Every finding on record at Villa Valencia Healthcare Center

Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen. * The facility failed to ensure a container of Sanicloth wipes was not stored next to boxes of Glucerna and Ensure nutritional supplements used for residents. Additionally, an unlabeled and undated sandwich was stored with boxes of cereal, and there were crumbs in the lower area of stove of an oven. * The facility failed to ensure a box was not stored five inches from sprinkler inside cooler fridge. Additionally, a box of unlabeled frozen tacos was stored inside the cooler fridge. There was a warped pot with an uneven surface and 14 salad plates were not dated and labeled in a meal cart inside cooler fridge. * The facility failed to ensure a facial covering was provided and used for the pastry chef's moustache and beard. These failures posed the risk of cross contamination to the residents.Findings: The facility was equipped with a satellite kitchen. The residents' meals were prepared in the main kitchen. Review of the facility's Diet Type Report for August 2026 showed a total of 48 of 53 residents received meals prepared by the main kitchen. 1. On 8/4/26 at 0600 hours, an initial tour of the satellite kitchen was conducted with Dietary Aide 1. The following was observed inside the satellite kitchen:- a container of Sani cloth wipes was stored next to boxes of Glucerna and Ensure nutritional supplements used for residents;- an unlabeled and undated sandwich was stored with boxes of cereal above the microwave; and- crumbs were observed, scattered inside the bottom side of the oven. Dietary Aide 1 verified the above findings. 2. On 8/4/26 at 0630 hours, an initial tour of the main kitchen was conducted with Chef 1. The following was observed inside the main kitchen:- one box was stored about six inches away from a sprinkler inside Cooler Fridge 1;- one box of unlabeled frozen tacos was stored inside Cooler Fridge 1;- one pot was observed warped on the bottom side; and- approximately 14 salad plates were stored, unlabeled and undated inside a food cart. Chef 1 verified the above findings. 3. On 8/4/26, at 0800 hours, an observation was conducted with Chef 1 in the main kitchen. Pastry Chef 1 was observed with a moustache and beard and without any facial covering. Chef 1 verified the findings.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure dietary services were followed. * The diet order was not followed for Resident 66, who was on a fortified diet. * The facility failed to ensure the meal trays for Residents 2, 25, 29, 32, 46, 56, and 78 were checked before serving it to the residents by CNA 1. These failures posed the risk of the residents not receiving the appropriate diet. Findings: The facility was equipped with a satellite kitchen. The residents' meals were prepared in the main kitchen. Review of the facility's Diet Type Report for August 2026 showed a total of 48 of 53 residents received meals prepared by the main kitchen. 1. On 8/5/26, at 1115 hours, a trayline observation was conducted in the satellite kitchen. Resident 66's diet card showed the resident's meal was to be served mince and moist. On 8/5/26 at 1130 hours, an observation and concurrent interview was conducted the Dietary Manager. When asked how the facility fortified the meals, the Dietary Manager stated butter was added to the food items to fortify meals. Resident 66's meal was observed plated from the trayline without adding anything additional such as butter to the meal. On 8/5/26, at 1150 hours, Resident 66's meal was served to the resident, however it was not fortified. On 8/5/26 at 1200 hours, an observation and concurrent interview was conducted with the RD. The RD verified Resident 66's diet on the list of diets showed Resident 66 was to be served a mince and moist fortified diet. The RD verified the diet on Resident 66's meal card did not show Resident 66's diet was to be fortified. When asked which was the correct diet, the RD stated the list of diets showed the correct diet orders for all residents. The RD acknowledged Resident 66's diet was not followed. Medical record review for Resident 66 was initiated on 8/5/26. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's H&P examination dated 7/13/26, showed Resident 66's diagnoses included post status poor oral intake, post status resident reported previous inadequate access to food, post status fall, and post status stroke. Resident 66 had impaired cognition. Review of Resident 66's physician orders showed an order dated 7/17/26, for mince and moist diet. Review of Resident 66's progress notes showed a progress note dated 7/24/26, which showed Resident 66's diet was changed to fortified mince and moist. 2. On 8/4/26 at 0745 hours, a dining observation was conducted for Residents 2, 25, 29, 32, 46, 56, and 78. There was no licensed nurse observed in the dining area. CNA 1 was observed distributing the meal trays to Residents 2, 25, 29, 32, 46, 56, and 78. CNA 1 was observed not having a list of residents' diet to verify each resident's diet order. On 8/4/26 at 0800 hours, an observation and concurrent interview was conducted with CNA 2 and RN 2. CNA 2 was observed distributing meal trays from the meal cart in hallway 1. The meals were not being checked by a staff, and CNA 2 did not have a list of the residents' diets to verify the diets were correct. When asked how she (CNA 2) knew it was okay to start taking meal trays out of the meal cart and deliver them to residents' rooms, CNA 2 verbalized she was notified via a walkie-talkie when meal carts were delivered to the hallway and ready to be distributed to the residents. RN 2 verified she did not check the residents' diets against the list of residents' diets prior to CNA 2 distributing meal trays to residents. On 8/4/26 at 0805 hours, an interview was conducted with CNA 1. CNA 1 stated usually the treatment nurse would assist in the dining area and the nurse would check the resident's meal tray before it would be served. On 8/4/26 at 0810 hours, an interview was conducted with LVN 2. LVN 2 stated the licensed nurse should check the resident's meal tray for correct diet before it was served. LVN 2 stated the CNAs were trained to check the diet orders as well. LVN 2 further stated they should check if the meal tray had the correct diet for the resident using the Diet Type Report. On 8/4/26 at 0815 hours, a follow-up interview was conducted with CNA 1. CNA 1 stated she was trained to check the diet orders for the residents. CNA 1 verified when she distributed the meal trays to Residents 2, 25, 29, 32, 46, 56, and 78, she did not have the Diet Type Report on hand and did not check the meal trays of the residents for the correct diet order. CNA 1 stated Residents 2, 25, 29, 32, 46, 56, and 78 were regular diners in the dining area so she was familiar with them. CNA 1 was asked how she would know if the resident's diet had been changed, the CNA stated any new diet order would be reflected in the Diet Type Report. On 8/7/26 at 1500 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the competency of the facility staff regarding contact isolation precautions. * The facility failed to ensure CNAs 1 and 4, RN 3 and the Janitor were able to demonstrate competency on contact isolation precautions. These failures had the potential for cross-contamination and placed the residents at risk for care not provided in a safe and competent manner.Findings: According to CDC, under Transmission-Based Precautions, use contact precautions for residents with known or suspected infections which represent an increased risk for contact transmission, and to use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Furthermore according to CDC, C. difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are an inactive form of the germ and have a protective coating allowing them to live on surfaces for months. The bacteria can be transferred to patients via the hands of healthcare providers who have touched a contaminated surface or item. When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. Current evidence demonstrates that C. difficile spores may not be fully removed from hands, regardless of the method used to clean hands. This further emphasizes the need for appropriate use of gloves for the care of patients with C. difficile. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 10/2018 showed the following:- when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. (a) The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room, and (b). Signs and notifications comply with the resident's right to confidentiality or privacy;- contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.- staff and visitors will wear gloves (clean, non-sterile) when entering the room.(a) While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage), (b) Gloves will be removed and hand hygiene performed before leaving the room, and (c) Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed; and- staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of the facility's document titled Nurse Supervisor (undated) showed the following duties and responsibilities:- make daily rounds of the nursing department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards, and report findings to the Director;- ensure that personnel follow established procedures for the use and disposal of PPE;- participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel; and- ensure nursing service personnel follow established infection control procedures when isolation precautions become necessary. Review of the facility's document titled Certified Nursing Assistant (undated) showed the following duties and responsibilities:- follow established isolation precautions and procedures; and- follow established procedures in the use and disposal of PPE. Review of the facility's document titled Maintenance Assistant (undated) showed the following duties and responsibilities:-Ensure that established infection control and universal precautions practices are maintained when performing maintenance procedures; and-Follow established policies governing the use/disposal of personal protective equipment and disposal of infectious wastes On 8/4/26 at 0739 hours, during the entrance conference with the DON, Administrator, and AIT, the DON stated Resident 20 was on contact isolation for possible C-difficile. On 8/4/26 at 0810 hours, during the initial tour of the facility, Resident 20 was observed in bed. An EBP sign was observed posted near the door and a small hand symbol placed below the resident's name, and an isolation cart located next to the entrance. Medical record review for Resident 20 was initiated on 8/4/26. Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's Order Summary Report showed the following physician's orders:- dated 7/28/26, EBP related to indwelling device. Apply enhanced barrier to prevent the spreadof infections for specific care activities such as: morning and evening care, toileting and changing, incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance, and preparing to leave the room, cleaning and disinfecting the environment;- dated 8/4/26, contact isolation precautions - single/private room for possible C-difficile every shift. PPE cart outside room, gown and gloves to be worn before entering the room; and- dated 8/5/26, contact isolation precautions - single/private room for possible C-difficile, all services provided in patient's room, therapy, dining, and activities every shift. PPE cart outside room, gown and gloves to be worn before entering the room; On 8/4/26 at 0859 hours, CNA 4 was observed going to Resident 20's room without any PPE. Then, CNA 4 went out of the room and told CNA 1 (Staffing Coordinator) Resident 20 wanted coffee. On 8/4/26 at 0904 hours, CNA 1 was observed going to Resident 20's room, and used the alcohol-based hand rub, but did not use PPE. On 8/4/26 at 0924 hours, an interview was conducted with CNA 1. CNA 1 verified she went inside Resident 20's room without PPE. CNA 2 stated she went inside Resident 20's room to give him his coffee. CNA 1 verified Resident 20 was on contact isolation. When asked what contact isolation mean, CNA 1 stated it means, we are to gown up, sanitize hands, and wash hands in the station. I just gave coffee. We wear the PPE only when we do contact with the resident. On 8/4/26 at 0940 hours, an observation, interview and concurrent medical record review for Resident 20 was conducted with RN 3. When asked what isolation Resident 20 was on, RN 3 stated enhanced. RN 3 was shown the physician's order for Resident 20 to be on contact isolation. RN 3 verified an EBP sign was posted near the door, and a small hand symbol placed below the resident's name. When asked where the contact isolation sign for Resident 20 was, RN 3 stated the small hand symbol meant Resident 20 was on contact isolation. During the interview, the DSD/IP was observed changing the EBP sign to a contact isolation sign near door. RN 3 verified the visitor inside Resident 20's room was not wearing any PPE. On 8/5/26 at 0835 hours, Resident 20 was observed in bed. A contact isolation sign was observed posted near the door, a small hand symbol placed below the resident's name, and an isolation cart located next to the entrance. The contact isolation sign alerted visitors to report to nursing station before entering, perform hand hygiene before entering and before leaving the room, wear gloves when entering room or cubicle, and when touching resident's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch resident items or potentially contaminated environmental surfaces, or use resident-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between residents. On 8/5/26 at 0837 hours, the Janitor was observed going in and out of Resident 20's room using ABHR, but no PPE. On 8/5/26 at 0839 hours, an observation for Resident 20, and concurrent interview was conducted with the Janitor. The Janitor verified he went inside Resident 20's room without PPE. The Janitor verified Resident 20 was on contact isolation. When asked what contact isolation mean, the Janitor stated if you are going to make contact with the resident and the bed, wear PPE. If no contact, just hand sanitize, can go in there and talk to the resident. The Janitor further stated he was not informed about the resident's infection. On 8/5/26 at 1500 hours, an interview and concurrent medical record review for Resident 20 was conducted with the DSD/IP. The DSD/IP verified Resident 20 was placed on contact isolation on 8/4/26. The DSD/IP verified the hand symbol was not a contact isolation sign but only meant to stop the staff and visitor, and to flip the sign to show where the infection could be, and it was stool for Resident 20. The DSD/IP verified the contact isolation was changed hours after the initial order for contact isolation was placed for Resident 20. When asked about the staff inservices, the DSD/IP stated the facility used online platform classes or online education classes, and in-person classes. Review of the SNF Clinic online classes included Principles of Infection Control and Asepsis offered on 1/1/26, failed to show the Janitor was provided with the infection control class. Review of the facility's in services document titled All Staff - Infection Control dated 6/11/26, failed to show CNA 4 and RN 3 were on the list. The DSD/IP verified the above findings. The DSD/IP stated the Janitor was a new employee and his infection control class was provided as part of his new employee orientation. The DSD/IP further stated when she talked about Infection Control to the staff, she always mentioned C. diff, and she also provided hand hygiene training for C. diff. On 8/7/26 at 0942 hours, an interview was conducted with CNA 4. CNA 4 verified she went inside Resident 20's room without PPE. CNA 4 stated she went inside Resident 20's room to give the activity paper, as she was assisting the activities department. CNA 4 verified Resident 20 was on contact isolation. When asked what contact isolation mean, CNA 4 stated If I am going into the room with any interaction with the resident or the surfaces, I used the hand sanitizer, gown, gloves, and do what I have to do. If I touch the resident, then gel in, PPE, do what I have to do, and then gel out. But if no contact with the resident or the surfaces, I just gel in, put the activity paper, then gel out. On 8/7/26 at 1347 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross-reference to F880 #3.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pain management care and services for one of five final sampled residents reviewed for unnecessary medications (Resident 2). * The facility failed to ensure a nonpharmacological intervention was provided to Resident 2 prior to the administration of lidocaine patch (topical local medication applied to the skin to numb specific painful areas). This failure posed the risk for the residents not to receive the appropriate and necessary interventions to manage the resident's pain.Findings: Review of the facility's P&P titled Pain Assessment and Management revised 5/2026 showed under the Pain Management Interventions section, nonpharmacologic interventions may be utilized as appropriate, based on preferences and tolerance. On 8/4/26 at 0840 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying in bed. Resident 2 stated she had on and off pain in her back and sides. Resident 2 stated she had the patch being applied to her sides, but it seemed not working. Medical record review for Resident 2 was initiated on 8/4/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/14/26, showed Resident 2's medical decision making was highly complexed, and resident was at high risk for life threatening deterioration. Review of Resident 2's Order Summary Report showed the following physician's orders:- dated 7/9/26, to apply Lidocaine External Patch 4 % (Lidocaine) to back topically one time a day for pain management; apply two patches and remove per schedule;- dated 7/29/26, to apply Lidoderm Patch 5 % (Lidocaine) to left ribs topically in the morning for pain management and remove per schedule; and- dated 7/29/26, to apply Lidoderm Patch 5 % (Lidocaine) to right ribs topically in the morning for pain management and remove per schedule. Review of Resident 2's MAR for July 2026 showed Resident 2 was applied with a lidocaine patch on 7/10, 7/12, 7/14, 7/16, 7/21, 7/22, 7/23, 7/26, and 7/31/26 at 0900 hours. Further review of Resident 2's medical record did not show documented evidence Resident 2 was provided with nonpharmacological interventions prior to the administration of the lidocaine patch. In addition, Resident 2 was not administered with other pain medications which would prompt the staff to provide nonpharmacological intervention on the days listed above between the hours of 0800 hours to 1000 hours. On 8/6/26 at 1553 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified the above findings for Resident 2. RN 1 stated the nonpharmacological interventions should be provided prior to administration of any pain medications. On 8/7/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 2.

Based on observation, interview, medical record review, the facility failed to ensure one of 14 final sampled residents (Resident 28) was provided with the appropriate respiratory care and services. * The facility failed to ensure Resident 28's nasal cannula was not touching the floor and underneath the wheel of Resident 28's wheelchair. This failure had the potential to affect the respiratory health and well-being of the resident in the facility.Findings: Medical record review for Resident 28 was initiated on 8/6/26. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's Order Summary Report showed an order dated 7/18/26, for oxygen two LPM via nasal cannula as needed to maintain Resident 28's oxygen saturation level at 93% and above. Review of Resident 28's H&P examination dated 7/20/26, showed Resident 28's diagnoses included post status acute respiratory failure, post status pneumonia, and pulmonary fibrosis. On 8/5/26 at 1420 hours, Resident 28 was observed sleeping in bed with the nasal cannula in place. Part of Resident 28's nasal cannula tubing was observed on the floor and underneath the left wheel of Resident 28's wheelchair. On 8/5/26, at 1446 hours, the above findings was verified with the DSD who acknowledged the nasal cannula should not be touching the floor.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the IV access for one of 14 final sampled residents (Resident 7) reviewed for the IV care. * The facility failed to measure the arm circumference during the PICC line dressing change for Resident 7 per physician's order. This failure had the potential to delay the identification of catheter-related complications for the resident.Findings: On 8/4/26 at 0630 hours, during the initial tour of the facility, Resident 7 was observed awake and lying in the bed. Resident 7 was observed with a PICC line in the right upper arm. Resident 7 stated he was getting antibiotics for his infection in the bone. Medical record review for Resident 7 was initiated on 8/4/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report showed a physician's order dated 7/8/26, for dressing change of the PICC Line site every day shift on Friday. Record the arm circumference and external catheter measurement in every dressing change. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had an intact cognition. Review of Resident 7's IV Record for July 2026 showed on 7/17/26, for the dressing change of the PICC line site, the box for arm circumference was marked X. Further review of Resident 7's medical record failed to show documented evidence the arm circumference was measured on 7/17/26, and for the week of 7/12 to 7/18/26 per the physician's order. On 8/6/26 at 1402 hours, an interview and concurrent Resident 7's medical record review was conducted with RN 1. RN 1 verified Resident 7 had a PICC line in the right upper arm. RN 1 stated the central line dressing change was done once a week and the facility scheduled it every Friday. RN 1 stated during the dressing change, they should also measure and document the size of the arm circumference & external catheter. RN 1 stated measuring the arm circumference was important because if it had increased in size from the baseline measurement, it could signify an inflammation or infection. RN 1 verified she was the one who did the PICC line dressing change on 7/17/26, and there was no measurement for the arm circumference. On 8/7/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed that RN 1 verified the above findings. The DON acknowledged the findings for Resident 7.

Based on interview, medical record review, and the facility P&P review, the facility failed to monitor the fluid intake accurately for two of 14 final sampled residents (Residents 25 and 56). * The facility failed to ensure Resident 25 and 56's fluid intake was monitored accurately by the licensed nurses. The licensed nurses did not consistently included the residents' fluid intake from the meal trays when calculating the residents' daily fluid intake and as documented by the licensed nurses in the MAR. In addition, the licensed nurses did not accurately calculate Resident 25's average weekly fluid intake. These failures placed Residents 25 and 56 at risk for undetected fluid imbalances and fluid overload and negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Intake and Output Monitoring revised 5/2026 showed to initiate intake and output monitoring when ordered by a physician/ practitioner or when clinically indicated based on the resident condition and overall goals of treatment. 1. On 8/4/26 at 0813 hours, during the initial tour of facility, Resident 25 was observed in bed. There was a note showing fluid restriction 1800 ml/ 24 hours observed on the bedside table, and a small of carton of juice was on the nightstand. Resident 25 stated he was on a fluid restriction, but stated he could have a little bit of orange juice. They know it, the nurses know it. They told me I cannot have it, when I am on my limit. Medical record for Resident 25 was initiated on 8/4/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report showed the following physician's orders:- dated 7/1/26, to monitor intake and output every shift for the Foley catheter use;- dated 7/1/26, to monitor average weekly intake and output every evening shift for seven days for the Foley catheter use; and- dated 7/31/26, for fluid restriction of 1800 ml per day. The nursing department to provide 600 ml, with a breakdown of 360 ml for the morning shift, and 240 ml for the night shift. The dietary department to provide 1200 ml, with a breakdown of 480 ml for breakfast, 360 ml for lunch, and 360 ml for dinner. Review of Resident 25's Documentation Survey Report v2 for July and August 2026, under Nutrition - Fluids section, showed the following fluid intake of Resident 25 as documented by the CNAs. For example:- on 7/21/26, the total fluid intake was 480 ml;- on 7/22/26, the total fluid intake was 880 ml;- on 7/26/26, the total fluid intake was 1100 ml;- on 7/27/26, the total fluid intake was 480 ml- on 7/28/26, the total fluid intake was 750 ml;- on 7/29/26, the total fluid intake was 500 ml; and- on 7/30/26, the total fluid intake was 720 ml. Review of Resident 25's MAR for July and August 2026 showed the following total fluid intake of Resident 25 as documented by the licensed nurses:- on 7/1/26, the total fluid intake was 480 ml;- on 7/2/26, the total fluid intake was 1800 ml;- on 7/3/26, the total fluid intake was 900 ml;- on 7/4/26, the total fluid intake was 950 ml;- on 7/5/26, the total fluid intake was 1020 ml;- on 7/6/26, the total fluid intake was 1020 ml;- on 7/7/26, the total fluid intake was 980 ml;- on 7/8/26, the total fluid intake was 1200 ml;- on 7/9/26, the total fluid intake was 1800 ml;- on 7/10/26, the total fluid intake was 1200 ml;- on 7/11/26, the total fluid intake was 1150 ml;- on 7/12/26, the total fluid intake was 1200 ml;- on 7/13/26, the total fluid intake was 850 ml;- on 7/14/26, the total fluid intake was 600 ml;- on 7/15/26, the total fluid intake was 1500 ml;- on 7/16/26, the total fluid intake was 1800 ml;- on 7/17/26, the total fluid intake was 1500 ml:- on 7/18/26, the total fluid intake was 1400 ml;- on 7/19/26, the total fluid intake was 650 ml;- on 7/20/26, the total fluid intake was 1120 ml;- on 7/21/26, the total fluid intake was documented as N/A;- on 7/22/26, the total fluid intake was 880 ml;- on 7/23/26, the total fluid intake was 1240 ml;- on 7/24/26, the total fluid intake was 1800 ml;- on 7/25/26, the total fluid intake was 960 ml;- on 7/26/26, the total fluid intake was documented as N/A;- on 7/27/26, the total fluid intake was documented as N/A;- on 7/28/26, the total fluid intake was 750 ml;- on 7/29/26, the total fluid intake was documented as N/A;- on 7/30/26, the total fluid intake was documented as N/A;- on 7/31/26, the total fluid intake was 950 ml.- on 8/1/26, the total fluid intake was 950 ml;- on 8/2/26, the total fluid intake was 940 ml;- on 8/3/26, the total fluid intake was 1200 ml;- on 8/4/26, the total fluid intake was 1320 ml;- on 8/5/26, the total fluid intake was 1240 ml; and- on 8/6/26, the total fluid intake was 1230 ml. Further review of Resident 25's MAR for July and August 2026 showed the following average weekly intake monitoring:- for the week of 7/1 to 7/7/26, the average weekly intake was 1021 ml;- for the week of 7/8 to 7/14/26, the average weekly intake was 1378 ml;- for the week of 7/15 to 7/21/26, the average weekly intake was 511 ml;- for the week of 7/22 to 7/28/26, the average weekly intake was 984 ml; and- for the week of 7/29 to 8/4/26, the average weekly intake was 846 ml. On 8/6/26 at 1358 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 3. RN 3 verified Resident 25 was on intake and output monitoring and had a daily fluid restriction of 1800 ml. RN 3 stated the resident's fluid intake from the dietary or meal tray were documented by the CNAs on the Task documentation. RN 3 stated the licensed nurses' documentation of the resident's fluid intake in the MAR included the resident's fluid intake from the nursing and dietary. When asked about the monitoring of Resident 25's fluid intake, RN 3 verified the resident's fluid intake monitoring was inconsistent when the CNAs documented Resident 25's fluid intake on 7/21, 7/26, 7/27, 7/29, and 7/30, but the licensed documented N/A' in the MAR. RN 3 further verified the CNA documentation on 7/22/26, showed Resident 25's fluid intake was 880 ml, and on 7/28/26, the resident's fluid intake was 750 ml, and these were the same amount documented in the MAR. RN 3 stated she would not know if the resident drank any fluids during medication pass. When asked about Resident 26's average weekly intake, RN 3 verified Resident 25's average weekly fluid intake documented in the MAR were inaccurate. RN 3 stated the resident's average weekly fluid intake for the week of 7/15 to 7/21/26, should have been 1138 ml, not 511 ml, for the week of 7/22 to 7/28/26, should have been 804 ml, not 984 ml, and for the week of 7/29 to 8/4/26, should have been 765 ml, not 846 ml. 2. Medical record review for Resident 56 was initiated on 8/4/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's Order Summary Report showed a physician's order dated 7/29/26, for fluid restriction of 1800 ml per day. The nursing department to provide 720 ml, with a breakdown of 580 ml for the morning shift, and 140 ml for the night shift. The dietary department to provide 1080 ml, with a breakdown of 360 ml for breakfast, 240 ml for lunch, and 480 ml for dinner. Review of Resident 56's Documentation Survey Report v2 for July and August 2026, under Nutrition - Fluids section, showed the following fluid intake of Resident 56 as documented by the CNAs:- on 7/29/26, the fluid intake on the day shift and evening shift was 360 ml, and 120 ml for night shift;- on 7/30/26, the fluid intake on the day shift and evening shift was 360 ml, and 120 ml on the night shift;- on 7/31/26, the fluid intake on the day shift and evening shift was 480 ml, and 120 ml on the night shift;- on 8/1/26, the fluid intake on the day shift and evening shift was 220 ml, and 120 ml on the night shift;- on 8/2/26, the fluid intake on the day shift and evening shift was 480 ml, and 240 ml on the night shift;- on 8/3/26, the fluid intake on the day shift and evening shift 120 ml and 240 ml on the night shift;- on 8/4/26 the fluid intake on the day shift and evening shift was blank, and 240 ml on the night shift;- on 8/5/26, the fluid intake on the day shift and evening shift was 120 ml, and 240 ml on the night shift; and- on 8/6/26, the fluid intake on the day shift and evening shift was 200 ml, and 240 ml on the night shift. Review of Resident 56's MAR for July and August 2026 showed the following:- on 7/29/26, the fluid intake on the day shift was 580 ml, and 580 ml on the night shift;- on 7/30/26, the fluid intake on the day shift was 580 ml, and 240 ml on the night shift;- on 7/31/26, the fluid intake on the day shift was 1320 ml, and 140 ml on the night shift;- on 8/1/26, the fluid intake on the day shift was 1200 ml, and 140 ml on the night shift;- on 8/2/26, the fluid intake on the day shift was 580 ml, and 120 ml on the night shift;- on 8/3/26, the fluid intake on the day shift was 580 ml, and 100 ml on the night shift;- on 8/4/26 the fluid intake on the day shift was 580 ml, and 120 ml on the night shift;- on 8/5/26, the fluid intake on the day shift was 900 ml, and 480 ml on the night shift; and- on 8/6/26, the fluid intake on the day shift was 790 ml, and 280 ml on the night shift. On 8/6/26 at 1340 hours, an interview and concurrent medical record review for Residents 25 and 56 was conducted with LVN 1. LVN 1 stated the licensed nurses combine the resident's fluid intake from nursing activities, such as med pass, with the resident's fluid intake from their meal tray, and as recorded by the CNAs, in their documentation of the resident's daily fluid intake in the MAR. On 8/6/26 at 1506 hours, an interview and concurrent medical record review for Resident 56 was conducted with RN 3. RN 3 verified Resident 56 was on intake and output monitoring and had a daily fluid restriction of 1800 ml. When asked about the monitoring process, RN 3 acknowledged the licensed nurses had not accurately tracked Resident 56's fluid intake. Specifically, RN 3 confirmed from 7/31/26 to 8/4/26, the documentation in the MAR by the licensed nurses did not include Resident 56's fluid intake from the dietary department. On 8/7/26 at 1415 hours, an interview and concurrent medical record review for Residents 25 and 56 was conducted with the DON. The DON verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for two of four final sampled residents reviewed for unnecessary medications (Residents 2 and 6) and one final sampled resident (Residents 20). * The facility failed to ensure the nonpharmacological interventions were provided prior to the administration of psychotropic medications for Residents 2, 6, and 20. These failures had the potential for adverse effects from the psychotropic medications, not providing the correct data to the prescriber to adjust the dosage of the medications and to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised 11/2025 showed the following: - the indications for initiating, withdrawing, or withholding medications(s), as well as the use of non­pharmacological approaches, shall be determined by: a. Assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment; b. Identification of underlying causes (when possible); - for psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition(s) as diagnosed by the physician. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation; - residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pha1macological interventions; and - residents who use psychotropic drugs shall also receive non-pharmacological interventions in accordance with their care plan to facilitate reduction or discontinuation of the psychotropic drugs. 1. Medical record review for Resident 2 was initiated on 8/4/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/14/26, showed Resident 2's medical decision making was highly complexed, and resident was at high risk for life threatening deterioration. Review of Resident 2's Order Summary Report showed the following physician's orders: - dated 6/24/26, to administer sertraline hydrochloride (antidepressant) 100 mg one tablet by mouth one time a day for depression as manifested by social isolation (reordered on 7/9/26); - dated 6/24/26, to monitor episodes of depression as manifested by social isolation and document number of episode(s) every shift for sertraline use (reordered on 7/9/26); - dated 6/24/26, to monitor episodes of anxiety as manifested by persistent yelling every shift and document number of episode(s) every shift for 14 days; - dated 7/1/26, to administer Ativan (antianxiety) 0.5 mg one tablet by mouth every eight hours as needed for anxiety as manifested by persistent yelling until 7/10/26 at 2359 hours; non drug intervention: 1-check for presence of pain, 2-change position for comfort, 3-offer snacks, 4-turn on tv to show program of choice, 5-listening to music of choice, 6-provide reading material and magazine; - dated 7/2/26, to administer hydroxyzine hydrochloride (antianxiety) 25 mg one tablet by mouth every six hours as needed for anxiety as manifested by inability to relax for 14 days; - dated 7/2/26, to monitor episodes of anxiety as manifested by inability to relax every shift and document number of episode(s) every shift for 14 days (reordered on 7/13/26); - dated 7/9/26, to administer hydroxyzine pamoate 25 mg one capsule by mouth every six hours as needed for anxiety as manifested by inability to relax for 14 days; 1 - check for presence of pain, 2 - change position for comfort, 3 - offer snacks, 4 – turn on tv to show program of choice, 5 - listening to music of choice; 6 - provide reading material and magazine (reordered on 7/26/26); - dated 7/9/26, to monitor episodes of anxiety as manifested by inability to relax every shift and document number of episode(s) every shift for hydroxyzine pamoate use for 14 days; - dated 7/9/26, to administer quetiapine fumarate (antipsychotic) 25 mg one tablet by mouth two times a day for psychotic disorder as manifested by angry outburst; - dated 7/9/26, to monitor episodes of psychotic disorder as manifested by angry outburst and document number of episode(s) every shift for quetiapine use; and - dated 7/13/26, non drug intervention prior to the use of psychotropic medication: 1 - check for presence of pain, 2 – change position for comfort, 3 - offer snacks, 4 - turn on tv to show program of choice, 5 - listening to music of choice, 6 - provide reading material and magazine; direction: use supplementary documentation and select corresponding number to indicate non drug intervention. every 6 hours as needed for 14 days. Review of Resident 2's MAR for July and August 2026 showed the following: a. Resident 2 was administered with sertraline medication on the following dates and times: - on 7/1 to 7/6/26 at 0900 hours; - on 7/10 to 7/31/26 at 0900 hours; and - on 8/1 to 8/4/26 at 0900 hours. Further review of the MAR showed Resident 2 was monitored to have episodes of depression as manifested by for sertraline use on 7/3, 7/4, and 7/5/26, one episode each on the day and night shifts. Review of Resident 2's medical record failed to show documented evidence nonpharmacological interventions were provided prior to the administration of the sertraline medication and when the resident had episodes of depression as manifested by social isolation the on the dates, times and shifts above. b. Resident 2 was administered with the Ativan medication on 7/1/26 at 0614 hours. Resident 2 was monitored to have episodes of anxiety as manifested by persistent yelling on 7/1/26, for three episodes on the night shift and on 7/2/26 for three episodes on the day shift. Review of Resident 2's medical record failed to show documented evidence nonpharmacological interventions were provided prior to the administration of Ativan medication and when the resident had episodes of anxiety as manifested by persistent yelling on the dates, times and shifts above. c. Resident 2 was administered with the hydroxyzine medication on the following dates and times: - on 7/3 at 1816 hours; - on 7/4 at 0911 hours and 1542 hours; - on 7/5 at 0934 hours and 2342 hours; - on 7/6 at 1116 hours and 1750 hours; - on 7/10 at 1834 hours; - on 7/11 at 0835 hours; - on 7/13 at 1957 hours; - on 7/14 at 0811 hours, 1435 hours and 2239 hours; - on 7/15 at 0451 hours and 2116 hours; - on 7/16 at 1306 hours and 2133 hours ; - on 7/17 at 0832 hours, 1633 hours and 2236 hours; - on 7/18 at 0607 hours and 1858 hours; - on 7/19 at 1958 hours; - on 7/20 at 0840 and 1948 hours; - on 7/21 at 0850 hours; - on 7/22 at 0940 hours and 1540 hours; - on 7/23 at 0603 hours; - on 7/26 at 1557 hours; - on 7/28 at 2140 hours; - on 7/29 at 1415 hours; - on 7/30 at 2232 hours; and - on 8/3/26 at 1323 hours. Further review of the MAR showed Resident 2 was monitored to have episodes of anxiety as manifested by inability to relax on the following dates and shifts: - on 7/2 = four episodes on night shift; - on7/3 = one episode on night shift; - on 7/4 = two episodes on day shift and three episodes on night shift; - on 7/5 = three episodes on day shift ; five episodes on night shift; - on 7/9 = five episodes on night shift - on 7/10 = five episodes on day shift; - on 7/11 = two episodes on day shift; - on 7/12 = two episodes on day shift; - on 7/13 = one episode on day shift - on 7/14 = two episodes on day shift; - on 7/15 = two episodes on day shift; - on 7/16 = one episode on day shift; - on 7/19 = one episode on day shift; - on 7/20 = one episode on day shift; - on 7/21= one episode on day shift; and - on 7/22/26 = two episodes on day shift; one episode on night shift. Review of Resident 2's medical record failed to show documented evidence nonpharmacological interventions were provided prior to the administration of the hydroxyzine medication and when the resident had episodes of anxiety as manifested by inability to relax on the dates, times and shifts above. d. Resident 2 was administered with the quetiapine medication on the following dates and times: - on 7/9 at 2100 hours; - on 7/10 to 7/12 at 0900 hours and 2100 hours; and - on 7/13/26 at 0900 hours. Further review of the MAR showed Resident 2 was monitored to have episodes of psychotic behavior as manifested by angry outburst on the following dates and shifts: - on 7/9 = five episodes on night shift; - on 7/10 = six episodes on day shift and five episodes on night shift; - on 7/11 = one episode on day shift; - on 7/12 = two episodes on day shift; - on 7/13 = one episode on day shift and two episodes on night shift; - on 7/14 = five episodes on day shift; - on 7/15 = two episodes on night shift; and - on 7/16/26 = one episode on day shift. Review of Resident 2's medical record failed to show documented evidence nonpharmacological interventions were provided prior to the administration of the quetiapine medication and when the resident had episodes of psychotic behavior as manifested by angry outburst on the dates, times and shifts above. On 8/6/26 at 1553 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified the above findings. 2. Medical record review for Resident 6 was initiated on 8/4/26. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 6/12/26, showed Resident 6 had no capacity for medical decision making. Review of Resident 6's Order Summary Report showed a physician's order dated 6/25/26, to administer Remeron Disintegrating (antidepressant) 15 mg two tablets via GT at bedtime for depression as manifested by inability to sleep. Review of Resident 6's MAR for July and August 2026 showed Resident 6 received the Remeron medication from 7/1 to 7/31/26 at 2100 hours, and from 8/1 to 8/3/26 at 2100 hours. Review of Resident 6's medical record failed to show documented evidence nonpharmacological interventions were provided prior to the administration of Remeron medication. On 8/6/26 at 1517 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified the above findings. On 8/7/26 at 1500 hours, an interview and concurrent medical record review for Residents 2 and 6 was conducted with the DON. The DON was informed of the above findings for Residents 2 and 6. The DON stated nonpharmacological interventions were documented in the care plan. The DON stated since the facility was only short-term, for residents who were receiving psychotropic medications, the staff knew what to look for, the licensed nurses would tell the resident to go to activities or if there was a significant change, a change of condition would be initiated. The DON stated they provided nonpharmacological intervention for the psychotropic medications ordered as needed only. The DON stated for routine psychotropic medication, they did not provide nonpharmacological intervention, it was not ordered but care planned. 3. Medical record review for Resident 20 was initiated on 8/4/26. Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 7/28/26, showed Resident 20's medical decision making was highly complex, and resident was at high risk for life threatening deterioration. Review of Resident 20's MDS assessment dated [DATE], showed Resident 20 had a moderate cognitive impairment. Review of Resident 2's Order Summary Report showed the following physician's orders dated 7/27/26: - to administer escitalopram 10 mg 0.5 tablet by mouth one time a day for depression manifested by verbalization of sadness; - to monitor episodes of verbalization of sadness and document number of episodes every shift; and - to monitor side effects of escitalopram such as (1) drowsiness, (2) dry mouth, (3) constipation, (4) dizziness, (5) blurred vision, (6) difficulty urinating, (7)blood pressure changes, (8) irregular heartbeat, (9) trouble sleeping, (10) weight loss, (11) confusion, (12) restlessness, (13) agitation, (14) rash, (15) headache, (16) weakness, (17) tremor , and (18) nausea or (0) None every shift. Review of Resident 20's MAR for July and August 2026 showed Resident 20 was administered with the escitalopram medications on 7/28 to 8/5/26 at 0900 hours, with no episodes of verbalization of sadness, and no side effects. The MAR did not show Resident 20 was provided with nonpharmacological interventions prior to the administration of the escitalopram medication. Review of Resident 20's plan of care showed a care plan problem dated 7/27/26, addressing the use of antidepressant medication (escitalopram) related to depression manifested by verbalization of sadness. The interventions include to provide non-drug intervention prior to the use of PRN antidepressant medication such as checking for presence of pain, changing position for comfort, offering snacks, turning the TV to show program of choice, listening to music of choice and providing reading materials and magazine. Review of Resident 20's medical record failed to show documented evidence nonpharmacological interventions were consistently implemented and evaluated in conjunction with the continued use of the routine escitalopram medication. On 8/6/26 at 1343 hours, an interview and concurrent medical record review for Resident 20 was conducted with RN 3. RN 3 verified Resident 20 was administered the escitalopram routinely. When asked what nonpharmacological interventions were provided prior to the administration of the routine escitalopram medication, RN 3 stated there were no nonpharmacological interventions provided if a psychotropic medication was given routinely, and nonpharmacological interventions were provided only for PRN psychotropic medications. RN 3 verified Resident 20's plan of care for escitalopram medication included an intervention for nonpharmacological interventions but for PRN antidepressant medication. When asked for any documentation the facility provided nonpharmacological interventions for escitalopram medication given routinely, RN 3 failed to show documented evidence of the less restrictive, nonpharmacological approaches implemented and evaluated prior to the administration of the routine escitalopram medication. On 8/7/26 at 1347 hours, an interview and concurrent medical record review for Resident 20 was conducted with the DON. When asked for any documentation the facility provided nonpharmacological interventions for escitalopram medication given routinely, the DON verified the nonpharmacological interventions were not documented but it was part of the resident's plan of care. The DON stated there were no nonpharmacological interventions provided if a psychotropic medication was given routinely, and nonpharmacological interventions were provided only for PRN psychotropic medications. The DON verified Resident 20's plan of care for the escitalopram medication included an intervention for nonpharmacological interventions in the care plan, but it was for the PRN antidepressant medication.

Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of advance directives for two of four final sampled residents (Residents 18 and 26) reviewed for advance directives. * The facility failed to ensure the copies of the Resident 18 and 26's advance directives for healthcare were obtained and maintained in the residents' medical record. This failure had the potential for the residents' decisions regarding their healthcare and end-of-life decisions to be unknown and not be honored, and the residents' healthcare decisions to be unavailable to the staff and healthcare providers when needed.Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed the following:- Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/ her family members and/ or his/ her legal representative, about the existence of any written advance directives;- Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; and- The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when a transfer from the facility via ambulance or other means is made. 1. Medical record review for Resident 18 was initiated on 8/4/26. Resident 18 was readmitted to the facility on [DATE]. Review of Resident 18's POLST dated 7/20/26, showed Section D Information and Signatures section was left blank, and failed to show whether Resident 18 had an advance directive or not. Review of Resident 18's H&P examination dated 7/21/26, showed Resident 18 had a fluctuating capacity to make decisions. Review of Resident 18's Social Services Assessment Packet - V4 dated 7/22/26, under the Resources section, showed the box for durable power of attorney/ durable power of attorney-healthcare was checked off. Further review of the assessment form did not show the social services staff request to obtain a copy of Resident 18's advance directive. Review of Resident 18's IDT Care Conference 4.0 dated 7/27/26, showed one of the areas reviewed was the advance directive/POLST. Further review of the care conference form did not show the IDT request to obtain a copy of Resident 18's advance directive. Review of Resident 18's Advanced Directives Acknowledgment dated 8/6/25, showed Resident 18 had executed an advance directive. Further review of Resident 18's medical record failed to show documented evidence a copy of Resident 18's advance directive was requested. 2. Medical record review for Resident 26 was initiated on 8/4/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's POLST dated 7/15/26, under Section D Information and Signatures section showed the resident had capacity, but the form failed to show whether Resident 26 had an advance directive or not. Review of Resident 26's Advanced Directives Acknowledgment dated 7/16/26, showed Resident 26 had executed an advance directive. Review of Resident 26's Social Services Assessment Packet - V4 dated 7/17/26, under the Resources section, showed advance healthcare directive. Further review of the assessment form did not show the social services staff request to obtain a copy of Resident 26's advance directive. Review of Resident 26's MDS assessment dated [DATE], showed Resident 21 was cognitively intact. Review of Resident 26's IDT Care Conference 4.0 dated 7/21/26, showed one of the areas reviewed was the advance directive/POLST. Further review of the care conference form did not show the IDT request to obtain a copy of Resident 26's advance directive. Further review of Resident 26's medical record failed to show documented evidence a copy of Resident 26's advance directive was requested. On 8/6/26 at 0958 hours, an interview and concurrent medical record review for Residents 18 and 26 was conducted with the MDS Coordinator. The MDS Coordinator stated the social services staff discussed the POLST and advance directive during the care conference. The MDS Coordinator verified Residents 18 and 26 indicated they executed an advance directive. The MDS Coordinator further verified the social services staff or any facility staff did not follow up to obtain copies of Resident 18 and 26's advance directives. On 8/6/26 at 1011 hours, an interview and concurrent medical record review for Residents 18 and 26 was conducted with the Medical Records Director. The Medical Records Director stated if a copy of the advance directive was obtained, the resident or resident representative will give a copy to the case manager or social worker who could also scan the copy of the advance directive to upload to the resident's electronic health record. The Medical Records Director verified there were no copies of Resident 18 and 26's advance directives in their physical charts, nor their electronic health records.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 14 final sampled residents (Resident 25) to self-administer the medications left at bedside. * The facility failed to ensure Resident 26 was assessed to self-administer the melatonin (supplement) and betamethasone (corticosteroid) medications. Additionally, there was no documentation of an order or the administration of the melatonin and betamethasone medications in the resident's medical record. These failures had the potential for Resident 26 to administer the medications inaccurately and could result in the resident taking medication at an incorrect dose or frequency, or with contraindications, and could affect the resident's well-being.Findings: Review of the facility's P&P titled Self-Administration of Medications dated 4/2008 showed the following:- If the resident desires to self-administer medications, an assessment is conducted by the IDT of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process;- The IDT determines the resident's ability to self-administer medications by means of a skill assessment conducted on a routine basis;- If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is permitted;- Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: (1) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked drawers or cabinets are required only if unlocked storage is deemed inappropriate. (2) The medications provided to the resident storage are kept in the containers dispensed by the provider pharmacy. (3) Notation of each dose self-administered is documented on the MAR; and- All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage, and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary On 8/4/26 at 0636 hours, an observation and concurrent interview was conducted with Resident 26. Resident 26 was observed lying in bed. The following medications were observed at bedside:- a tube of betamethasone (corticosteroid);- a tube of cortisone-10 (corticosteroid);- an inhaler containing Trelegy Ellipta (maintenance treatment for COPD and asthma)-a bottle of Afrin nasal spray (nasal decongestant);- a container of Xyzal (antihistamine);- an inhaler containing albuterol (treatment for acute bronchospasm, asthma symptoms, and exercise-induced bronchospasm);- a bottle of Xdemvy eyedrops (antiparasitic); and- a container of melatonin (supplement). During the interview, Resident 26 stated he applied the betamethasone and cortisone medications on his buttocks, he takes the Trelegy and albuterol once a day, the eyedrops and nasal spray in the morning, and the melatonin at night. Resident 26 also stated he takes the Xyzal for his allergies. Resident 26 further stated the nurses were aware he keeps the medications and takes the medications by himself. On 8/4/26 at 0641 hours, an observation for Resident 26 and concurrent interview was conducted with MDS RN. The MDS RN verified the above medications were found at Resident 26's bedside. Medical record review for Resident 26 was initiated on 8/4/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Self-Administration of Medication dated 4/2/24, showed Resident 26 was fully capable of administering medications and storing the medications in a secure location, and was approved for self-administering of medications, and may keep medications at bedside. Review of Resident 26's Order Summary Report did not show a physician's order to administer the betamethasone and melatonin medications. Furthermore, there was no physician's orders for Resident 26 to self-administer the betamethasone and melatonin medications. Review of Resident 26's MAR did not show Resident 26's self-administration of betamethasone and melatonin medications was documented. On 8/6/26 at 0825 hours, an interview and concurrent medical record review for Resident 26 was conducted with the MDS RN. The MDS RN verified there were no physician's orders for Resident 26 to self-administer the betamethasone and melatonin medications. The MDS RN further verified Resident 26's self-administration of the betamethasone and melatonin medications was not documented in the resident's MAR. On 8/7/26 at 1409 hours, an interview and medical record review for Resident 26 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 17.86%. One of three licensed nurses (RN 4) was found to have made an errors during the medication administration observation. * The facility failed to ensure RN 4 checked Resident 7's blood pressure and heart rate before administering carvedilol (antihypertensive medication), and the resident's blood pressure before administering lisinopril (antihypertensive medication), per the parameters set in the physician's orders. In addition, Resident 7 had physician's order to administer Wellbutrin (antidepressant), Adderall (mixed amphetamine salts), carvedilol, and Eliquis (anticoagulant medications) BID to be given at 0900 and 1700 hours per the facility's scheduled administration time, however, RN 4 administered these medications at 1100 hours. These failures had the potential to result in the antihypertensive medications being administered when Resident 7's BP and heart rate were outside the physician's ordered parameters at the time of the medication administration, increasing the risk of adverse effects. Additionally, administering the medications outside the prescribed schedule could potentially result to the treatments to be less effective or delay their intended therapeutic benefits.Findings: Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed the following:- medications are administered in accordance with written orders of the attending physician; and- medications are administered within 60 minutes of scheduled time (one hour before and one hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. According to the facility's document titled Schedule of Medication Administration Times (undated) medications prescribed with a BID frequency are scheduled to be administered at 0900 and 1700 hours. On 8/4/26 at 1044 hours, a medication administration observation for Resident 7 was conducted with RN 4. RN 4 prepared Resident 7's medications including the following:- one tablet of Adderall 30 mg;- one tablet of Eliquis 5 mg;- one tablet of lisinopril 20 mg;- one tablet of carvedilol 12.5 mg; and- one tablet of Wellbutrin 150 mg. On 8/4/26 at 1105 hours, RN 4 was observed going into Resident 7's room with the resident's medications in a medication cup. Resident 7 took all the medications from the medication cup. RN 4 was not observed checking Resident 7's BP nor his heart rate. Medical record review for Resident 7 was initiated on 8/4/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report showed the following physician's orders dated:- dated 7/8/26, to administer Adderall 30 mg one tablet by mouth two times a day;- dated 7/8/26, to administer carvedilol 12.5 mg one tablet by mouth two times a day. To hold if SBP was less than 110 mmHg or if heart rate was less than 60 beats per minute;- dated 7/8/26, to administer lisinopril 20 mg one tablet by mouth one time a day. To hold if SBP was less than 110 mmHg;- dated 7/16/26, to administer Wellbutrin 150 mg one tablet by mouth two times a day; and- dated 7/26/26, to administer Eliquis 5 mg one tablet by mouth two times a day. On 8/4/26 at 1115 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 4. RN 4 was observed clicking Resident 7's list of medications shown in the resident's electronic medical record, which were all marked in red. RN 4 explained if the medications were not administered within one hour after 0900 hours, the electronic health record changes the medication status to pink to indicate they were late. RN 4 verified Resident 7's medications were supposed to be given at 0900 hours, but she administered his medications at 1100 hours. RN 4 stated the facility's scheduled administration time for BID was 0900 and 1700 hours. RN 4 confirmed she administered Resident 7's medications late. RN 4 stated she was late because of her workload. RN 4 was also observed taking out a list of vital signs from her packet and began typing Resident 7's BP and heart rate into the resident's medical record. RN 4 verified she did not check Resident 7's BP and heart rate prior to administering the lisinopril and carvedilol medications. RN 4 stated the resident's vital signs including the BP and heart rate were checked by the CNAs at 0900 hours. RN 4 further stated the CNAs would report to the licensed nurses when the resident's vital signs were not within range, and then she would assess the resident, and recheck the resident's vital signs. On 8/7/26 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to ensure the control measures to minimize the risk of Legionella entering the facility were followed and documented. * The facility failed to ensure the three areas in the facility with stagnant water were properly checked to prevent the growth of Legionella. * The facility failed to ensure one of three industrial washing machines was in a sanitary condition. * The facility failed to ensure the window in the wall where the folding table with clean linens, towels and gowns used for the residents were directly touching it were cleaned. * The facility failed to ensure Resident 20 was placed on contact isolation per the physician's order. In addition, the facility failed to implement contact isolation precautions for Resident 20. These failures posed the risk of not identifying the residents' infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease revised 7/2018 showed the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; - specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained; and - maintains compliance with other applicable federal, state, and local requirements. Review of the CDC-Controlling Legionella-Monitoring Building Water dated 3/15/24, showed the following: - it's important to monitor the temperature, disinfectant residuals, and pH of building water, and identify areas where water move slowly; - promptly addressing any identified issues can help reduce the risk of Legionella growth and spread within a building's water system; - Legionella grows best between 77 degrees F–113 degrees F (25 degrees C–45 degrees C). There's potential for Legionella growth in the absence of other Legionella controls under either of the following conditions: cold water temperatures rise above 77 degrees F (25 degrees C) and warm water temperatures fall below 120 degrees F (49 degrees C); - store and circulate cold water at temperatures below 77 degrees F, although Legionella may grow at temperatures as low as 68 degrees F (20 degrees C); - store hot water at temperatures above 140 degrees F (60 degrees C). Ensure hot water in circulation doesn't fall below 120 degrees F (49 degrees C) and recirculate hot water continuously, if possible. Maintain water heaters at appropriate temperatures while following local and state anti-scald regulations. Sometimes maximum temperatures allowed by a state may be too low to limit Legionella growth. Engineering controls that mix hot and cold water together at or near the point of use can both reduce the risk of scalding and allow water in pipes to remain hot enough to limit Legionella growth; - measure the time it takes for hot water to reach the maximum temperature. This is an indication of how quickly or efficiently hot water travels in the system; and - maintaining a disinfectant residual throughout a system can help prevent Legionella growth. Measure the disinfectant residual to confirm its presence. Note the difference between the disinfectant residual value at the water supply and at fixtures. The difference between incoming and point-of-use disinfectant residual values can indicate an issue. Water age, sediment and biofilm, and warm temperatures are all things that increase depletion of disinfectant residuals. Certain disinfectants work best within an optimal pH range. Review of the facility's P&P titled Legionella: Water Management Program Policy revised 8/28/25, showed Legionellosis is a condition caused by the presence of the bacterium Legionella, which can reside in the facilities water distribution systems. Legionella can cause a severe respiratory disease called Legionnaires' disease that can affect vulnerable populations, such as the elderly or immunocompromised. Legionella and other water-borne pathogens spread through the droplets of water and through contaminated devices using facility water, such as ice machines or showers. The water management program used by our facility includes the following elements: - the identification of areas in the water system that could encourage the growth and spread of the Legionella or other waterborne bacteria, including- storage tanks, water heaters, filters, aerators, showerheads and hoses, hot tubs; - the identification of situations that can lead to Legionella growth, such as water temperature fluctuations; - specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); - the control limits or parameters that are acceptable and that are monitored; and - documentation of the program. Review of the facility's Infection Control-Water Management (undated) under The Building Water Systems section showed: - water enters the facility's main water system through the left hand side of the building. Distributing to the laundry, kitchen and water heaters and domestic water for the patients at the faucets and toilets. - cold water is distributed directly to water heaters, patients' rooms and nurse's station and shower rooms. Water is also distributed to laundry faucets, washing machines, dishwasher, ice machines and kitchen faucets. - hot water is heated for shower rooms for patients use and nurse's station to 105 degrees F to 120 degrees F by boiler. - hot water in the laundry room is heated to 160 degrees F by two water heaters located inside the laundry room that is located in the left-hand side. - hot water is distributed to all the floors from the storage tank and is tempered/mixed with cold water at the fixtures to ensure scald prevention. Facility has three sinks that are not being used, where stagnated water may provide an area of ideal temperature for pathogen growth: Hallway 2 - central supply room sink and Hallway 4 -medication room sink and supply room sink. Further review of the facility's Infection Control-Water Management, showed under the Legionella Environmental Assessment Form (Centers for Disease Control and Prevention); and - keep the following key factors that contribute to Legionella growth in mind as you complete the form: Temperature- Legionella generally grow well between 77 degrees F and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and legionella becomes dormant below 68 degrees F. a. On 8/5/26 at 1540 hours, an observation of the water heater tank on the open roof deck of the facility and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated he based the temperature when using it as preventative measure for Legionella to the water tank heater's temperature. The water heater tank's thermometer reading was observed at 110 degrees F. The temperature setting was observed at 120 degrees F. The Maintenance Director verified the findings and stated he set the temperature of this boiler at 120 degrees F. The Maintenance Director stated this was the water heater tank for the facility and the other two were in the laundry area. The water heater tank's temperature was observed to go up to 120 degrees F and fluctuated again to less than 120 degrees F. The Maintenance Director stated he inspects the water heater tank once daily and the temperatures would fluctuate below 120 degrees F or go up to 125 degrees F. The Maintenance Director stated nothing alerts him if the water heater tank's temperature went below 120 degrees F. The Maintenance Director stated he did not keep a record or log of the daily temperature of the water heater tank for the facility. b. On 8/5/26 at 1610 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated the facility had identified three areas with stagnated water. When asked what measures he used to prevent the Legionella growth in those three areas, the Maintenance Director stated he runs the water for three to five minutes and checks the water temperature. The Maintenance Director stated he records the monitoring in an application called TELS Report Builder. Review of the Legionella Monitoring-Building: Main Building report provided by TELS Report Builder dated 12/6/25 to 8/1/26, showed the following: - steps section showed, conduct temperature checks of any areas at risk for water stagnation as well as other water temperature control points. Verify the water temperatures at control points are within the acceptable ranges. Domestic and patient supply (105-120 degrees F). Kitchen/laundry supply (140-160 degrees F). - the Task Completion column for all the dates recorded showed Marked done on-time by the Maintenance Director - the Has Logs column for all the dates recorded showed Yes and - the Has Doc column for all the the dates recorded showed No. Further review of the document did not show which areas were inspected and water temperatures obtained during the monitoring. The Maintenance Director stated when he recorded it in the application using the computer, he could enter which area he checked and the water temperature. The Maintenance Director stated he did not have any physical log for the water temperature of the three areas with stagnant water. The Maintenance Director stated he would try to reach out to TELS if there was any way to print the report showing the areas he checked and the water temperatures. On 8/5/26 at 1640 hours, an interview was conducted with the Administrator, Maintenance Director, and IP. The Administrator, Maintenance Director, and IP were informed of the above findings. On 8/6/26 at 1630 hours, the IP provided a report of the Legionella Monitoring-Building: Main Building from April to July 2026 showing the three areas- Hallway 2 - central supply room sink and Hallway 4- medication room sink and supply room sink were checked, however, the report did not show the water temperature for the three areas. The IP stated there was no way to enter in the TELS application the water temperature. The IP was informed the Maintenance Director verified he did not have the log for the water temperature of the three areas stated above for his weekly inspection. 2. Review of the facility's P&P titled Departmental (Environmental Services) – Laundry and Linen revised 1/2014 showed the purpose of the procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. a. On 8/5/26 at 1000 hours, an inspection of the laundry room-dirty area was conducted with the Maintenance Director. Three industrial washing machines were observed. The Maintenance Director stated they were using all three industrial washing machines to wash the blankets, linens, towels and gowns used in the facility. Washing Machine 3 was observed not being used. Washing machine 3's door was observed with rust and thick hardened white and brown sediments. The Maintenance Director verified the findings. The Maintenance Director stated the laundry staff work every day from 0800 hours to 1600 hours. The Maintenance Director stated the washing machines were cleaned at the end of the day. b. On 8/5/26 at 1015 hours, an inspection of the laundry room-clean area was conducted with the Maintenance Director and Laundry Assistant. The window in the wall where the folding table with files of clean linens, towels, and gowns used for the residents were directly touching it. The window was observed with cobwebs and thick layer of dust. The Maintenance Director and Laundry Assistant verified the findings. The Laundry Assistant stated she already informed the housekeeping staff to clean it several times. The Maintenance Director stated it was not good for infection control. On 8/6/26 at 1200 hours, an interview with the IP was conducted. The IP stated she checked the laundry regularly. The IP was informed of the findings in the laundry area. On 8/7/26 at 1500 hours, an interview was conducted with the DON. The DON was informed and acknowledged all the above findings. 3. According to CDC, under Transmission-Based Precautions, use contact precautions for residents with known or suspected infections which represent an increased risk for contact transmission, and to use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Furthermore according to CDC, C. Difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are an inactive form of the germ and have a protective coating allowing them to live on surfaces for months. The bacteria can be transferred to patients via the hands of healthcare providers who have touched a contaminated surface or item. When entering the room of a patient with C. Difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. Current evidence demonstrates that C. Difficile spores may not be fully removed from hands, regardless of the method used to clean hands. This further emphasizes the need for appropriate use of gloves for the care of patients with C. difficile. Review of the facility's P&P titled Isolation – Categories of Transmission-Based Precautions revised 10/2018 showed the following: - when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. (a) The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room, and (b). Signs and notifications comply with the resident's right to confidentiality or privacy; - contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. - staff and visitors will wear gloves (clean, non-sterile) when entering the room.(a) While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage), (b) Gloves will be removed and hand hygiene performed before leaving the room, and (c) Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed; and - staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. On 8/4/26 at 0739 hours, during the entrance conference with the DON, Administrator, and AIT. The DON stated Resident 20 was on contact isolation for possible C. difficile. On 8/4/26 at 0810 hours, during the initial tour of the facility, Resident 20 was observed in bed. An EBP sign was observed posted near the door and a small hand symbol placed below the resident's name, and an isolation cart located next to the entrance. Medical record review for Resident 20 was initiated on 8/4/26. Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's Order Summary Report showed the following physician's orders: - dated 7/28/26, EBP related to indwelling device. Apply enhanced barrier to prevent the spread of infections for specific care activities such as: morning and evening care, toileting and changing, incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance, and preparing to leave the room, cleaning and disinfecting the environment; - dated 8/4/26, contact isolation precautions – single/private room for possible C. Difficile every shift. PPE cart outside room, gown and gloves to be worn before entering the room; and - dated 8/5/26, contact isolation precautions – single/private room for possible C. Difficile, all services provided in patient's room, therapy, dining, and activities every shift. PPE cart outside room, gown and gloves to be worn before entering the room. On 8/4/26 at 0859 hours, CNA 4 was observed going to Resident 20's room without any PPE. Then CNA 4 went out of the room and told CNA 1 Resident 20 wanted coffee. On 8/4/26 at 0904 hours, CNA 1 was observed going to Resident 20's room, and used the ABHR but did not use PPE. On 8/4/26 at 0923 hours, a visitor was observed inside Resident 20's room. The visitor was not observed wearing any PPE. On 8/4/26 at 0924 hours, an interview was conducted with CNA 1. CNA 1 verified she went inside Resident 20's room without PPE. CNA 2 stated she went inside Resident 20's room to give him his coffee. CNA 1 verified Resident 20 was on contact isolation. When asked what contact isolation mean, CNA 1 stated it means, we are to gown up, sanitize hands, and wash hands in the station. I just gave coffee. We wear the PPE only when we do contact with the resident. On 8/4/26 at 0940 hours, an observation, interview and concurrent medical record review for Resident 20 was conducted with RN 3. When asked what isolation Resident 20 was on, RN 3 stated enhanced. RN 3 was shown the physician's order for Resident 20 to be on contact isolation. RN 3 verified an EBP sign was posted near the door, and a small hand symbol placed below the resident's name. When asked where the contact isolation sign for Resident 20 was, RN 3 stated the small hand symbol meant Resident 20 was on contact isolation. During the interview, the DSD/IP was observed changing the EBP sign to a contact isolation sign near door. RN 3 verified the visitor inside Resident 20's room was not wearing any PPE. On 8/5/26 at 0835 hours, Resident 20 was observed in bed. A contact isolation sign was observed posted near the door, a small hand symbol placed below the resident's name, and an isolation cart located next to the entrance. The contact isolation sign alerted visitors to report to nursing station before entering, perform hand hygiene before entering and before leaving the room, wear gloves when entering room or cubicle, and when touching resident's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch resident items or potentially contaminated environmental surfaces, or use resident-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between residents. On 8/5/26 at 0837 hours, the Janitor was observed going in and out of Resident 20's room using ABHR, but no PPE. On 8/5/26 at 0839 hours, an observation for Resident 20, and concurrent interview was conducted with the Janitor. The Janitor verified he went inside Resident 20's room without PPE The Janitor verified Resident 20 was on contact isolation. When asked what contact isolation mean, the Janitor stated if you are going to make contact with the resident and the bed, wear PPE. If no contact, just hand sanitize, can go in there and talk to the resident. The Janitor further stated he was not informed about the resident's infection. On 8/5/26 at 1500 hours, an interview and concurrent medical record review for Resident 20 was conducted with the DSD/IP. The DSD/IP stated Resident 20 was on monitoring for symptoms of C. Difficile, such as loose stools and abdominal cramping since 7/28/26, and they were still waiting for the result of the C. Difficile, PCR test. When asked why Resident 20 was not placed on contact isolation then, the DSD/IP stated the isolation was placed on hold per the licensed nurse documentation, to which she showed the resident's progress notes. Review of Resident 20's Progress Notes showed a nurses note dated 7/31/26 at 0030 hours, showing hold isolation until results are finalized. The DSD/IP verified Resident 20 was placed on contact isolation on 8/4/26. The DSD/IP stated she placed the order at 0700 hours on 8/4/26. When asked if she clarified the contact isolation order with Resident 20's physician, the DSD/IP stated I will have to check the communication with the nurses, when I came in Tuesday morning. The DSD/IP verified the hand symbol was not a contact isolation sign but only meant to stop the staff and visitor, and to flip the sign to show where the infection could be, and it was stool for Resident 20. The DSD/IP verified the contact isolation was changed hours after the initial order for contact isolation was placed. On 8/7/26 at 0942 hours, an interview was conducted with CNA 4. CNA 4 verified she went inside Resident 20's room without PPE. CNA 4 stated she went inside Resident 20's room to give the activity paper, as she was assisting the activities department. CNA 4 verified Resident 20 was on contact isolation. When asked what contact isolation mean, CNA 4 stated If I am going into the room with any interaction with the resident or the surfaces, I used the hand sanitizer, gown, gloves, and do what I have to do. If I touch the resident, then gel in, PPE, do what I have to do, and then gel out. But if no contact with the resident or the surfaces, I just gel in, put the activity paper, then gel out. On 8/7/26 at 1347 hours, an interview was conducted with the DON. The DON stated Resident 20 had consistent diarrhea, but no foul-smell, and he was placed on contact isolation on 8/3/26, with a pending result of the C. Difficile PCR test. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper storage of medications in one of two medication carts inspected (Medication Cart A). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure an unlabeled container with unidentified white powder was not stored inside Medication Cart A. * The facility failed to ensure a medication intended for an individual resident was labeled inside Medication Cart A. * The facility failed to ensure the medications belonging to the residents who were discharged from the facility were removed from the Medication Cart A, and separated from the medications of current residents These failures had the potential for unauthorized access to the medications inside the unlocked medication cart, and medications to be accidentally administered and/or diverted.Findings: Review of the facility's P&P titled Storage of Medications revised 1/2025 showed the following:- only license nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access;- medications labeled for individual residents are stored separately from floor stock medication when not in medication cart; and- outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. On 8/4/26 at 0557 and 0559 hours, Medication Cart A was observed parked in front of the nurses' station and facing the hallway. Medication Cart A was observed unlocked and unattended, while the staff were observed passing by. On 8/4/26 at 0600 hours, an inspection of Medication Cart A and concurrent interview was conducted with RN 1. RN 1 verified Medication Cart A was left unlocked and unattended. During an inspection of Medication Cart A, the following was observed:- an unlabeled container with white powder;- a tube of triamcinolone (corticosteroid) ointment with the label torn off;- a tube of fluocinonide (corticosteroid) cream for Resident 33 stored with the current medications;- a tube of triamcinolone ointment for Resident 75 stored with the current medications; and- a tube of mupirocin 2% (antibacterial) ointment for Resident 41 stored with the current medications. a. Medical record review for Resident 33 was initiated on 8/4/26. Resident 33 was readmitted to the facility on [DATE]. Review of Resident 33's physician's order showed an order dated 7/27/26, to transfer the resident to acute care hospital. b. Medical record review for Resident 75 was initiated on 8/4/26. Resident 75 was readmitted to the facility on [DATE]. Review of Resident 75's physician's order showed an order dated 7/9/26, to transfer resident to acute care hospital. c. Medical record review for Resident 41 was initiated on 8/4/26. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's physician's order showed an order dated 8/2/26, to transfer resident to acute care hospital. RN 1 verified the above findings. RN 1 could not identify the white powder inside the unlabeled container. RN 1 verified the label was torn off from the triamcinolone medication. RN 1 further verified the medications for Residents 33, 41, and 75 were still stored with the current medications, and should have been stored separately from the current or active medications. On 8/7/26 at 1424 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the accuracy of the medical record for one of 14 sampled residents (Resident 7). * RN 1 failed to document the IV Vancomycin (antibiotic) medication was administered to Resident 7 on 7/14/26. This failure had the potential for the resident's care needs not being met as the clinical information was not accurate and complete.Findings: Review of the facility's P&P titled Charting and Documentation revised 2017 showed all the services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including:a. The date and time the procedure/treatment was provided;b. The name and title of the individual(s) who provided the care;c. Whether the resident refused the procedure/treatment; andd. The signature and title of the individual documenting. On 8/4/26 at 0630 hours, during the initial tour of the facility, Resident 7 was observed awake and lying in the bed. Resident 7 was observed with PICC line in the right upper arm. Resident 7 stated he was getting antibiotics for his infection in the bone. Medical record review for Resident 7 was initiated on 8/4/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report showed a physician's order dated 7/11/26, to administer Vancomycin Hydrochloride (antibiotic) Intravenous Solution 1.5 grams IV every 12 hours for Osteomyelitis until 8/11/26 at 2359 hours. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had an intact cognition. Review of Resident 7's IV Record for July 2026 showed on 7/14/26, the IV Vancomycin at 0900 hours was left blank. Further medical record review for Resident 7 failed to show documented evidence the IV Vancomycin was administered on 7/14/26 at 0900 hours. On 8/6/26 at 1402 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified Resident 7 was receiving IV Vancomycin for Osteomyelitis at 0900 hours and 2100 hours. RN 1 verified the IV Record for July 2026 showed on 7/14/26 at 0900 hours, the IV vancomycin medication was not signed off and left blank. RN 1 stated she was assigned to Resident 7 on 7/14/26 and she administered the IV Vancomycin medication on 7/14/26 at 0900 hours. RN 1 stated after the medication was administered, the nurse should document or sign it off right away or at least before the end of the shift. RN 1 was observed signing off the IV Record for the IV Vancomycin on 7/14/26 at 0900 hours. On 8/7/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 7.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 2 and 5) reviewed for unnecessary medications were free from the unnecessary medications. * The facility failed to monitor Residents 2 and 5 for the signs and symptoms of bleeding related to the use of the apixaban medication (an anticoagulant used to prevent blood clots). This failure had the potential for the residents to receive unnecessary medications and develop significant adverse effects.Findings: Review of the FDA approved Highlights of Prescribing Information for Eliquis (apixaban) issued on 4/2025 showed the most common adverse reaction in adult patients (residents) are related to bleeding. 1. Medical record review for Resident 2 was initiated on 8/4/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/14/26, showed Resident 2's medical decision making was highly complexed, and the resident was at high risk for life threatening deterioration. Review of Resident 2's Order Summary Report showed the following physician's orders:- dated 7/9/26, to administer apixaban oral tablet 5 mg one tablet by mouth two times a day for a fibrillation (a fast, uncoordinated heart rhythm where heart muscle fibers quiver instead of pumping blood normally); and- dated 7/21/26, for anticoagulant intake: check for sign of bleeding secondary to anticoagulant intake and call the physician if signs of bleeding is present -gum bleeding, coffee ground emesis, hematuria, bruising, epistaxis, abnormal bleeding on the injection site every shift; for anticoagulant usage legend: document, 0 = if no signs of bleeding, 1 = for presence of bleeding and notify the physician. Review of Resident 2's MAR for July 2026 showed Resident 2 received the apixaban medication from 7/1 to 7/5/26 at 0900 hours and at 2100 hours; 7/6/26 at 0900 hours; 7/9/26 at 2100 hours; 7/10 to 7/20/26 at 0900 hours and at 2100 hours; and on 7/21/26 at 0900 hours. Further review of Resident 2's medical record did not show documented evidence Resident 2 was observed or monitored for the signs and symptoms of bleeding for the days listed above. On 8/6/26 at 1553 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified there was no documented evidence Resident 2 was observed or monitored for the signs and symptoms of bleeding for the days listed above. 2. Medical record review for Resident 5 was initiated on 8/5/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/7/26, showed Resident 5 had the capacity to understand and make decisions. Review of Resident 5's Order Summary Report showed the following physician's orders:- dated 6/6/26, to administer Eliquis (apixaban) oral tablet 2.5 mg one tablet by mouth two times a day for atrial fibrillation; and- dated 7/21/26, for anticoagulant intake: check for sign of bleeding secondary to anticoagulant intake and call the physician if signs of bleeding is present -gum bleeding, coffee ground emesis, hematuria, bruising, epistaxis, abnormal bleeding on the injection site every shift; for anticoagulant usage legend: document, 0 = if no signs of bleeding, 1 = for presence of bleeding and notify the physician. Review of Resident 5's MAR for July 2026 showed Resident 5 received the apixaban medication from 7/1 to 7/20/26 at 0900 hours and at 2100 hours, and on 7/21/26 at 0900 hours. Review of Resident 5's plan of care initiated on 6/6/26, showed a care plan addressing Resident 5's high risk for signs and symptoms of bruising and bleeding related to the Eliquis medication use for atrial fibrillation. The interventions included to observe and report signs and symptoms of bruising, bleeding of the gums, coffee ground emesis, tarry stool, and hematuria. Further review of Resident 5's medical record did not show documented evidence Resident 5 was observed or monitored for the signs and symptoms of bleeding for the days listed above. On 8/7/26 at 1039 hours, an interview and concurrent medical record review for Resident 5 was conducted with LVN 1. LVN 1 verified there was no documented evidence Resident 5 was observed or monitored for the signs and symptoms of bleeding for the days listed above. LVN 1 stated as a nurse, she always checked the residents who were receiving anticoagulant medication for signs and symptoms of bleeding. LVN 1 further stated if there was an episode of bleeding, they would document it and initiate a change of condition. On 8/7/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the findings for Residents 2 and 5. The DON stated the black box warning next to the medication order has an indication to monitor bleeding. The DON stated they had a process to identify the adverse reactions of the anticoagulant medication so that if it was positive they would initiate a change in condition when asked where the monitoring for signs and symptoms of bleeding was because the MAR only showed the medication was administered.

Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for two of five sampled residents (Residents 1 and 3). * The facility failed to develop a care plan to address when Resident 1 had an actual fall on 11/26/25. * The facility failed to develop a care plan to address Resident 3's upper back abrasion. These failures had the potential risk of not providing the appropriate, consistent, and individualized care to these residents.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised December 2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation section showed the IDT must review and update the care plan when there has been a significant change in the resident's condition. 1. Medical record review for Resident 1 was initiated on 12/24/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 1's eINTERACT Change in Condition Evaluation V5 dated 11/26/25, showed the resident had an unwitnessed fall. Review of Resident 1's plan of care failed to show a care plan was developed to address the resident's actual fall on 11/26/25. On 1/21/26 at 1353 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified there was no care plan to address Resident 1's actual fall on 11/26/25. RN 2 stated the licensed nurse should have created the care plan for the actual fall and placed interventions and goals. On 1/21/26 at 1518 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no care plan for Resident 1's actual fall on 11/26/25. The DON stated the licensed nurse should have developed a care plan. 2. Medical record review for Resident 3 was initiated on 1/20/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 3's Post Fall IDT dated 1/12/26, showed Resident 3 had an upper back abrasion. Review of Resident 3's plan of care failed to show a care plan was developed to address Resident 3's upper back abrasion. On 1/21/26 at 1405 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified there was no care plan to address Resident 3's upper back abrasion. RN 2 stated the licensed nurse should have created a care plan for the upper back abrasion so the interventions would be implemented and to create the goals. On 1/21/26 at 1530 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no care plan to address Resident 3's upper back abrasion. The DON stated the care plan should have been done to address Resident 3's upper back abrasion.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of five sampled residents (Resident 3). * The facility failed to ensure Resident 3's change in condition documentation was accurate. This failure had the potential for the resident's health care needs not met as the medical record was inaccurate.Findings: Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation section showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 3 was initiated on 1/20/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severe cognitive impairment. Review of Resident 3's eINTERACT Change in Condition Evaluation V5 dated 1/12/26, showed the resident had an unwitnessed fall. Under the question whether Resident 3 was on other anticoagulant (direct thrombin inhibitor or platelet inhibitor), showed no. Review of Resident 3's Order Summary Report dated 1/20/26, showed a physician's order dated 12/25/25, to administer clopidogrel bisulfate (antiplatelet medication used to prevent blood clots) oral tablet 75 mg, give one tablet by mouth one time a day for CAD. On 1/21//26 at 1405 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 acknowledged Resident 3 had an unwitnessed fall and was on clopidogrel bisulfate medication. RN 2 stated the licensed nurse should have answered yes on the question because Resident 3 was on anticoagulant and at risk of bleeding. On 1/21/26 at 1530 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 3 was on clopidogrel bisulfate medication stated the licensed nurse should have answered yes on the question for the accuracy of documentation.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of four sampled residents (Resident 1). * The facility failed to ensure the follow-up assessment, physician notification, and documentation were completed when Resident 1 had low pulse rate and poor oral intakes. These failures posed the risk of the resident not receiving the appropriate care and delay in the provision of care to the resident.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the following:- the nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition;- a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention and impacts more than one area of the resident's health status;- prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form; and- the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 10/9/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 14 (cognitively intact). Review of Resident 1's H&P examination dated 9/10/25, showed Resident 1 had the capacity to understand and make decisions. a. According to AHA (American Heart Association) document titled Bradycardia: Slow Heart Rate revised on 9/25/24, showed bradycardia is a heart rate that is too slow, usually less than 60 beats per minute. Review of Resident 1's admission and Baseline Care Plan dated 9/5/25, showed a blood pressure of 118/79 mmHg and pulse rate of 76 bpm (beats per minute). Review of Resident 1's Weights and Vital Summary for September 2025 showed the following pulse rate readings:- dated 9/9/25 at 0930 hours, the pulse rate was 55 bpm;- dated 9/9/25 at 1645 hours, the pulse rate was 50 bpm; and- dated 9/13/25 at 2026 hours, the pulse rate was 57 bpm. Review of Resident 1's medical records failed to show documentation if the follow up assessments were done and the physician was notified of the low pulse rate. On 10/9/25 at 1429 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 1's abnormal pulse rates dated 9/9 and 9/13/25. RN 1 verified Resident 1's medical record it failed to show the follow up assessments, interventions, notification of the physician, and documentation when Resident 1 had low pulse rate. RN 1 was asked what she considers a change in condition in a resident and RN 1 stated it could be abnormal vital signs, altered level of consciousness, weakness, skin problems, fall, increased pain, and any changes in resident's condition from his or her baseline. b. Review of Resident 1's Meal Intake from 9/5 to 9/12/25, showed the percentage of the meals eaten by Resident 1 on the following dates:- dated 9/13/25, breakfast = 0 - 25%, lunch = 26-50%, dinner = 26 - 50%;- dated 9/14/25, breakfast = 25 - 50%, lunch = 0-25%, dinner = 0 - 25%;- dated 9/15/15, breakfast = 0 - 25%, lunch = 0-25%, dinner was refused;- dated 9/16/25 breakfast = 0 - 25%, lunch = 0-25%, dinner = 51-75%; and- dated 9/17/25 breakfast = 0 - 25%, lunch = 0 - 25%, dinner = resident not available. On 10/10/25 at 0930 hours, a follow-up interview and concurrent medical record review was conducted with RN 1. Resident 1's meal intakes dated 9/13-9/17/25, was reviewed with RN 1 which showed decreased meal consumption with refusal. RN 1 verified there was no documented evidence if the follow up assessments, physician notification, change of condition evaluation, and care plan was developed when Resident 1 had poor meal intake. Furthermore, RN 1 stated the negative outcome would cause Resident 1's condition to decline because he was not consuming the appropriate nutrients. On 10/10/25 at 1100 hours, an interview and concurrent medical record review were conducted with CNA 1. CNA 1 verified Resident 1's poor meal intakes dated 9/13 to 9/17/25. CNA 1 stated Resident 1 became weaker, refused to participate with activities, and refused to get up in wheelchair after four to five days of admission. CNA 1 stated she reported Resident 1's change of condition including the significant decrease in meal intake to the charge nurses. On 10/10/25 at 1212 hours, a telephone interview was conducted with LVN 2. LVN 2 was asked what she would consider a change of condition, and stated fever, abnormal labs, decline in activities of daily living (ADL), new pain or increase pain, ALOC (altered level of consciousness), abnormal vital signs blood pressure below100/60 mmHg or pulse rate below 60 bpm or above 90 bpm, and refusal of meals or below 25% meal consumption. LVN 2 stated the assigned licensed nurse must assess the resident, complete the change of condition evaluation, notify the physician, notify responsible party or family, initiate a care plan, add to the alert charting, and document the monitoring every shift for 72 hours. Furthermore, LVN 2 stated the negative outcome would be not being able to provide the appropriate quality care and monitoring for the resident's change of condition and resident's condition could become worse. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated abnormal vital signs were not a significant change and not considered a COC (Change of Condition). The DON stated she did not expect her licensed nurses to do a follow up entry when there are abnormal vital signs and after providing interventions to reflect resident's current condition. The DON was asked how she would know when the resident's abnormal vital signs (pulse rate) improve if there were no follow up assessments and documentation of the outcome, the DON stated the nurses cannot document every hour since they had a lot of residents. The DON stated she considered a significant COC if the resident's meal intake was 0 - 25% consecutively with refusal for three to four days. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one of four sampled residents (Resident 3). * The facility failed to ensure CNA 3 wore the appropriate PPE when providing high-contact resident care for Resident 3. This failure had the potential to transmit communicable disease to other residents throughout the facility.Findings: Review of the facility's P&P titled EBP dated 6/20/24, showed the following:- EBP used in conjunction with the standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing reduce transmission;- facility staff shall post a visual alert by the resident's door indicating the high-contact resident care activities requiring the use of gowns and gloves for residents with the following criteria for the duration of a resident's stay in the facility or until resolution of the targeted criteria that placed them at higher risk like indwelling medical devices with or without secretions or excretions even if the resident is not known to be infected or colonized with a MDRO such as central lines, urinary catheters, feeding tube, and tracheostomies;- the facility shall provide required PPEs and alcohol-based hand rub (ABHR) readily available, and PPEs may be discreetly accessible to staff to use to help maintain a home-like environment as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; and- facility staff shall perform hand hygiene and will don gown and gloves before performing the following high-contact resident care activities like dressing, bathing/showering/transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy or ventilator, and wound care on chronic wounds requiring a dressing. Medical record review for Resident 3 was initiated on 10/10/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary report showed a physician's order dated 10/6/25, for EBP related to the indwelling devices. Review of Resident 3's H&P examination dated 10/7/25, showed Resident 3 had the capacity to understand and make decisions. On 10/10/25 at 0855 hours, an observation of Resident 3 and concurrent interview was conducted with CNA 3. Resident 3's door had signage indicating the resident's roommate was on EBP. Upon entering Resident 3's room, CNA 3 was observed wearing only gloves and transferred Resident 3 to the wheelchair. CNA 3 stated he assisted Resident 3 with the morning care like brushing his teeth and transferring to the wheelchair in preparation for dialysis pick up. CNA 3 stated he was aware Resident 3 has dialysis and verified he wore only gloves. CNA 3 verified the signage outside the door showed Resident 3's roommate was on EBP and should have worn the proper PPE. On 10/10/25 at 0904 hours, an observation, interview and concurrent medical record review for Resident 3 was conducted with RN 3. RN 3 verified Resident 3 had a physician's order for EBP related to the indwelling device due to having a central line for dialysis access. RN 3 stated the EBP sign outside Resident 3's room should have shown Resident 3 was also on EBP per the physician's order. RN 3 stated the sign must be updated by the DSD because the DSD was responsible for checking and updating residents who have orders for EBP. RN 3 stated all the staff should don gowns and gloves during high-contact resident's care activities like morning care and transfers to prevent the spread of infection. On 10/10/25 at 1350 hours, an interview was conducted with the IP nurse. The IP nurse stated for any residents who have an order for EBP, all staff must wear gloves and gown when providing morning care and transferring the residents. In addition, the IP nurse stated she was responsible for placing the EBP signage and PPE carts with the help of her assistant. Furthermore, the IP nurse stated the negative outcome of the staff not following EBP would be spreading the staff's germs to the residents. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated it was important for all the staff to follow the EBP to prevent direct caregiver transmission of any infection to the residents. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of four sampled residents (Resident 2) reviewed for communication needs. * The facility failed to ensure Resident 2 was provided with the means to communicate her daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care.Findings: Review of the facility's P&P titled Translation and/or Interpretation of Facility Services revised 5/2017 showed the following:- when encountering LEP (Limited English Proficiency) individuals, staff members will conduct the initial language assessment (e.g., I Speak Cards) and notify the staff person in charge of the language access program;- the coordinator of this facility's language access program is the Director of Social Services, or his/her designee; - all LEP persons shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge. If written notice is not possible, such notice shall be given orally;- this facility shall provide written translation of vital information pertaining to health services, resident rights and facility policy if the LEP population represents at least five (5) percent of the population or 1000 people eligible to be served by the facility (whichever is fewer);- family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information;- it is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English; and- it is understood that to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. Review of the facility's P&P titled Resident Rights revised 12/2016 showed the following:- federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communication with and access to people and services, both inside and outside the facility and exercise his or her rights as a resident of the facility and as a resident or citizen of the United States. Medical record review for Resident 2 was initiated on 10/9/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's admission Screen and Baseline Care Plan dated 9/27/25, showed Resident 2's mental status was alert and oriented to name, place, and time, need or want an interpreter to communicate with a doctor or health care staff, and preferred language is Cantonese. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's Brief Interview for Mental Status (BIMS) score was 12, which meant the resident had moderate cognitive impairment. On 10/8/25 at hours, Resident 2 was observed sitting up in wheelchair awake, alert, and Vietnamese and Cantonese speaking. Resident 2 was able to speak and understand very limited English. Resident 2 was asked how long she has been staying in the facility and the reason for her stay in the facility. Resident 2 gestured with her hand and stated, No and was not able to answer. Resident 2 was interviewed with the assistance of the translation services via phone for Vietnamese language . Resident 2 was asked how she communicated her daily needs to the staff and how the staff understood her since Resident 2 spoke mainly Vietnamese and Cantonese. Resident 2 stated there were no Vietnamese or Cantonese speaking staff to translate, communication board provided and available to use in her room, and the facility staff did not use any translator via telephone. In addition, Resident 2 stated since no one can understand, speak, or translate in her language, she had to wait for her family to arrive and communicate her needs. On 10/8/25 at 1132 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 1. LVN 1 was asked which was the preferred language of Resident 2 and how the resident communicated her daily needs. LVN 1 stated Resident 2 spoke Chinese or Korean language and able to express her needs. LVN 1 stated Resident 2's family member visited the resident every day from morning until bedtime, at around 2100 hours. LVN 1 was asked how the facility staff would understand and communicate with Resident 2 when the family member was not around or between the hours of 2200 to 0700 hours. LVN 1 stated if a family member was not present, there were staff from rehabilitation department who can translate, use a communication board, or use the facility's telephone to translate. In addition, LVN 1 was asked to show Resident 2's communication board. LVN 1 was followed to Resident 2's room to look for the communication board consistent with the resident's preferred language; however, LVN 1 failed to show a communication board was present and available for Resident 2 to use to communicate her needs. LVN 1 stated the communication board was not necessary to be available inside Resident 2's room. Furthermore, when LVN 1 was asked how to use the language line using the facility's telephone, LVN 1 was not able to show how to use the language line via facility's telephone and walked away. On 10/8/25 at 1140 hours, an observation and concurrent interview for Resident 2 was conducted with CNA 2. CNA 2 was asked to show the communication board for Resident 2. CNA 2 was observed looking for the communication board inside Resident 2's room. CNA 2 stated she could not find the communication board and was not available inside Resident 2's room. CNA 2 stated if any resident was not able to communicate their needs, the resident's needs might not be met. On 10/8/25 at 1145 hours, an observation and concurrent interview for Resident 2 was conducted with the DSD. The DSD stated the nurses use the language line solutions and there were staff who spoke Korean. The DSD was asked to show the communication board inside Resident 2's room; however, the DSD failed to show the communication board was available for Resident 2 and facility staff to use. On 10/8/25 at 1217 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 2 spoke Chinese and Vietnamese language and very limited English. Family Member 1 stated Resident 2's family member visited daily and stayed until 2200 hours so the family member can be there to communicate Resident 2's daily needs because the resident could not understand English. However, during the family's absence or night hours (2300-0700 hours), Family Member 1 stated she was concerned if Resident 2's needs were met because she did not know how the facility staff could understand Resident 2 and vice versa. Family Member 1 was asked how the facility staff communicated with Resident 2, if facility staff have used a communication board or a language line to translate. Family Member 1 stated she has not seen a communication board in Resident 2's preferred language(s) provided and available in the room, nor did the facility staff have used a communication board during Resident 2's stay. In addition, Family Member 1 stated she has not observed any facility staff using the language line translation with Resident 2. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided basic life support to one of two sampled residents (Resident 1). The nursing staff did not follow the American Heart Association guidelines and the facility's P&P in providing basic life support prior to the arrival of emergency medical services (EMS) personnel for Resident 1. The licensed nurses failed to activate the emergency response system in a timely manner prior to the arrival of emergency medical personal. This failure resulted in Resident 1 not receiving CPR timely and continuously until the EMS personnel arrived. Findings: Review of the facility's P&P titled Emergency: Initiation of Code Blue dated [DATE], showed a licensed staff person must remain with the resident at all times, call 911 for emergency transfer to an acute care center, and continue CPR efforts until the ambulance service arrives or until spontaneous respirations, pulse, and blood pressure return. Review of the American Heart Association (AHA) Basic Life Support Sequence and Basic Life Support Healthcare Provider Adult [MEDICAL CONDITION] Algorithm dated (YEAR) showed, if the victim is unresponsive, shout for nearby help, and activate the emergency response system. Review of the AHA Ethical Issues-CPR and Emergency Cardiovascular Care guidelines dated (YEAR) showed rescuers who start basic life support (BLS) should continue resuscitation until one of the following occurs: * Restoration of effective spontaneous circulation, * Care is transferred to a team providing advanced life support, * The rescuer is unable to continue because of exhaustion, or * Reliable and valid criteria indicating irreversible death are met. Closed medical record review was initiated for Resident 1 on [DATE]. Resident 1 was admitted to the facility under hospice care on [DATE]. Hospice care was revoked by Resident 1's family on [DATE]. Resident 1 expired on [DATE]. Review of Resident 1's POLST dated [DATE], showed the box was checked for staff to attempt resuscitation/CPR when the resident has no pulse and was not breathing. Review of the History and Physical dated [DATE], showed the physician and Resident 1's family members had a discussion regarding the resident's plan of care including the code status. The documentation showed Resident 1's family members decided Resident 1 was to be on a full code status. This would mean the facility staff was to initiated CPR and call 911 in the event Resident 1 went into [MEDICAL CONDITION]. On [DATE] at 0950 hours, an interview was conducted with the DON concerning Resident 1. The DON stated, when she arrived to the facility on [DATE] at approximately 0755 hours, she saw RN 1 walking toward the nurses' station. RN 1 informed her Resident 1 had passed away. The DON asked RN 1 if CPR had been done and if 911 had been called. RN 1 stated CPR had been stopped and 911 had not been called. The DON instructed RN 1 to go back to Resident 1's room and resume CPR, and for LVN 1 to call 911. On [DATE] at 1045 hours, an interview was conducted with LVN 1. LVN 1 stated, during her rounds on [DATE] at approximately 0710 hours, she observed Resident 1 and he appeared to be sleeping in bed. At approximately 0745 hours, a CNA reported they could not obtain Resident 1's vital signs. LVN 1 stated she called out for RN 1's help and they entered Resident 1's room together. Resident 1 was found without a pulse or respirations. LVN 1 stated RN 1 started CPR and LVN 1 left the room to get the crash cart (a wheeled cart with supplies and equipment used in a medical emergency). LVN 1 stated she returned to the room and assisted RN 1 with CPR. LVN 1 stated after approximately 3 to 4 rounds of CPR, LVN 1 stated she left the room to call the physician. At around 0755 hours, the DON had arrived and asked if 911 had been called. LVN 1 stated no as she called the physician first. LVN 1 stated the DON instructed her to call 911. LVN 1 was asked if she remembered her training in basic life support (BLS) CPR and the sequence to follow. LVN 1 stated she could not recall from her BLS training when to call 911. On [DATE] at 0933 hours, a telephone interview was conducted with Physician 1. Physician 1 stated he had received a telephone call from the facility's nurse on [DATE] approximately 0755 hours, about CPR being performed on Resident 1. He stated he asked the nurse if 911 had been called, the nurse said no and he instructed the nurse to call 911. On [DATE] at 1628 hours, a telephone interview was conducted with RN 1. RN 1 stated, on [DATE] at approximately 0745 hours, LVN 1 called her to come to Resident 1's room. RN 1 stated both she and LVN 1 checked Resident 1's pulse and respirations. RN 1 stated Resident 1 did not have a palpable pulse or respirations and she initiated CPR. RN 1 stated LVN 1 left the room and returned with the crash cart. She stated they performed two person CPR (one person was at the chest performing chest compressions and the other person was giving rescue breaths) for about 10 minutes. LVN 1 then left the room to call the resident's physician while she continued to perform one person CPR (same person will do chest compression and rescue breathing). RN 1 stated she walked out of the resident's room when she was met by the DON. The DON asked RN 1 if 911 had been called. RN 1 stated she had informed the DON 911 had not been called. The DON then instructed her to resume CPR. RN 1 stated two person CPR was continued until the Paramedics arrived and took over CPR. RN 1 was asked if she remembered her training in BLS CPR and the sequence to follow. RN 1 stated to try and arouse first, then call 911, and then start CPR. RN 1 was asked if she followed the BLS sequence? RN 1 stated no; they had started CPR and 911 had not been called until the DON instructed staff to do so. Review of the Official Incident Report from the county emergency response authority dated [DATE], showed the emergency response system was activated on [DATE] at 0805 hours. This was approximately 20 minutes after the CNA reported they could not obtain Resident 1's vital signs.

Based on interview, and clinical record review, the facility failed to ensure one of three sampled residents (Resident 1) had sufficient fluid intake to maintain adequate hydration to meet his daily needs. The facility identified Resident 1 was at risk for dehydration. The RD recommended 1854 ml of fluid daily for hydration. However, Resident 1 was consuming an average of 880 ml of fluid a day. The facility failed to promptly develop and implement interventions to improve the resident's hydration status. In addition, the facility failed to notify the attending physician of the resident's poor oral intake. These failures contributed to Resident 1's admission to the acute care hospital with [DIAGNOSES REDACTED]. According to the Mayo Clinic (web based resource), signs and symptoms of severe dehydration include dry oral mucous, little or no urination, dry skin and sunken eyes. Signs and symptoms of severe dehydration may include disorientation, sleepiness, extreme thirst and lethargy. Review of the facility's P&P titled Hydration/Fluid Management revised date 1/5/11, showed residents will be monitored for physical signs of dehydration (sunken eyes, concentrated urine, poor skin turgor, etc.). Any resident with signs and/or symptoms of dehydration is to be reported to the RD, nursing and the attending physician. These healthcare professionals will review the fluid status of the resident. In addition, the physician is to be notified when there is a significant change in the resident's fluid intake or output. On 3/13/13, clinical record review for Resident 1 was initiated. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]." Review of the Minimum Data Set (an assessment tool) dated 2/13/13, showed Resident 1 has moderate cognitive impairment, and requires extensive assistance for all ADLs, including the intake of fluids. Review of a Vital Signs and Weight Record form dated 2/6/13, showed Resident 1's admission weight was 136 pounds and he was 5'8" tall. A physician's order dated 2/6/13, showed an order for [REDACTED]. every shift. According to Lexi-Comp Online (web base resource for health professionals), a side effect/risk of [MEDICATION NAME] includes "volume depletion and dehydration." A care plan problem titled "Noncompliance" dated 2/7/13, showed Resident 1 was at risk for weight loss/dehydration related to episodes of "refusing food and liquids." The approaches showed to give the resident positive reinforcement and choices, monitor his meal consumption, mucous membranes, changes in condition, and any labs ordered. However, there was no documentation to show the resident had been started on [MEDICATION NAME]. Another care plan problem titled "Eating/Nutrition" dated 2/7/13, showed Resident 1 was at risk for alteration in nutrition related to dysphagia (difficulty swallowing), poor appetite and weight loss. The approaches included RD assessment/evaluation of caloric needs, "food/fluid consumption measured/documented/monitored daily, alert nursing if less than 25% of food or fluids taken in 24 hours." However, there were no specific interventions or parameters on how to meet the resident's daily hydration needs. In addition, there were no interventions to address how to encourage the resident to eat/drink. Review of a laboratory report dated 2/6/13, (from the acute hospital upon discharge to the facility) showed Resident 1's BUN was 29 mg/dL (normal range = 5 to 20 mg/dL), his Creatinine was 1.04 mg/dL (normal range = 0.61 to 1.24). Review of the Nutritional assessment dated [DATE], showed the RD identified Resident 1 to be at risk for dehydration related to dysphagia and poor oral intake. The resident's current oral intake was documented as less than 50%. The RD estimated Resident 1 needed between 1854 to 2163 calories per day. The resident's fluid intake needs were identified to be 1854 ml per day. The RD recommended a CMP blood test to assess the resident's organ function; and to monitor the resident's oral intake. Review of the laboratory report dated 2/12/13, showed Resident 1's BUN had increased to 32; his sodium level was 147 (normal = 136-144 mmol/L). The Nutritional Progress Note dated 2/22/13, showed the RD documented Resident's 1 current weight was 130.8 pounds. This was a loss of 4.4 pounds or 3% in one week. The resident's average intake was 58% (less than his estimated needs). The RD also noted the resident's laboratory values (from 2/12/13) and documented they were "suggestive of a decrease in fluids status." The RD recommendation was to obtain a BMP (Basal Metabolic Panel, a blood test to evaluate kidney function to assess hydration status). Review of the ADL Status form from 2/6 to 2/26/13, showed Resident 1's daily fluid intake was approximately 880 ml a day (50% of his daily needs). In addition, his average meal intake was approximately 50%. Review of the ADL Status form from 2/21 to 2/26/13, showed Resident 1 refused 15 of 18 snacks offered. On 2/22/13, a CNA documented Resident 1 refused food and liquids; "nurse was notified. There was no documented evidence staff notified the resident's attending physician of Resident 1's poor oral intake. On 2/22/13, Resident 1's weighed 130.8 pounds. This was a loss of 5.2 pounds or 4% in 16 days. Review of the Dietary Conference Meeting dated 2/22/13, showed the IDT recommendation was to obtain a BMP the following week. There was no explanation as to the reason they were waiting another week to obtain this test. Resident 1 had a known history of mild dehydration and his laboratory values from 2/12/13, showed his BUN and sodium were elevated; and he continued to have a poor oral intake. Review of the physician's orders showed an order dated 2/22/13, for a BMP to be done on 3/1/13 (seven days later). During an interview with the RD on 3/14/13 at 0830 hours, the RD stated recommendations need to be acted upon immediately. On 3/14/13 at 0900 hours, an interview was conducted with RN 1. She was asked why the IDT decided to wait one week to check Resident 1's BMP. She stated Resident 1 had no signs or symptoms of dehydration. When asked if she informed the physician regarding Resident 1's poor fluid intake, weight loss, and his refusal of snacks, she stated, "no." Resident 1 was seen by a ST on 2/7/13. Review of a Speech Therapy of Care Evaluation form dated 2/8/13, showed Resident 1 was tolerating a mechanical soft diet with prolonged mastication (chewing), and required nectar thick liquids. On 2/26/13 at 1400 hours, the ST documented Resident 1 was seen in the dining room for lunch. The resident was observed eating a mechanical soft meal and he had an extremely prolonged mastication, was pocketing food, requiring cues to swallow. The ST also documented Resident 1 was unable to hold his head up for longer than several seconds; due to frequently falling asleep during the meal. Review of a Narrative Progress Note (Significant Clinical Findings) dated 2/26/13 at 1530 hours, showed Resident 1's family member stated Resident 1 "did not look the same." Staff documented they assessed the resident. He was verbally responsive, though weak, afebrile (without a fever) with no short of breath or distress noted. The physician was called and a message was left regarding the resident's status. At 1730 hours, the licensed nurse documented "Waiting for attending physician's response at this time." On 3/12/13 at 0930 hours, an interview with Resident 1's family member was conducted. The family member stated, when Resident 1 was admitted to the facility, he was able to feed himself and could walk. However, for the last two weeks he was at the facility, he could not eat or drink well. She stated, during the lunch time meal on 2/26/13, she noted he was not able to swallow anything that was offered to him. In addition, she stated, in the last two days, his mental status was declining and he became more confused, weak and disoriented. Additional clinical record review showed a physician's order dated 2/27/13 at 2430 hours, to transfer Resident 1 to an acute care hospital, emergency department for evaluation of "scrotal laceration." Review of the acute care hospital's Laboratory Report form dated 2/27/13, showed Resident 1 had an elevated BUN of 124, his Creatinine was 3.3 and his Sodium was 172. In addition, the resident's white blood cell count was 12.1 (normal range 3.6-11.0 K/UL). A urinalysis was completed with findings positive for Urinary Tract Infection [MEDICAL CONDITION]. Review of the acute care hospital's History and Physical form dated 2/27/13 at 1358 hours, showed Resident 1's admitting [DIAGNOSES REDACTED]. The resident was admitted to the hospital for IV hydration and monitoring of his kidney function. A physician's note dated 2/28/13, showed "...suspect his acute changes is secondary to the marked electrolyte abnormalities." The acute care hospital's Laboratory Report dated 3/4/13, showed, after Resident 1's electrolytes and dehydration abnormalities were corrected, he had a normal BUN of 16 mg/dL and his sodium was 137. On 3/14/13 at 1100 hours, an interview was conducted with the DON. The DON stated Resident 1 had episodes of refusing fluids. The DON stated the facility does not have a specific hydration plan, but staff do monitor residents to ensure adequate hydration is offered. She stated residents have a right to refuse. On 3/20/13 at 1448 hours, an interview was conducted with Resident 1's attending physician. The attending physician was asked if he was notified regarding Resident 1's poor oral intake, weight loss, refusal of multiple meals, or the RD's recommendation for a BMP. The physician stated "No; nobody informed me, or I would have ordered more labs and started an IV.