. LN 2 stated she was familiar with Resident 62. LN 2 stated Resident 62 was very quiet but ate well. LN 2 opened the resident's electronic medical record and reviewed Resident 62's Psychotropic Medication Monitoring flowsheet (behavior monitoring documentation) for July 2026. LN 2 acknowledged that Resident 62's targeted behaviors monitoring documentation for quetiapine and sertraline were not done on the following shifts: July 1, 2026-dayshift July 3, 2026-nightshift July 5, 2026-nightshift July 8, 2026-evening shift July 9, 2026-dayshift July 11, 2026-evening shift July 12, 2026- evening shift July 15, 2026-dayshift July 17, 2026-nightshift July 18, 2026-dayshift July 18, 2026 evening shift July 19, 2026-dayshift July 19, 2026 evening shift July 21, 2026-dayshift July 24, 2026-nightshift LN 2 stated Resident 62 targeted behaviors monitoring documentation should have been done every shift. The documentation was necessary to determine if the resident's medication doses would need to be changed. On 7/30/26 at 3:30 P.M., an interview was conducted with manager (MGR) 3. MGR 3 stated licensed nurses were expected to check psychotropic medication orders and to know which targeted behaviors to monitor. MGR 3 stated it would be difficult to assess the effectiveness of the medications and to determine if doses could be reduced if Resident 62's targeted behaviors were not monitored and documented. A review of the facility's policy titled, Patient Rights and Responsibilities, 01805, last revised 2/2026, indicated, .As a patient. you have rights.regarding your treatment.16. Receive care in a safe setting.17. Be free from restraints or seclusion of any form intended as a means of discipline.or for the mere convenience of staff or physicians. A review of the facility's policy titled, Monitoring of Antipsychotic Medications, 39103, last revised 2/2024, indicated, .B. When antipsychotic therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions. C. The continued need for and the effectiveness of the antipsychotic medication is reassessed. addressed in nursing notes in the resident's chart.

Based on observation, interview and record review, the facility failed to develop and implement an individualized care plan for one of 33 sampled residents (Resident 71) when Resident 71's repeated refusal of her dental paste (a soft moldable substance used in oral care) was not developed into an individualized care plan.This deficient practice had the potential to negatively affect Resident 71's dental health.Findings:A review of Resident 71's facility provided facesheet indicated the resident was admitted to the facility on [DATE].A review of Resident 71's History and Physical, dated 7/13/26, indicated a past medical history of functional quadriplegia (loss of ability to move all four limbs and trunk) and subarachnoid hemorrhage (bleeding in the brain). A review of Resident 71's medical record indicated Resident 71 had an order for sodium fluoride (used to prevent dental caries [tooth decay and cavities] and dental plaque [sticky film on teeth]) 1.1% (strength) dental paste, started 4/15/25. The order indicated to brush teeth with the dental paste two times daily for the prevention of dental plaque and caries.On 7/29/26 at 8:20 A.M., a joint observation and interview was conducted with Resident 71 in her room. Resident 71 was lying in her bed, awake, conversant. Resident 71 stated the resident's doctor ordered a dental paste for her. Resident 71 stated the dental paste was for this and then pointed to a black-colored upper left tooth.On 7/29/26 at 8:25 A.M., a joint interview and record review was conducted with licensed nurse (LN) 21. LN 21 stated she had worked with Resident 71 for a while and knew the resident well. LN 21 stated the resident had an order for a dental paste to be used twice daily. LN 21 stated Resident 71 had refused the dental paste multiple times. LN 21 reviewed Resident 71's medication administration record (MAR) for the month of July 2026. LN 21 acknowledged Resident 71 refused the dental paste 29 times. LN 21 reviewed Resident 71's care plan. LN 21 stated there was no care plan for the resident's repeated refusal of the dental paste.On 7/29/26 at 8:45 A.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 71's MAR for June 2026 and July 2026. LN 1 acknowledged Resident 71 refused the dental paste 31 times during June 2026 and 29 times during July 2026. LN 1 reviewed Resident 71's care plan and stated there was no care plan for the resident's repeated dental paste refusal. LN 1 stated there should have been a care plan developed and implemented.On 7/30/26 at 3:30 P.M., an interview was conducted with manager (MGR) 2. MGR 2 stated a care plan should be developed and implemented for known residents' behavior including the refusal of medications and treatment. MGR 2 stated through care planning, interventions would be identified to assure the residents' well-being.A review of the facility's policy titled, Care Plan/Interdisciplinary Care Conference, 39503, last revised 2/2025, indicated, .B. Plan of Care will be: 1. Developed and implemented.2. Based on assessments.chart review.and resident/patient.input.

Based on interview and record review the facility failed to ensure the dementia care plan for one of three residents (Resident 62) was revised and reviewed to reflect the resident's improved condition, current preferences, and individualized interventions following a change of behavior.This failure had the potential for Resident 62 to not receive person-centered care and individualized services necessary to address his current dementia-related needs and preferences.FINDINGS:A review of Resident 62's admission Record indicated Resident 62 was admitted to the facility on [DATE], with a diagnosis of G31.83 (Dementia, cognitive disorder).A review of Resident 62's dementia care plan, with a start date of 2/14/24, indicated, problem: Cognitive Loss/Dementia. Goal: I will return to baseline cognitive status and orientation. Assess and re-assess resident's level of orientation daily. Assess decision making ability. Assist resident with establishing a routine and adhering to it. Assess for mood changes. Provide resident/family information on diagnoses. Environmental precautions (confusion). Assess level of sensory function.On 7/28/26 at 9:25 A.M., an interview was conducted with licensed nurse (LN) 7. LN 7 stated she was very familiar with Resident 62. LN 7 stated that when Resident 62 was first admitted to the facility, he frequently exhibited dementia like behaviors including yelling, throwing himself on the floor, and pinching and grabbing himself and staff. LN 7 stated that over the past year, Resident 62's behavior had significantly improved, and he no longer exhibited those behaviors. LN 7 stated Resident 62 was now pleasant, could answer yes-or-no questions, and communicated his needs to staff. LN 7 further stated Resident 62 enjoyed participating in activities, spending time with his family, going on outings with his family, listening to music, and watching television.On 7/28/26 at 9:42 A.M., a concurrent interview and record review was conducted with LN 1. LN 1 reviewed Resident 62's dementia care plan and stated it was not individualized and lacked resident-specific interventions. LN 1 stated the care plan did not reflect Resident 62's current condition, including his improvement in dementia-related behaviors and his current preferences. LN 1 stated that, based on this care plan, she would not know how to provide individualized dementia care specific to Resident 62 because it did not accurately describe his current needs or appropriate interventions. On 7/28/26 at 10:01 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 reviewed Resident 62's dementia care plan and stated it was, outdated. LN 7 stated the care plan appeared to be based on Resident 62's admission and has not been updated to reflect his current dementia needs. LN 7 stated the care plan should have included individualized, resident- specific goals and interventions such as prompting Resident 62's ability to recognize family members and offering simple choices during care such as asking whether he would like a red shirt or a blue shirt.On 7/30/26 at 3:04 P.M., a concurrent interview and record review was conducted with nursing manager (MGR) 1. MGR 1 reviewed Resident 62's dementia care plan and stated it should have been revised when Resident 62 experienced an improvement in his dementia-related behaviors. MGR 1 stated the care plan should have reflected Resident 62's current preferences and meaningful interventions including his enjoyment of food, calling his wife, and listening to My Melodies music. MGR 1 stated the care plan was supposed to guide staff in delivering individualized care and communicated what mattered most to the residents.A review of the facility's policy titled Care Plan / Interdisciplinary Care Conference, revised February 2025, indicated, . A care plan will be. Based on assessments, MDS, chart review, transfer papers, and resident/ patient and family input. Reviewed and revised by IDT members as needed weekly, with significant changes, and at least quarterly.

Based on observation, interview and record review, the facility failed to provide treatment and care according to professional standards of practice for one of nine sampled residents when a physician's order to apply bilateral palm protector was not provided to a resident (88), reviewed for position and limited range of motion (ROM, a joint or body part cannot move through its normal range of motion). This failure had the potential to place Resident 88 at risk for worsening contractures (tightening of the muscles, tendons, skin, and joints). Findings: Resident 88 was admitted to the facility on [DATE], per the facility's Face Sheet. On 7/27/26 at 10:49 A.M., an observation was conducted of Resident 88 in his room. Resident 88 had a tracheostomy (opening into the windpipe from outside the neck) and was connected to oxygen. Resident 88 did not respond to his name. Resident 88's arms were exposed and observed Resident 88's bare hands and were stiff. A note above Resident 88's bed indicated, Bilateral palm protectors at all times except skin checks, RNA PROM [sic, Restorative Nursing Assistant Passive ROM] and during change of DRI-GO [antibacterial wicking sheet] in order to prevent skin breakdown and to facilitate positioning and prevent further contractures. Per Wound nurse, please make sure DRI-GO is in the hand. There was no activity going on with Resident 88 at the time of observation. On 7/28/26 at 10:08 A.M., a concurrent review of Resident 88's electronic medical record (EMR) and an interview was conducted with Licensed Nurse (LN) 31. LN 31 stated Resident was admitted with contractures and was on vegetative state per the physician's notes dated 2/17/26. LN 31 stated the physician order was to apply Bilateral palm protectors at all times except skin checks, RNA PROM [sic, Restorative Nursing Assistant Passive ROM] and during change of DRI-GO [antibacterial wicking sheet] in order to prevent skin breakdown and to facilitate positioning and prevent further contractures. Per Wound nurse, please make sure DRI-GO is in the hand was a recommendation from the wound nurse. LN 31 stated the attending physician okayed and ordered it for Resident 88. LN 31 stated the DRI-GO was paper towel like cloth to absorb moisture and prevent fungal infection. LN 31 stated the DRI-GO should always be in Resident 88's hands. On 7/29/26 at 3:40 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 31. CNA 31 stated she was familiar with Resident 88. CNA 31 stated Resident 88 was non-responsive and required total dependence on staff. On 7/29/26 at 4:50 P.M., a concurrent review of Resident 88's EMAR and interview was conducted with LN 32. LN 32 stated LNs were responsible to apply the palm protector and the DRI-GO to the residents. LN 32 stated the DRI-GO and the palm protector should be always applied to Resident 88's hands to prevent moisture and prevent further contractures of Resident 88's hands. On 7/30/26 at 10:43 A.M., an interview was conducted with Manager (MGR) 2. MGR 2 stated nurses should follow the physician's order to prevent worsening of contractures and maintain skin integrity for Resident 88. A review of the facility's policy and procedure titled, Hand, Care of Contracture, effective date 5/25, indicated, Purpose: To maintain cleanliness, injury of skin breakdown and to prevent progression of the contracture. Procedure.10. Each shift will check all resident with contracted hand to ensure handrolls are in place and are appropriately applied. The facility did not provide policy and procedure regarding following physician's orders.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided in accordance with professional standards of practice for two out 33 sampled residents (Resident 101 and 62) when:1. Licensed nurse (LN) 22 did not follow the controlled substance (medications that carry a risk of physical and psychological dependence [experiencing unpleasant symptoms if a medication is suddenly stopped], misuse, abuse and diversion [unlawful distribution or use]) waste process for Resident 101's diazepam (used to calm the nerves), a controlled medication.2. Resident 62's insulin lispro (a type of insulin, used to control high blood sugar) was administered without a corresponding documented meal intake percentage.These deficient practices had the potential for diversion and harmful medication errors.Findings: 1. A review of Resident 101's facility provided Patient Demographics indicated the resident was admitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy (an opening through the skin to the stomach for insertion of a feeding tube, a device used to administer food and medication to individuals with difficulty swallowing), tracheostomy (a surgical opening in the neck to the windpipe, used to help with breathing) and pneumonia (a lung infection).A review of Resident 101's medical record indicated an order for diazepam 2 mg tablet every 6 hours via the feeding tube, dated 4/10/26.On 7/28/26 at 12 P.M., a medication administration observation was conducted with LN 22 in Resident 101's room. LN 22 prepared medications for Resident 101 including diazepam 2 mg tablet, one tablet that was crushed. After administration of a liquid medication followed by 60 milliliter (ml, a unit of volume) water through Resident 101's gastrostomy tube (GT, a type of feeding tube), Resident 101 vomited. LN 22 stated she would not be able to administer the crushed diazepam tablet and needed to waste it. LN 22 carried the medicine cup containing the medication to the Subacute 2 medication room. LN 22 was observed pouring the medication into a narcotic (controlled substances, such as opioids, potent painkillers) waste container that was affixed to the wall. LN 22 was conversing with another LN in the room who was sitting, facing away from LN 22. When asked if she had a witness to the diazepam waste, LN 22 stated the other LN was in the room. LN 22 then left the medication room and returned to her medication cart.On 7/29/26 at 3:45 P.M., a joint interview and record review was conducted with LN 80. LN 80 stated controlled substances were to be documented and recorded in the Pyxis machine (a computer-controlled cabinet that stores and dispenses medications). LN 80 reviewed Resident 101's medication record in the Subacute 2 Medication Room Pyxis. LN 80 stated there was no documentation of a waste for Resident 101's diazepam 12 P.M. dose for 7/28/26. LN 80 stated the medication was not wasted in the Pyxis.On 7/30/26 at 3:30 P.M., an interview was conducted with manager (MGR) 2. MGR 2 stated the process for controlled substance waste should have been followed for Resident 101's diazepam. MGR 2 stated nursing staff were expected to waste a controlled medication by pouring it into the narcotic waste bin with a witness and record the waste in the Pyxis machine with a witness.A review of the facility's policy titled, Medication Administration, 30035.99, last revised 8/2024, indicated .To provide guidelines for the safe and accurate administration of medications to patients.A. PRIOR To any medication administration.2. The provider's medication order(s) will be reviewed.M. Wasted Narcotic/Controlled Substance: all wasted narcotics/controlled substances will be documented in Pyxis .The primary nurse is responsible to document the medication name and amount wasted. A second nurse will verify and witness the waste with the primary nurse.A review of the facility's policy titled, Controlled Substances, 43089.99, last revised 2/9/26, indicated, .M. Disposal of Controlled Substances.2. Pyxis areas: Information for wastage must be entered into the Pyxis. and witnessed and co-signed by two licensed, authorized staff. 3. Witness of Controlled Substance Waste a. Verify that the dose removed/dispensed=[equals] dose to be administered or compounded + [plus] dose to be wasted.d. Document witness of waste.2. A review of the facility provided facesheet for Resident 62 indicated the resident was admitted to the facility on [DATE].A review of Resident 62's History and Physical, dated 10/30/25, indicated past medical history of diabetes mellitus (a condition of having high blood sugar), Lewy body dementia (a brain disease affecting thinking, mood and behavior), functional quadriplegia (loss of ability to move all four limbs and trunk) and depression (a mood disorder causing sadness). A review of Resident 62's medical record indicated an order for insulin lispro (a type of insulin, used to control high blood sugar) injection seven units to be given three times daily after meals. The order included an administration instruction, EATING RESISTANT SCALE MEAL DOSE.if resident ate < 50% [less than 50 percent], hold [do not administer] this meal coverage [dose]. with a start date of 7/7/26.On 7/30/26 at 9:33 A.M., a joint interview and record review was conducted with LN 5 of Resident 62's electronic medical record. LN 2 reviewed Resident 62's insulin orders and stated the resident's meal consumption percentages were not consistently documented. LN 5 acknowledged that in the date range of 7/7/26 to 7/30/26, the resident received seven units of insulin lispro without a meal intake documented on the following dates and mealtimes:7/14/26 breakfast7/15/26 breakfast7/19/26 dinner7/21/26 lunch7/29/26 lunch 7/29/26 dinnerLN 5 stated Resident 62's meal intake should have been recorded every day for breakfast, lunch and dinner. LN 5 stated staff should have documented the meal percentages consumed and followed the resident's insulin order accordingly.On 7/30/26 at 3:30 P.M., an interview was conducted with MGR 2. MGR 2 stated she expected nursing staff to follow medication orders including parameters for insulin. MGR 2 stated it was the responsibility of the licensed nurses to know their residents' meal intake percentages and follow the ordered insulin sliding scale (a predetermined dose based on meal consumption) for meal intake . MGR 2 stated staff needed to ensure meal intake documentation was done. MGR 2 stated Resident 62 could have experienced hypoglycemia (low blood sugar) if he ate below 50 percent of his meals and was given insulin.A review of the facility's policy titled, Medication Administration, 30035.99, last revised 8/2024, indicated .To provide guidelines for the safe and accurate administration of medications to patients.A. PRIOR To any medication administration.2. The provider's medication order(s) will be reviewed.A review of the facility's policy titled, Pharmacist Management of Subcutaneous [injected into the fat under the skin] Insulin; Adults, 43159, last revised 7/2026, indicated, .Purpose.B. To provide instructions for a systematic approach to promote optimal glycemic [level of blood sugar in the blood].1. Factors that can increase insulin needs.increased caloric intake [amount of food eaten] .2. Factors that can decrease insulin needs.decreased caloric intake (tube feeds or meals) .2. Adjustments to the Meal Dose are reviewed and adjusted daily as required.H. Monitoring: 1. Utilize the Electronic Health Record to review .all insulin doses, nutrition status/caloric intake.that increase/decrease insulin needs.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%, when three medication errors occurred out of 33 opportunities during the medication administration for two of eight sampled residents (Residents 71 and 101). The medication error rate was 9.09 %.These failures had the potential for Resident 71 and 101 to experience negative side effects and decreased therapeutic benefit of their medications. Findings:1. A review of Resident 71's facility provided facesheet indicated the resident was admitted to the facility on [DATE].A review of Resident 71's History and Physical, dated 7/13/26, indicated a past medical history of functional quadriplegia (loss of ability to move all four limbs and trunk) and subarachnoid hemorrhage (bleeding in the brain).On 7/28/26 at 9:02 A.M., a medication administration observation was conducted with licensed nurse (LN) 21. LN 21 prepared and administered two medications to Resident 71: gabapentin (medication for nerve pain and seizure (a condition characterized by abnormal electrical activity in the brain) 300 milligrams (mg, a unit of weight), 1 tablet by mouth, and levetiracetam (medication to treat seizures)100 mg per one milliliter (ml, unit of measure for volume) (concentration), 10 ml by mouth.On 7/28/26 at 11 A.M., a record review was conducted with manager (MGR) 3 of Resident 71's medical record. Resident 71's medical record indicated active orders due at 9 A.M. for the following medications:sodium fluoride dental paste (a prescription used to prevent dental caries [tooth decay and cavities] and dental plaque [sticky film on teeth]) 1.1% (strength), started 4/15/25. The order indicated to brush teeth with the dental paste two times daily at 9 A.M and at 9 P.M., for the prevention of dental plaque and caries andaspirin (medication used to prevent blood clots) chewable tablet 81 milligram (mg, a unit of weight) by mouth two times daily, to be given at 9 A.M. and at 9 P.M, for blood clot prevention, started 2/22/26.The medication administration of the dental paste and aspirin was not observed. Further review of Resident 71's medical record indicated LN 21 documented the medications as refused by the resident.On 7/29/26 at 8:20 A.M., a joint observation and interview was conducted with Resident 71 in her room. Resident was lying in bed, awake, and alert. Resident 71 stated she did not remember being offered the dental paste on her 7/28/26 morning medication administration with LN 21.On 7/29/26 at 8:25 A.M., a joint interview and record review was conducted with LN 21. LN 21 reviewed Resident 71's medication administration record (MAR) for 7/28/26. LN 21 stated she assumed the resident would refuse the aspirin and the dental paste. LN 21 stated she documented the medications as refused by Resident 71. LN 21 stated she should have offered the medications to Resident 71. LN 21 stated assuming the resident would refuse and documenting based on her own assumption, was an error on her part. 2. A review of Resident 101's facility provided Patient Demographics indicated the resident was admitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy (an opening through the skin to the stomach for insertion of a feeding tube, a device used to administer food and medication to individuals with difficulty swallowing), tracheostomy (a surgical opening in the neck to the windpipe, used to help with breathing) and pneumonia (a lung infection).On 7/28/26 at 12 P.M., a medication administration observation was conducted with LN 22 in Resident 101's room. LN 22 prepared the following medications for Resident 101: potassium chloride (a mineral) 20 milliequivalent (mEq, a unit of measure of minerals) per 15 ml oral solution (in a liquid state), 30 ml, with a start date of 7/28/26diazepam (medication to treat anxiety [a feeling of fear and worry] and muscle spasms) 2 mg tablet, one tablet crushed with a start date of 4/10/26 and propranolol (medication to lower blood pressure) 40 mg, one tablet crushed with a start date of 7/28/26LN 22 was then observed to administer the potassium chloride 30 ml via Resident 101's gastrostomy tube (GT, a medical device inserted through the skin of the abdomen to the stomach to deliver food, liquids and medications) followed by 60 ml of water.On 7/29/26 at 9:31 A.M., a joint interview and record review of Resident 101's medical record was conducted with LN 75. Resident 101's medical record indicated an active order of potassium chloride 20 mEq/15 ml oral solution 40 mEq two times daily for two doses. The order had an administration instruction, Must be diluted, mix with juice or water. LN 75 stated potassium chloride should be mixed and diluted with water before administration as indicated in the medication order.On 7/29/26 at 10:27 A.M., a joint interview and record review was conducted with LN 22. LN 22 reviewed Resident 101's potassium chloride order and stated the medication needed to be diluted before administering to the resident. LN 22 stated she did not follow the administration instructions for dilution when she administered it to Resident 101 on 7/28/26. LN 22 reviewed the facility's drug reference ([NAME]-Drug, a nationally renowned drug information resource) for potassium chloride which indicated to not administer undiluted. On 7/30/26 at 3:30 P.M., an interview was conducted with MGR 2. MGR 2 stated LNs were expected to follow medication orders and to clarify with pharmacy and with the charge nurse if unclear with orders. MGR 2 also stated LNs could not assume that residents would refuse medications based on previous residents' refusals. MGR 2 stated LNs documentation should be factual and cannot be based on assumptions.A review of the facility provided drug information for potassium chloride indicated, .Oral solution.Do not administer full-strength; must be diluted prior to administration. To avoid gastrointestinal irritation, the manufacturer recommends diluting potassium chloride oral solution in at least 120 ml.of cold water.A review of the facility's policy titled, Medication Administration, 30035.99, last revised 8/2024 indicated .To provide guidelines for the safe and accurate administration of medications to patients.A. PRIOR To any medication administration.2. The provider's medication order(s) will be reviewed.F. All administered medications will be documented on the administration record (MAR).G. All scheduled medications will be administered at times specified on the MAR.T. All patients have the right to refuse a medication being offered to them.5. Medication Confirmation: a. Observe for any alerts.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored safely according to acceptable standards of practice when: 1. Resident 71's expired aloe vera (used to moisturize sunburned and dry skin) gel (in a semi-solid physical state) was observed stored in one of one inspected treatment carts (Villa Treatment Cart). 2. An opened budesonide (used to treat breathing conditions) foil pouch in one of six inspected medications carts (Subacute [a medical care unit] 1 Medication Cart 4) did not have an open date recorded. In addition, an opened arformoterol tartrate (a respiratory medication) foil pouch did not have a beyond use date (BUD, the final date or time a medication can be safely used before it potentially loses strength or grows harmful bacteria) in one of two inspected Pyxis (a computer-controlled cabinet that stores and dispenses medications) refrigerators. These deficient practices had the potential to negatively alter the potency and efficacy of the medications.Findings: 1. On 7/27/26 at 11:35 A.M., a joint observation of the Villa Treatment Cart and interview with licensed nurse (LN) 2 was conducted. Resident 71's aloe vera gel was observed stored in the treatment cart and had an expiration date of 6/19/26. LN 2 stated Resident 71's aloe vera gel was expired. 2a. On 7/27/26 at 3:20 P.M., a joint observation of the Subacute 1 Medication Cart 4 and interview with LN 1 was conducted. An opened budesonide foil pouch containing multiple medication doses was observed stored inside the medication cart. The pouch had an affixed label that indicated, .DATE OPENED_______.DISCARD AFTER 14 DAYS. There was no date recorded next to DATE OPENED. The manufacturer's product instructions on the pouch indicated to discard doses 14 days after opening the pouch. LN 1 acknowledged the manufacturer's product instructions. LN 1 stated the opened date should have been recorded on the pouch to know how long the medication was safe to use. 2b. On 7/29/26 at 10:45 A.M., a joint observation of the Subacute 2 Medication Room Pyxis refrigerator and interview with LN 3 was conducted. Inside the Pyxis refrigerator was an opened pouch of arformoterol tartrate doses. The pouch had an affixed label that indicated, .DISCARD AFTER 42 DAYS EXP. [expiration] DATE______. There was no expiration date recorded. The manufacturer's instructions on the pouch, indicated to discard aformoterol tartrate six weeks (42 days) after the pouch was opened. LN 3 acknowledged the manufacturer's product labeling. LN 3 stated the pouch should have the expiration date recorded. LN 3 stated the aformoterol tartrate doses in the opened pouch could not be used since it was unknown when the pouch was first opened and when the medication would expire. On 7/30/26 at 3:30 P.M., an interview was conducted with Manager (MGR) 2. MGR 2 stated licensed nurses were expected to check medications for expiration dates and proper labeling. MGR 2 stated there should be no expired medications and treatment products administered to the residents. MGR 2 stated all medications including respiratory medications and treatment gels should have a BUD and expiration date to assure medication safety and potency. A review of the facility's policy titled, Labeling of Medications, 43021.99, last revised 12/2025, indicated, .5. All drugs or compounds should shall have the beyond use date clearly indicated on the label.

Based on observation, interview and record review, the facility failed to ensure the Food and Nutrition Services (FNS) staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to the facility's policies and standards of practice when [NAME] (CK) 2 improperly calibrated a food thermometer. This failure had the potential to result in obtaining inaccurate food temperature and may cause food borne illness for the facility's residents who consume food from the kitchen. Findings: On 7/29/26 at 12:35 P.M., an observation and interview were conducted with CK 2. CK 2 stated he calibrated the food thermometer and knew how to calibrate the food thermometer. CK 2 took a plastic clear pitcher and dipped the pitcher into the pot on the stove. CK stated he would use the boiling water, and he was looking for the temperature to be at 212-degree Fahrenheit ( F). CK 2 dipped the food thermometer into the clear pitcher with hot water, and the temperature reading was 205 F. CK 2 stated he would use the cold water instead of the boiling water. CK 2 took another clear pitcher, went to the ice machine, filled up the pitcher with ice cubes then dipped the thermometer into the ice cubes. When asked CK 2 if he needed to put some water on the pitcher with ice, CK 2 stated it was not required since he was checking the ice and was looking at the temperature to be at 33 F. FNS Manager (FNSM) came and stated to CK 2 he needed to put some water to the pitcher of ice. On 7/30/26 at 3:03 P.M., an interview was conducted with FNSM and Area Clinical Manager (ACM). FNSM stated the kitchen staff should have known how to calibrate the thermometer to ensure foods were served at proper temperature to prevent pathogen like salmonella (bacteria) and prevent food borne illnesses. Per the Supplement to the 2022 Food Code, chapter 3-47, titled Utensils, Equipment and Vending, . Food and nonfood-contact surfaces cleanable, properly designed, constructed and used. Equipment must be properly used and in proper adjustment, such as calibrated food thermometers. Per review of the facility's document titled, Food Safety Training, Food Thermometers - Use, Calibration and Verification, Thermometer Calibration & Verification - Ice Point, Calibrate means to make, adjust or check the setting of some type of control such as a thermometer while verification ensures the accuracy of the thermometer reading when used for taking temperature. Over time, changes usually occur to thermometers as a result of temperature cycling and day-lo-day handling. By calibrating them, we can ensure that they are accurate when we are taking temperature measurements of the food that we serve. Follow these steps to calibrate a thermometer, 1. Ice Point Method: A. Fill a container with crushed ice. Add water until the container is full. Stir the ice water slurry well.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to facility policy and standards of practice when: 1. Kitchen Staff (KS) 1 did not perform handwashing upon entering the kitchen. 2. Kitchen Staff (KS) 2 did not clean and sanitize the thermometer probe appropriately. 3. Food items were not stored appropriately when: a. Dry storage food items were not labeled and dated. b. Canned items in the dry storage were dented and not removed from the food storage. c. Outdated/expired food items in the storage room were not discarded on or before the expiration date. These failures exposed the residents to contaminated food and unsanitary practices, which had the potential to place them at risk for developing a foodborne illness. Findings: 1. An observation was conducted on 4/29/25 at 7:47 A.M. with KS 1 in the kitchen. KS 1 entered the kitchen with a cart. KS 1 did not wash her hands upon entering the kitchen. KS 1 emptied the food tray from the cart to the dirty sink area and later touched the clean and sanitized trays and cups. A concurrent observation and interview were conducted on 4/29/25 at 7:50 A.M. with the Food and Dietary Manager (FDM). The FDM approached KS 1, reminded staff to perform hand hygiene, and placed the touched tray and cups in the dirty area. The FDM acknowledged that KS 1 did not wash her hands upon entering the kitchen area. The FDM stated that everyone should perform handwashing upon entering the kitchen area. According to the 2022 US FDA Food Code, Section 2-301.11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section 2-301.14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities . Employees must wash their hands after any activity which may result in contamination of the hands . A review of facility's policy and procedure titled, Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .C. Handwashing and Glove Use .1. Hands are washed by all FANS (Food and Nutrition Services) employees: a. When beginning work . Between handling soiled dishes or equipment and handling clean food or utensils . 2. A tray-line observation was conducted in the kitchen on 4/30/25 at 11 A.M. KS 2 removed a thermometer probe from its container and checked the temperature of the cooked fish. After checking the temperature, KS 2 dipped the tip of the thermometer probe into the red bucket (container of sanitizer used for cleaning the kitchen surfaces) and wiped the thermometer probe with a towel. An interview was conducted on 4/30/25 at 12:15 P.M. with the Registered Dietitian Operations Manager (RDOM). The RDOM stated that the thermometer probe should be cleaned with thermometer wipes or sanitizer specifically for the thermometer probe. The RDOM stated the sanitizer in the red bucket cannot be used to clean the thermometer probe, to prevent cross contamination of food-borne pathogens. An interview was conducted on 4/30/25 at 2:30 P.M. with KS 2. KS 2 stated that he was in a hurry and later realized that he cleaned and sanitized the thermometer probe with the sanitizer in the red bucket. KS 2 stated he should have used wipes or the sanitizer specifically for the thermometer probe, to prevent cross contamination. According to the 2022 US FDA Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .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 microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .E. Equipment/ Sanitation .2. All kitchen equipment, such as choppers, grinders, mixers, slicers and knives are washed and sanitized between each use . 3. A joint kitchen observation and interview were conducted on 4/29/25 at the dry storage room and the walk-in refrigerator with the Food and Dietary Manager (FDM). The following items were observed: a. An undated box of doughnuts was found on top of the storage shelf. In addition, one canned item was not labeled with a date. The FDM stated that the box of doughnuts should include a date to indicate when it was placed in the storage room. The FDM acknowledged that the items stored in the food storage room should have been labeled, with a date, but were not. The FDM stated it was important to ensure stored items included labels, date and time, for the safety of residents from foodborne illness. According to the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .G. Food Storage/Disposal . 1. All foods are labeled, covered and dated when stored .Outdated foods are discarded . b. Three (3) canned items were dented: 1 can of [NAME] Pear halves; 1 can of Diced Peaches; and 1 unlabeled can. The FDM acknowledged that the dented canned items should have been removed from the food storage to prevent use of contaminated food. According to the 2022 US FDA Food Code, section 3-101.11 (Annex), .dented, pitted, and rusted cans can potentially be a serious hazard. According to the 2022 US FDA Food Code, section 3-202.15 (Annex), .damaged cans may allow the entry of bacteria or other contaminants and must be returned. c. A container of dry peppers with dates 4/14 - 5/14, and multiple vegetable containers in the refrigerator had expired dates. The FDM stated that the expired food items should have been removed prior to the expiration dates. The FDM stated it was important to ensure expired food items were removed from the food storage room and discarded, for the safety of residents from food borne illness. According to the 2022 US Food and Drug Administration (FDA) Food Code, section 3-501.17 titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Manufacturer's use-by dates, It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages. Although most use-by and sell-by dates are not enforceable by regulators, the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. According to the 2022 US FDA Food Code, section 6-404.11 titled Segregation and Location, Vegetable storage: Even if foods are held long enough, even under proper refrigeration, extended shelf life may be a problem. A study on fresh vegetables inoculated with harmful contaminants and the growth of these contaminants increased during that extended storage period . A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .G. Food Storage/Disposal .1.All foods are labeled, covered and dated when stored .Outdated foods are discarded .

Based on observation, interview, and record review, the facility failed to ensure a urethral catheter (UC-flexible tube which passes through the urethra and into the bladder to drain urine) was appropriately positioned for one of four sampled residents (Resident 81). This failure had the potential to result in health complications for Resident 81. Resident 81 was admitted to the facility on [DATE] with medical diagnoses including paraplegia (inability to move lower extremities) and neurogenic bladder (loss of bladder control) per the History and Physical (H & P; assessment/examination). During an observation of Resident 81 on 4/29/25 at 8:17 A.M., Resident 81's urinary drainage bag (UDB- container to collect urine) was hanging on the bedside rail, with the UC tube looped (curled) back towards Resident 81. During a follow-up observation and interview with Clinical Lead (CL) 1 on 4/29/25 at 9:30 A.M., Resident 81's UDB was still hanging on the bedside rail and was within the height of Resident 81's waist level. CL 1 acknowledged that Resident 81's UDB should had been placed below Resident 81's bedside rails to prevent the UC tube from looping and prevent the urine from flowing back to Resident 81's bladder. During an interview with Clinical Manager (CM) 1 on 5/1/25/at 3:30 P.M., the DON acknowledged that UDB's should hang below the bladder level to prevent infection and complications. The facility's policy titled, Nursing Skills (undated), indicated Catheter Care .11. Secure the drainage bag and tubing below the level of the bladder.

Based on interview and record review, the facility failed to ensure effective pain management for two of four sampled residents (Resident 81 and Resident 77) when: 1. Resident 81 did not receive the prescribed medication order for severe pain. 2. Resident 77's severe pain was not reported to the physician. This failure had the potential for Residents 81 and 77 to have unrelieved pain. Findings: 1. Resident 81 was admitted to the facility on [DATE] with diagnoses which included coccyx (tailbone) pressure injury and paraplegia (inability to move lower extremities). On 4/29/25 at 8:18 A.M., an interview was conducted with Resident 81. Resident 81 stated that the pain medication that the facility was giving to him, did not work in the past. A review of Resident 81's physician orders indicated: Norco 5-325 mg (milligrams) give one tablet by mouth every four hours as needed for moderate 5-6 (pain level) pain . Norco 10-325 mg give one tablet by mouth every six hours as needed for severe 7-10 (pain level) pain. On 5/1/25 at 9:01 A.M., a joint interview and record review was conducted with Clinical Lead (CL) 1. Resident 81's pain assessment dated [DATE] at 8:30 P.M. indicated that Resident 81 complained of severe pain. Resident 81 received one Norco 5-355 mg tablet. CL 1 acknowledged that Resident 81 should have received Norco 10-325 mg, one tablet for severe pain, as ordered. 2. Resident 77 was admitted to the facility on [DATE] with diagnoses which included severe discitis (inflammation of the spine discs) and osteoarthritis (inflammation of the joint that causes pain). On 4/29/25 at 9:18 A.M., an interview was conducted with Resident 77. Resident 77 stated that his pain medications sometimes did not work. A review of Resident 77's physician orders indicated: Roxicodone 5 mg (milligrams) one tablet by mouth every four hours as needed for moderate 5-6 (pain level) pain. Roxicodone 10 mg one tablet by mouth every four hours as needed for severe 7-10 (pain level) pain. On 5/1/25 at 9:21 A.M., a joint interview and record review was conducted with CL 1. Resident 77's pain assessment on 4/4/25 at 2:04 P.M. indicated, Resident 77 complained of severe pain and was given Roxicodone 10 mg. A pain reassessment of Resident 77 was conducted on 4/4/25 at 2:20 P.M. and indicated Resident 77 still had severe pain. CL 1 acknowledged that the licensed nurse (LN) who reassessed Resident 77's pain level should have called the physician to report Resident 77's unrelieved severe pain. On 5/1/25 at 2:17 P.M., an interview was conducted with Clinical Manager (CM) 1. CM 1 stated that LNs should follow physician's medication order for managing resident's level of pain and that LNs should follow-up with the resident's physician if the pain was unrelieved after interventions. The facility's policy titled, Patient Screening, Assessment and Management of Pain revised 5/2/24 indicated, .J. Implement pain management interventions to achieve optimal patient functional status .L. The provider will be notified if pain remains above the acceptable level of pain following pain management interventions

Based on interview and record review, the facility failed to ensure nursing staff competency when one licensed nurse (LN) 1 did not complete the required abuse training. This failure had the potential to affect residents' care and treatment. Findings: During an interview with the Senior Specialist (SS) on 5/1/25 at 11:08 A.M., the SS stated that nursing personnel should complete a two-hour abuse training within the calendar year (January to December). A concurrent interview and record review with the Staffing Manager (SM) was conducted on 5/2/25 at 10:17 A.M. A review of LN 1's abuse training indicated LN 1 attended a one-hour classroom abuse training on 11/1/24. There was no indication on the employee profile, that LN 1 attended another abuse training course to complete the required two-hour abuse training. The SM acknowledged that LN 1 missed one hour of abuse training. The SM further stated that the training was conducted twice a year to reinforce the knowledge for staff to properly care for the residents. During an interview with Clinical Manager (CM) 1 on 5/2/25 at 2 P.M., CM 1 acknowledged that nursing staff should have completed abuse training as required. The facility's policy titled Elder Abuse - Identification and Reporting revised 1/10/25 indicated, .J. Special staff meetings and training will be held semi-annually.

Based on interview and record review, the facility failed to ensure that irregularities noted by the pharmacist on the monthly regimen review (MRR) were addressed timely and documented consistently in the medical record for 1 of 30 residents (Resident 51). This failure had the potential to affect and delay interventions necessary for the resident's care and well-being. Findings: Resident 51 was admitted to the facility on [DATE] with diagnoses which included psychosis (mental disorder characterized by a disconnection from reality) and Down Syndrome (genetic disorder causing developmental delays) per undated admission Records. A review of Resident 51's Physician orders medication orders indicated Trazodone (antidepressant medication) tablet, 50 mg, oral, every night ordered on 9/18/24; Aripiprazole (antipsychotic medication) tablet, 15 mg, oral, daily ordered on 9/18/24. A review of the facility's Monthly Regimen Review (MRR) binder dated 9/2024 to 4/2025 was conducted on 5/1/25. A list of residents reviewed for MRR was not consistently available in the binder. A review of the facility's MRR binder of written reports with pharmacist's recommendations and irregularities dated 9/2024 to 4/2025 was conducted on 5/1/25 and indicated an incomplete list of written reports. A review of Resident 51's Pharmacy Consultant's MRR written reports with pharmacist's recommendations and irregularities dated 9/2024 to 4/2025 was conducted. On 9/26/24: Consultant Pharmacist Communication to Nursing indicated, Please remind doctor to review and sing med orders via '30-day med reviews by provider', and Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh[behavior] date. On 10/20/24: Nursing Recommendation from Pharmacist indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh (behavior) date.; Consultant Pharmacist Communication to Nursing indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh date. On 11/25/2024: Nursing Recommendation from Pharmacist indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh date. On 12/17/24: Consultant Pharmacist Communication to Nursing indicated, Patient is on routine and/or PRN (pro re nata - as needed) opioid. Please eval (evaluate) and consider taper down dose or usage, eg (exempli gratia - for example) from 2 tabs to 1 tab, freq (frequency) change to q (every) 12 h (hour) instead of q4h prn, etc . Please add to order check and hold if RR<12. Nursing Recommendation from Pharmacist indicated, Patient is on routine and/or PRN opioid. Please eval and consider taper down dose or usage, eg from 2 tab to 1 tab, freq change to q 12h instead of q4h prn, etc. On 1/23/25: Nursing Recommendation from Pharmacist indicated, RE: Meloxicam 7.5 mg (milligrams). Please clarify the above hold order to either DC (discontinue) or restart asap (as soon as possible) to avoid confusion and error. On 2/20/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. Consultant Pharmacist Communication to Physician indicated, 30 days recap - reviewed all orders and approved for next 30 days. Provider must reviewed and approved all orders monthly for next 30 days. Please sign 30 days recap section as documentation . Consultant Pharmacist Communication to Nursing indicated, RE: wound dressing paste. Please provide us a stop date ., or Indefinitely for . or .until healed. On 3/4/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. Consultant Pharmacist Communication to Nursing indicated, RE: wound dressing paste. Please provide us a stop date ., or Indefinitely for . or .until healed. On 4/16/25: Consultant Pharmacist Communication to Physician indicated, Would you agree to have a ***TSH level soon and q6 (every six) months to monitor *** levothyroxine treatment? On 4/25/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. An interview and record review were conducted on 5/1/25 at 1 P.M., with Clinical Manager (CM) 1. CM 1 stated that the MRR report and binder were not readily available and complete. CM 1 stated that Resident 51's Consultant Pharmacist's written reports communication to Physician and Nursing were either not responded and documented, responded with done, but did not clarify what was done, and was not documented in the resident's medical record. CM 1 acknowledged that the MRR report should have been readily available and complete, and the written reports of the Pharmacy Consultant should have been addressed and acted upon. A review of facility's policy and procedure titled Medication Regimen Review (MRR) Report and Nursing Documentation last reviewed on 5/4/23 indicated, I. Purpose: To facilitate the safe and effective use of medication, the pharmacist will review the medication regimen of each patient monthly and report, in writing, any irregularities . III. Text: A. The pharmacist reviews each patient's medication regimen .to determine if any irregularities exists or recommendations are needed . G. The consultant pharmacist medication regimen review and nursing documentation review reports are processed as follows: 1. Physician Report/Communication Note: a. The report or communication note is provided by the consultant pharmacist or facility to the Director of nursing or his/her designee and responsible physician, as needed within 7 working days of the review. The Report of Communication note is forwarded to Medical Director monthly . b. The physician shall provide a written or verbal response to the report slash communication to the facility within one month after the report is forwarded . If. Physician fails to provide a written or verbal response, the facility will continue to follow up on report until such time as response is noted . c. A copy of the report/communication note is kept by the facility until the nursing response or physician's response is returned . d. The physician's response is provided to the consultant pharmacist for review and then filed by the facility. e. The facility maintains copies of signed reports, communication and file for at least one year.

Based on observation, interview and record review the facility failed to ensure infection control practices were implemented for one of 80 residents (Resident 48) when a trash can with a hanging urine container (UC) was observed on a bedside table, close to Resident 48's tumbler (drinking cup). This failure had the potential to result in the spread of infection and cross contamination that may affect Resident 48 and/or care providers. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- disease that can be spread to other individuals) and impaired mobility, per Resident 48's admission record. During a concurrent observation and interview with Clinical Lead (CL) 1 on 4/29/25 at 8:24 A.M., Resident 48's trash can with a hanging UC was observed on the bedside table, close to Resident 48's tumbler. CL 1 stated that urine spillage from the UC could potentially contaminate another person. CL 1 acknowledged that the trash can should not have been placed on the bedside table, and that the UC should not have been left next to Resident 48's tumbler. During an interview with Clinical Manager (CM) 1 on 5/2/25 at 2:02 P.M., CM 1 stated that trash cans should not be placed on the resident's table, and that UC and dirty materials should be kept away from resident's personal items to minimize the spread of infection. Review of Centers for Disease Control and Prevention (CDC) guideline dated 4/3/24 indicated Infection Control Basics .Make use of common-sense practices. Properly handle, clean and disinfect patient care equipment, tables

Based on observation, interview and record review, the facility failed to ensure kitchen staff stored and served food in a safe manner when: 1. The ice machine bin lid was open, exposing ice to potential contamination, and, 2. Breakfast trays were served to residents prior to food temperatures being documented. These failures had the potential to cause cross-contamination and expose residents to the risk of foodborne illness. Findings: 1. On 5/13/24 at 7:46 A.M., an observation of the kitchen was conducted with the General Manager (GM). A large ice machine and bin was located inside the kitchen entrance. The ice machine bin had a brown plastic cover, which was in an upright position, exposing the ice. On 5/13/24 at 7:48 A.M., an interview was conducted with the GM. The GM stated the lid to the ice machine should be kept closed to keep the ice from becoming contaminated. The GM stated leaving the lid open had the potential to contaminate the ice. Per a facility document, effective 3/1/24 and titled Hazard Management & Prevention, Ice Handling, Policy: The Food and Nutrition Services Department prepares and serves ice under strict procedures. Purpose: To prevent the transmission of disease .Cover the container properly. 2. On 5/13/24 at 7:58 A.M., a concurrent observation, interview and record review was conducted with [NAME] 1, and the Executive Chef (EC). [NAME] 1 had completed preparing breakfast trays on the trayline. The temperature log was reviewed for the foods which had been served, and the temperature log was blank. [NAME] 1 stated he had checked the temperatures prior to serving any food, but had written the temperatures on a piece of paper rather than the temperature log. [NAME] 1 stated he was unable to find the piece of paper. Per the EC, it was his expectation temperatures were documented on the temperature log prior to service. The EC stated it was not safe to serve foods without taking temperatures, as it could cause foodborne illness. On 5/16/24 at 2 P.M., an interview was conducted with the GM. The GM stated it was her expectation all food temperatures were documented on the temperature log prior to serving any foods, to prevent foodborne illness. Per a facility policy, revised 4/1/22 and titled Food Safety Management System, .Hot and Cold Holding .Classification: Critical .Monitoring Activity: Service - Take temperatures at the time food is placed in hot/cold holding for service .Forms and Record Keeping: Required: Hot/Cold Holding .Cold foods must be held and served at a temperature of 40 degrees or below, Hot foods must be held and served at a temperature of 140 degrees or above .

Based on observation, interview and record review, the facility failed to ensure the prevention and spread of infection when: 1. Family members (FM) of Resident 80 were not wearing Personal Protective Equipment (PPE, special equipment such as gowns, masks and gloves designed to protect staff and patients from infection risk) while in a room requiring PPE, 2. Staff entered a resident room identified as contact precaution (preventing the spread of germs by using PPE) without wearing PPE, 3. Staff brought a medication container inside a contact isolation room and returned the unsanitized container back in the medication cart, and, 4. Staff did not perform hand hygiene (handwashing with soap and water or use of alcohol-based hand rub) before putting on gloves and removing gloves These failures had the potential to spread infection to residents, staff, and/or visitors. Findings: 1. Resident 80 was admitted to the facility on [DATE], per the facility Facesheet. On 5/13/24 at 11:49 A.M., an observation of Resident 80's room was conducted. Outside of the room, a sign in English directed staff to wear PPE if they would touch the patient, her clothing or bedding. A small cart containing the PPE was located outside of the room. On 5/13/24 at 11:51 A.M., a concurrent observation and interview was conducted in Resident 80's room. Resident 80 was in bed, not responding to questions. Resident 80's FM's were sitting at the bedside, holding Resident 80's hands and touching Resident 80's hair. Neither FM was wearing PPE. FM 1 stated he had not been told to wear PPE while visiting his family member. FM 1 stated his English was not good and he had not read the sign on the door. On 5/13/24 at 12 P.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 80 was assigned to him that day. LN 11 stated he was aware Resident 80 was in isolation due to an infection, and the sign outside the door applied to anyone who touched Resident 80, not just staff. LN 11 stated it was his responsibility to ensure visitors and staff wore PPE when touching Resident 80. LN 11 stated PPE was necessary to minimize the transfer of germs to and from Resident 80. LN 11 stated he had not educated the visitors before they entered Resident 80's room, but he should have. On 5/15/24, a record review was conducted. Resident 80's physician ordered Isolation Precautions to be initiated on 4/17/24. On 5/16/24 at 2:55 P.M., an interview was conducted with Manager 2 (MGR 2). MGR 2 stated she was responsible for oversight of Resident 80's care. MGR 2 stated it was her expectation that all staff members would help family understand the need for PPE and assist them as needed, in order to prevent the spread of infection. Per a facility policy, effective 11/14/23 and titled Standard Precautions and Transmission-Based Precautions for hospitalized Patients, .8 a. Educate patients and their families/visitors .about infection prevention strategies including isolation precautions as needed .d. Visitors are encouraged to wear isolation gowns and gloves . 49330 2. On 5/15/24 at 8:27 A.M., a concurrent observation and interview was conducted while in the hallway outside Resident 25's room. A sign was posted on the wall with Contact Precautions for the room, indicating staff and visitors were required to wear PPE. LN 7 was observed entering Resident 25's room without PPE. LN 7 stated he did not wear PPE because he had not touched anything in the room. On 5/15/24 at 8:40 A.M., an interview was conducted with LN 7. LN 7 stated he should have worn PPE into a contact precautions room to protect residents and staff from infections. 3. On 5/15/24 at 8:27 A.M., an observation was conducted of LN 7. LN 7 prepared Resident 25's medications and placed them on a tray. LN 7 entered Resident 25's room and administered medication. LN 7 exited with the medication and placed it back in the medication cart without sanitizing the medication container. On 5/15/24 at 8:40 A.M., an interview was conducted with LN 7. LN 7 stated he should have sanitized the medication container before returning it to the medication cart to prevent infections. 4. On 5/15/24 at 8:35 A.M., a medication administration observation was conducted inside Resident 25's room. LN 7 was observed administering Resident 25's medications. LN 7 removed his gloves and put on new gloves without performing hand hygiene. On 5/15/24 at 8:40 A.M., an interview was conducted with LN 7. LN 7 stated it was important to perform hand hygiene before and after removing gloves for infection control. On 5/15/24 a record review was conducted. Resident 25's Physician's Orders, dated 2/21/24 indicated Resident 25 was to be on contact precautions. On 5/15/24 at 9:46 A.M., an interview was conducted with the Infection Preventionist Nurse (IPN). The IPN stated PPE should be worn prior to entering a contact precaution room, no matter what purpose or care the staff will do inside the resident room. The IP further stated hand hygiene should be done before and after applying gloves at all times to avoid the exchange of germs. The IPN stated if a medication entered a contact isolation room, it should be sanitized before and after going in the room. On 5/16/24 at 3 P.M., an interview was conducted with Unit Manager 1 (MGR 1). MGR 1 stated it was important for staff to wear PPE prior to entering a contact isolation room, and to perform hand hygiene before and after wearing gloves to protect residents and staff from the spread of infection. MGR 1 stated LNs should not return a medication container from a contact isolation room to the medication cart to avoid cross contamination. MGR 1 further stated if a medication container was brought in a contact isolation room, the LN should sanitize the container before placing it back into the medication cart to avoid contamination. A review of the facility's policy titled Standard Precautions and Transmission-Based Precautions for hospitalized Patients, effective 11/14/2023, indicated, .PPE Required: Isolation Gown and Gloves .Perform hand hygiene and don clean isolation gown and gloves upon entry into the patient room . and .Prior to exiting patient room or cubicle, doff isolation gown and gloves in a method to prevent self-contamination, and perform hand hygiene In addition, the policy indicated .re-usable medical equipment (RME) and devices must be cleaned and disinfected and maintained .to prevent patient-to-patient transmission of potentially infectious material