Every finding on record at Westwood Vlge NRSG and RHB CTR

Based on interview and record review, the facility failed to provide an accurate quarterly statements to the residents who have Individual Resident Fund accounts for four (R1, R2, R3 and R6) of six residents (R1-R6) reviewed for resident funds and has the potential to affect all 111 residents residing in the facility. Findings include: 1. According to the Electronic Health Record (EHR) R1 had diagnoses including Parkinson's disease with dyskinesia, unspecified dementia, hypertensive heart disease without heart failure, anemia, dysphagia, Cognitive communication deficit, bilateral primary osteoarthritis of hip, scoliosis, insomnia, benign prostatic hyperplasia with lower urinary tract symptoms, major depressive disorder, and blepharospasm. R1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] shows R1's cognition was intact with a fourteen out of fifteen points requires on the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment). On 1/9/2026 at 10:45 a.m., R1 was observed in the dining room eating lunch. R1 stated he didn't get his trust fund money for the last two weeks, stated he wanted to get the entire $200 in the Resident Trust Sheet but the facility did not give it to him because he was told he can only get $30. R1 also stated he has not received a quarterly statement of his trust fund account during his entire stay here. V1 (Administrator) presented the facility Trust Fund Sheet which documents that R1 received trust fund money on the following dates and amount received:4/24/25 $30.00; 5/1/25 $15.00; 5/15/25 $15.00; 7/31/25 $30.00; 9/11/25 $25.00; 10/30/25 $30.00; 11/6/25 $30.00; 11/20/25 $15.00; 11/25/25 $15.00; 12/20/25 $30.00.2. On 1/9/2026 at 1:10 p.m., R2 stated that he has been getting his $30 from the trust fund every Thursday but he has never received a quarterly statement of the trust fund account. R2 also stated he asked for an audit of his account but was not provided with a statement of accounts and would like to receive it regularly.The Minimum Data Set (MDS) dated [DATE] shows R2's cognition was intact with a fifteen out of fifteen points requires on the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment).3. On 1/9/2026 at 2:20 p.m., R3 also stated that R3 has never received a quarterly statement of R3's trust fund account.The Minimum Data Set (MDS) dated [DATE] shows R3's cognition was moderately impaired with a twelve out of fifteen points requires on the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment).4. On 1/9/2026 at 2:00 pm, R6 stated that he has been getting his $30 trust fund money regularly but he has not received a quarterly statement. The Minimum Data Set (MDS) dated [DATE] shows R6's cognition was intact with a fourteen out of fifteen points requires on the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment).On 1/09/2026 at 2:00PM, V3 (Business Office Manager) affirm that a quarterly statement is not provided to the residents but every time they get their trust fund money every week, they can see their balance. V3 also affirm that the balance on the Trust Fund Sheet is not accurate because it does not consider any deposits or credits that go into the account. V3 stated that the balances on the sheet does not reflect the statement on the RFMS. V3 stated V3 has not provided the quarterly statements since 2023 but starting this month, V3 will make sure that all the deposits are added to the Resident Trust Fund Sheet to make it accurate and that V3 will send out the quarterly statements to the residents. On 1/09/2026 at 2:20 V3 provided the quarterly statements that she will provide to R1-R6.Facility policy titled Resident Personal Trust Fund Policy and Procedure dated 4/15/2024 states that the quarterly statement of all transactions for the individual resident's account including withdrawals, direct charges, deposits, and interest will be prepared and provided to the resident or legal representative. The Center for Medicare and Medicaid Services Form 671 titled Long term Care Facility Application for Medicare and Medicaid, dated 01/09/2026 and signed by V1 (Administrator) documents 111 residents currently reside in the facility.

Based on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in the sample of five. Findings include:R1's face sheet documents R1 was admitted to the facility on 11.3.2023, with diagnoses including but not limited to: Other intestinal obstruction, schizoaffective disorder, bipolar type; Chronic obstructive pulmonary disease, Cognitive communication deficit. R1's MDS (Minimum Data Set of 9.2.2025) documents a BIMS (Brief Interview for Mental Status) of 14 denoting R1 is cognitively intact.R2's face sheet documents R2 was admitted to the facility on 1.5.2025 with diagnoses including but not limited to: Chronic obstructive pulmonary disease, Hypertensive heart disease without heart failure, Chronic respiratory failure, other schizophrenia. R2's MDS (Minimum Data Set of 9.28.2025) document R2's Cognitive Skills for Daily Decision Making as Independent-decisions consistent/reasonable.10.2.2025 12:00 PM, surveyor attempted to ask R1 about the incident. R1, who uses a dry erase board for communication, refused to answer questions; became agitated (throwing arms up in the air) and left the room.10.2.2025 at 12:10 PM V2 (Director of Nursing/DON) said R1 declined to speak with police or file a report. She initially said nothing happened then told V1 (Administrator) that it did happen; that they (R1 and R2) were on the patio, and it happened on the patio, R2 slapped her (R1) in the face.10.2.2025 at 1:15 PM, R3 said, we were sitting there with our cigarettes on the patio. R2 was on the patio picking up butts. She went over to R1 and asked for a light. R1 backed away from R2, then R2 slapped R1 in the face with an open hand. We heard it too.10.2.2025 at 3:11 PM, V9 (Licensed Practical Nurse) said, I was alerted by a resident that R2 had slapped another resident (R1). I asked R1 simple yes/no questions. She indicated that no one hit her. R2 denied hitting R1. I'm thinking it did happen. R1 refused to give a statement to the police or press charges. R2 continued to deny striking (R1).R2 was not in the facility during the investigation.Facility's initial incident report of 9.27.2025 documents in part, R1 and R2 were involved in an altercation on the patio. R2 was removed from the room and placed on 1:1 monitoring. Investigation ongoing.R1's witness statement documents, She (R2) asked for a light and my cigarette cigar was short. I said no. She (R2) grab (grabbed) the cigarette she hit.R2 's witness statement documents, (R1) is not terribly slapped by me? No. I don't do it? R3's witness statement documents, (R2) came out to have a cigarette and she cannot find the lighter. She walked up (R1) and asked for a light. (R1) said no and (R2) slapped (R1) on her face and grabbed the cigarette out of her (R1) mouth. (R2) walked to the corner and smoked (R1) cigarette.V9's witness statement documents, (R2) and (R1) had (a) physical altercation in (on) patio over a cigarette. (R1) stated that (R2) hit her (R1) left cheek. No injuries noted. Police (non-emergency) came to talk to both resident(s). (R1) declined to give a statement and refused to place charge.All the above statements were dated/timed 9.27.2025 at 6:30 PM.R1's progress note of 9.27.2025 at 12:01 AM (Recorded as Late Entry on 9.28.2025 12:09 AM) documents in part, Resident had physical altercation with another female resident on the patio, over a cigarette, when writer asked (R1) what happened, she stated she was hit by (R2) on the left cheek.R2's progress note of 9.27.2025 at 7:00 PM (Recorded as Late Entry on 9.28.2025 12:09 AM) documents in part, Resident had physical altercation with another female resident on the patio, over a cigarette.Abuse Prevention Policy (2.7.2017) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to prevent and protect residents from verbal abuse for two (R1 and R2) out of four residents reviewed for resident-to-resident abuse. The findings include:R1's face sheet showed R1's admission date was on 1/6/25 with diagnoses not limited to Asthma, Bipolar disorder, Hypertensive heart disease without heart failure, Delusional disorders, Other psychoactive substance use, Other chronic pain, Anxiety disorder, Insomnia. MDS (Minimum Data Set) dated 7/9/25 showed R1's cognition was intact.R2's face sheet showed R2's admission date was on 5/30/25 with diagnoses not limited to Hemiplegia, unspecified affecting left dominant side, Bipolar disorder, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Myelodysplastic syndrome, Pathological fracture left ankle, Spinal stenosis cervical region, Hypertensive heart disease without heart failure, Chronic kidney disease, Generalized anxiety disorder, Schizoaffective disorder, Personal history of transient ischemic attack (TIA), and cerebral infarction, Nicotine dependence. MDS dated [DATE] showed R2's cognition was moderately impaired.On 8/24/25 At 10:05AM observed R1 ambulating with a walker with steady gait, alert, oriented x 3, and verbally responsive. R1 said about a couple of weekends ago, R2 threatened/harassed her. She said R2 was going to attack me or hit me. R2 was shouting at me. R1 further stated that R2 cursed her and stated, B****, get out of my way. F*** you. I will beat you're a** out. On 8/24/25 at 10:24am R2 observed sitting up in a wheelchair by his bedside, alert and oriented x 3, verbally responsive. He said about a couple of weekends ago, R1 called him N***R. R2 said R1 is mad at him whenever she saw him. He said R1 cursed him and called out names whenever he is coming. R2 stated R1 yelled/screamed at him saying F*** you, F*** off. R2 said he cursed back at R1 and stated leave me alone, CRAZY or I will knock on your a** out, F*** you. R2 said he yelled/screamed/cursed R1 too. On 8/24/25 At 10:53AM V3 (Licensed Practical Nurse/LPN) said had worked with R1. Surveyor reviewed R1's EHR (electronic health record) with V3 and he stated he wrote progress notes for R1 on 8/10/25. V3 said there was incident between R1 and R2 on 8/10/25. He said R1 was verbally aggressive with R2, there was a lot of back and forth between R1 and R2 but did not hear specific words that they (R1 and R2) were saying to each other. V3 said both R1 and R2 were raising voices/yelling at each other. V3 said he could hear upset voices from R1 and R2 but was not able to hear specific words. He said staff separated R1 and R2. V3 said it was reported to him that that R1 was harassing R2 with yelling profanities or using swear words probably F*** words. V3 said R1 and R2 were using not appropriate language - more of aggressive words but can't say specific words or appropriate language that were used by R1 and R2. R1's Progress Note dated 8/10/25 by V3 (LPN) showed in part: R1 has been verbally aggressive with various staff/peers. Staff received complaints from peers/staff that R1 was agitating other clients unprovoked by yelling profanities at them.R1's Care plan dated 1/6/25 showed in part: R1 is at risk for abuse due to residing at a long-term care facility. Resident will be free of abuse/neglect daily.On 8/24/25 At 11:07AM V9 (Certified Nursing Assistant/CNA) stated she had worked with R2 but not with R1. Stated she knew R1. V9 said there was an encounter between R1 and R2 about couple of weekends ago, both R1 and R2 were yelling/screaming/cursing at each other. V9 stated R1 said to R2 shut the f*** then R2 cursed back to R1 stating, get the f*** out of my way. V9 said both R1 and R2 were exchanging F words to each other. She said both residents were separated. V9 said it was verbal abuse between R1 and R2 because they were yelling/screaming and cursing at each other. Stated she thought the administrator was aware of it because there were nurses who heard or witness the verbal abuse at that time. On 8/24/25 At 12:08PM V12 (CNA) stated had seen R1 and R2 yelling and screaming at each other and staff need to break up and control the situation. V12 said it happened about a couple of weekends ago when R1 and R2 passed or saw each other. V12 said R2 cursed at R1, stated F*** you. I am tired of this shit. I want the f*** out of here. I am tired of that b****. V12 said R1 did cursed back to R2 and stated F*** you, F*** off. V12 said it was a verbal abuse between R1 and R2 and he thought the Administrator knew about it. On 8/24/25 At 1:25PM V13 (LPN) stated she had been working with R2. She said R2 is alert and oriented x 3, Easily agitated, cursing, yelling and screaming to staff. Surveyor reviewed R2's EHR with V13 and stated that R2 had a verbal altercation with R1 on 8/10/25. V13 said R1 and R2 were going back and forth. She said R1 and R2's voices were raised or were yelling at each other. V13 said R2 yelled at R1, R2 stated leave me the F*** alone. V13 said R1 was threatening R2 to call the police on him and R1 will put R2 in jail. V13 said R1 called R2 N***R. She said R1 does not like R2. V13 said she heard R1 cursing but could not identify or remember the words R1 said to R2. V13 said they separated both residents (R1 and R2). She said the Administrator was informed about the incident. V13 said the incident between R1 and R2 could be viewed as verbal abuse to each other due to raising of voices/yelling and threatening. R2's Progress Note by V13 (LPN) dated 8/10/2025 showed in part: R2 was involved in a verbal altercation with peer. This resident was in his room when he was approached by a peer. Peer called this resident a N***r and stated she was going to call the state and the police and have this resident arrested. Peer threatened to have this resident placed in (County jail). R2 then stated leave me the f*** alone I am not bothering you. Peer continued to make inappropriate statements to R2. Residents were separated at this time.On 8/24/25 At 1:54PM V15 (CNA) stated she had worked with R2 but did not work with R1, but she knows R1. V15 said R2 could be verbally and physical abusive with staff, would try to hit staff. V15 said R1 and R2 screamed or yelled at each other. She said R1 does not want to be around R2. V15 said did not hear R1 or R2 cursing each other. Stated she could not recall the specific words/cursed words used by R1 and R2.On 8/24/25 At 2:16PM V2 (Director of Nursing/DON) she said an example of Verbal abuse is belittling, name calling, cursing, screaming/yelling at each other. She said resident in the facility should be free from abuse. On 8/24/25 At 2:29PM V1 (Administrator) stated she has been working in the facility for 32 years and she is the Abuse coordinator. Stated Types of abuse are Physical, verbal, mental, sexual, exploitation, inv seclusion, neglect, chemical restraint. V1 said example of verbal abuse is screaming/yelling, cursing, calling out their names, demeaning/belittling resident. V1 said the goal is for all residents to be free of any abuse in the facility. Facility's abuse prevention program policy dated 2/2017 showed in part: The facility affirms the right of our residents to be free from abuse. Verbal abuse is the use of oral language that willfully includes disparaging and derogatory terms to residents within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. Facility's residents' rights policy dated 11/18 showed in part: You must be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on observation, interview and record review, the facility failed to ensure that the air temperature in the facility resident rooms was 71 to 81 degrees Fahrenheit (F) for 23 residents (R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24 and R25) reviewed for inadequate cooling. Findings include: On 6/24/25 at 2:05 PM, R9 stated that R8 and R9's room had been feeling warm for a few days prior to the fire department staff coming into the facility on 6/21/25. R9 stated that the air conditioner (AC) unit in R8 and R9's room in the ceiling had been leaking water recently and wasn't blowing cool air. R9 stated that R9 reported it to V24 (Housekeeping Supervisor) and then reported it to V14 (Social Services Director/SSD) who informed R8 that R8's room was on the list for the AC to be fixed. R9 stated that on 6/20/25, R8 saw the air temperature reading on the thermostat in R8 and R9's room reading 85 degrees F and knew that it was still going to be hot over the weekend, so R8 requested a temporary room change to a different room in the facility which was granted by staff. R9 stated that on 6/21/25 in the evening, R9 walked back towards the nurse's station near R9's original room (with R8) for R9's medications and then R9 walked back into room to retrieve a belonging. R9 stated that R8 was still in the room laying on the bed, and It was oppressive. It was too hot in there. R9 stated that the fire department staff arrived that evening (6/21/25) around 10:00 PM. R9 stated that R9 moved back to R8 and R9's room after the AC was fixed. R9's Face Sheet documents, in part, diagnoses of diabetes mellitus, spondylosis with myelopathy, hypertensive heart disease, hyperlipidemia, polyneuropathy, major depressive disorder, generalized anxiety disorder, restless leg syndrome and otalgia left ear. On 6/25/25 at 9:30 am, R8 stated that the room AC in R8 and R9's room was leaking water from the AC unit in the ceiling, but now it's fixed. R8 stated that the temperature was warm in R8 and R9's room for several days prior to 6/21/25, but R8 likes the warmer air temperature and chose to stay in R8's room. R8's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus, hypertension, chronic kidney disease stage 2, seizures, primary open-angle glaucoma bilateral, conductive hearing loss bilateral, schizoaffective disorder, malignant neoplasm of kidney, acquired absence of kidney, folate deficiency anemia, major depressive disorder, mild intellectual disabilities, and age-related nuclear cataract bilateral. On 6/25/25 at 9:32 am, R20 stated that R20 is now in a different room in the facility due to the temperature in the other room was very poor, too hot. R20 stated that R20 can't recall which day it was that R20 moved, but it was hot outside and hot inside the facility. R20 stated that R20 is blind and needed help to move. R20 stated that R20 complained to the nurse, and the nurse moved R20. R20's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus with diabetic retinopathy, orthostatic hypotension, hypertensive heart disease, difficulty in walking, lack of coordination, cognitive communication deficit, nicotine dependence, age-related nuclear cataract bilateral, and legal blindness. On 6/25/25 at 9:36 am, R15 stated that it was so warm in R12, R13, R14 and R15's room on 6/21/25, and the staff moved me out of the room that night. R15's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, psychosis, and paranoid schizophrenia. On 6/25/25 at 9:42 am, R3 stated that for R3, R17 and R24's room AC unit in the ceiling, there was a problem where it had been dripping water, and the blower wasn't working. R3 stated that on 6/21/25, R3 read the air temperature reading on their room's thermostat at 87 degrees F with it being very warm R3's room. R3 stated that R3 was not moved from R3, R17 and R24's room on 6/21/25 or 6/22/25, and the facility brought in a portable AC unit. R3's Face Sheet documents, in part, diagnoses of asthma, polyarthritis, schizoaffective disorder, hypothyroidism, hypertensive heart disease, hyperlipidemia, major depressive disorder and nicotine dependence. On 6/25/25 at 9:45 am, R10 stated that R10 was in a room with R11 on 6/21/25, and it was hot and humid in their room. R10 stated that R10 was moved to a different room on 6/21/25 at night after the fire department staff arrived. R10's Face Sheet documents, in part, diagnoses of dementia, schizophrenia, obesity, major depressive disorder, and obesity. On 6/25/25 at 9:50 am, R24 stated that it was recently warm in R3, R17 and R24's room but was unable to provide additional details. R24's Face Sheet documents, in part, diagnoses of hypothyroidism, major depressive disorder, hypertension, hyperlipidemia, bipolar disorder, schizoaffective disorder, extrapyramidal and movement disorder, anxiety disorder, insomnia, legal blindness, and neoplasm of left kidney. On 6/25/25 at 9:53 am, R17 stated that water had been leaking from R3, R17 and R24's room AC unit in the ceiling recently and now it's been fixed. R17 stated that R17's naturally feels cold, so the warmth that R17 felt in R17's room was not a problem for R17. R17's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, hypertensive heart disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, anemia, and tachycardia. On 6/25/25 at 10:00 am, R18 stated on 6/21/25, it was hot like a sun of a gun. R18 stated, Everyone knew that it was hot in here, I (R18) told them (staff) too, and R16, R18 and R25's room AC unit in the ceiling wasn't working on 6/21/25. R18 stated that when the fire department staff came late in the evening on 6/21/25, then the staff moved R16, R18 and R25 to a different room in the facility. R18's Face Sheet documents, in part, diagnoses of hemiplegia affecting left dominant side, bipolar disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, myelodysplastic syndrome, spinal stenosis, anemia, hypothyroidism, anemia, benign prostatic hyperplasia, chronic kidney disease, generalized anxiety disorder, schizoaffective disorder, and nicotine dependence. On 6/25/25 at 10:07 am, R16 stated that R16, R18 and R25's room AC wasn't working prior to 6/21/25, and the air temperature in their room kept going up. R16 stated that R16, R18 and R25 were moved to a different room in the facility late on 6/21/25. R16's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertensive heart disease, generalized osteoarthritis, hyperlipidemia, benign neoplasm of parotid gland, hyperlipidemia, open-angle glaucoma, and Bell's palsy. On 6/25/25 at 2:47 PM, R14 stated that it was warm in R12, R13, R14 and R15's room recently but was unable to provide additional details. R14's Face Sheet documents, in part, diagnoses of asthma, schizophrenia, dementia, type 2 diabetes mellitus, gastrostomy status, epilepsy, chronic obstructive pulmonary disease, hypothyroidism, and glaucoma. On 6/25/25 at 2:49 PM, R4 stated that on 6/21/25 at night, R4 was moved from R2 and R4's room due to their room being warm with the AC unit in the ceiling not working. R4's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus, hypertensive heart disease, chronic obstructive pulmonary disease, anemia, schizoaffective disorder, hyperlipidemia, chronic kidney disease, low back pain, nicotine dependence, and sleep apnea. On 6/25/25 at 2:51 PM, R2 stated that R2 and R4's room in the facility was hotter than h*** on 6/20/25 and 6/21/25. R2 stated that R2 read their room air temperature on the thermostat as 88 degrees F on 6/21/25, and with the increased humidity, it felt hotter than 88 degrees F. R2 said that R2 complained to 2 nursing staff members on 6/21/25, and no one was doing anything. R2 stated that R2 called 911 around 6:30 PM on 6/21/25 telling the operator that the heat was unbearable in the facility. R2 stated that R2 spoke with the fire department staff in the facility in the evening on 6/21/25, and R2 and R4 were moved to separate rooms that night. R2's Face Sheet documents, in part, diagnoses of emphysema, chronic obstructive pulmonary disease end stage, severe protein-calorie malnutrition, hypertensive heart disease, cerebral infarction, cerebral ischemia, major depressive disorder, iron deficiency anemias, benign prostatic hyperplasia, dry eye syndrome and nicotine dependence. On 6/25/25 at 3:27 PM, R11 stated that R11 was moved from R10 and R11's former room on 6/21/25 due to the warmth in that room. R11's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus, schizoaffective disorder, chronic kidney disease stage 3, hypertensive heart disease, orthostatic hypotension, hyperlipidemia, major depressive disorder, benign prostatic hyperplasia, obstructive sleep apnea, and chronic respiratory failure. On 6/25/25 at 3:32 PM, R25 stated that it was warm in R16, R18 and R25's room on 6/21/25, and they were moved to a different room in the facility later that night. R25's Face Sheet documents, in part, diagnoses of hypertension, hyperlipidemia, schizoaffective disorder, hypothyroidism, open-angle glaucoma bilateral, and cataract. On 6/25/25 at 3:34 PM, R22 stated that it was getting warmer in R22 and R23's room on 6/21/25, but they stayed in their room. R22's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, combined systolic and diastolic (congestive) hear failure, hypothyroidism, major depressive disorder, schizoaffective disorder, sciatica, hyperlipidemia, and migraine. On 6/30/25 at 1:07 PM, R23 stated that R22 and R23's room AC unit wasn't working right, and there's a portable AC unit in R22 and R23's room due to room being warm. R23's Face Sheet documents, in part, diagnoses of dementia, polyneuropathy, type 2 diabetes mellitus, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, post-traumatic stress disorder, osteoarthritis, low back pain, major depressive disorder, and sleep apnea. On 6/30/25 at 1:09 PM, R13 stated that R12, R13, R14 and R15's room was real warm on 6/21/25, and the fan that was provided by staff in their room wasn't helping to cool the room. R13 stated that R13 was moved to a different room at night on 6/21/25 because it was too hot in their room. R13's Face Sheet documents, in part, diagnoses of hypertensive heart disease, iron deficiency anemia, paranoid schizophrenia, pain in hip and knee, and osteoarthritis. On 6/30/25 at 1:11 PM, R12 stated that R12, R13, R14 and R15's room was very warm on 6/21/25, and the fan that was provided by staff in their room wasn't helping to cool the room. R12 stated that R12 was moved to a different room at night on 6/21/25. R12's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus, epilepsy, dysphagia, paranoid schizophrenia, hypothyroidism, hyperlipidemia, and edema. On 6/30/25 at 1:15 PM, R21 stated that R21 was moved from R19 and R21's former room due to it being so hot, and the AC unit in their former room was broken. R21's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, schizophrenia, type 2 diabetes mellitus, hypertensive heart disease, respiratory failure, epilepsy, absolute glaucoma bilateral, psoriasis and sudden idiopathic bilateral hearing loss. On 6/30/25 at 1:18 PM, R19 observed in R19 and R21's new room and not responding verbally to surveyor questions. R19 nodded yes to moving to a different room due to elevated air temperature in the former room. R19's Face Sheet documents, in part, diagnoses of Parkinson's disease, chronic obstructive pulmonary disease, emphysema, schizophrenia, severe protein-calorie malnutrition, systolic (congestive) heart failure, retention of urine, hypertensive heart disease, benign prostatic hyperplasia, major depressive disorder, and post-traumatic stress disorder. On 6/30/25 at 1:20 PM, R6 stated, It was so hot, I (R6) couldn't sleep. R6 stated that the AC unit in the ceiling in R6 and R7's room was broken. R6 stated that the staff knew about the hot situation on 6/21/25, and that one unknown female staff member had come into R6's room saying that it was hot in this room. R6 stated that then the fire department staff came that night (6/21/25-6/22/25), and the facility staff then moved R6 and R7 to a different room. R6's Face Sheet documents, in part, diagnoses of type 2 diabetes mellitus, schizoaffective disorder, generalized anxiety disorder, delusional disorders, and nicotine dependence. On 6/30/25 at 4:14 PM, R7 stated that R7 was moved to a different room and is happy to be back in R6 and R7's room with the AC unit fixed. R7's Face Sheet documents, in part, diagnoses of vascular dementia, chronic obstructive pulmonary disease, hypertensive heart disease, hyperlipidemia, osteoarthritis, major depressive disorder, respiratory failure, schizophrenia, severe protein-calorie malnutrition, syncope and collapse, convulsions, epilepsy, absolute glaucoma bilateral and polydipsia. On 6/24/25 at 2:29 PM, V5 (Licensed Practical Nurse/LPN) stated that there were four nurses assigned and working on 6/21/25 for the 7:00 am to 3:00 PM shift, and V5 was working on side 1. V5 stated that a majority of V5's residents' rooms were cool; however, several rooms V5 noted that the AC was not working well like it wasn't working fast enough. V5 stated that R19 and R21's room was warm. V5 stated that there was a manager on duty (MOD) who was the DON, V2 (Director of Nursing/DON), and that V5 did not notify V1 (Administrator) or V2 of R19 and R21's room air temperature being too warm on 6/21/25. On 6/24/25 at 2:47 PM, V6 (LPN) stated that V6 was working on 6/21/25 during the 7:00 am to 3:00 PM shift, and V6 was assigned to side 4. V6 stated that when V6 walked through the hallway passing by resident rooms on side 3, V6 stated, It was so hot. V6 stated that some residents had towels on the floor due to the AC units in the ceiling leaking water to the floor. V6 stated that some residents were stepping out of their rooms saying that it's too warm in their rooms, including R16. V6 stated that V6 did know what happened to R16's leaking AC unit but it was so hot in that room. V6 stated that V6 did not report to nobody. I won't lie. I didn't. I didn't talk to the next shift (oncoming evening shift). It's the AC, there's nothing that I can do about it. Besides it's Saturday (6/21/25). They (residents) have to wait to Monday. On 6/24/25 at 3:02 PM, V7 (Certified Nursing Assistant/CNA) stated that V7 worked on 6/21/25 from 7:00 am to 3:00 PM and was assigned to side 3. V7 stated that some resident rooms felt warm that day, including R2 and R4's room. V7 stated that R2 was complaining that it was too hot in R2 and R4's room, and V7 stated that it felt warm over there on side 3. V7 stated that V7 had informed V3 (Housekeeper) of the increased air temperature while working on 6/21/25. On 6/24/25 at 3:41 PM, V8 (LPN) stated that V8 was working on 6/21/25 from 3:00 PM to 11:00 PM and was assigned to side 1 residents. V8 stated that one resident, R20, complained of it being too warm in R20's room. V8 stated that it was hot outside and that R20 had just come back from being outside in the smoking patio so asked R20 to give it some time for R20's room to cool down. V8 stated that around 6:00 PM on 6/21/25, R20 was still complaining of R20's room being too warm, so V8 moved R20 to a different room. V8 stated that around 10:00 PM, a fire department staff member entered the facility telling V8 that a resident had called saying that the temperature was unbearable in the facility. V8 stated that V8 instructed V19 (Registered Nurse/ RN) to call V1 (Administrator), and V8 then phoned and notified V2 (DON) about the fire department staff wanting to tour the facility to check on residents' welfare. V8 stated that V2 was working in the facility on 6/21/25 as the MOD but left the facility around 6:00 PM. On 6/24/25 at 3:54 PM, V9 (RN) stated that V9 worked on 6/21/25 from 7:00 am to 11:00 PM. V9 stated that one resident, R2, came up to the nurse's station to complaint about R2's room being too hot. V9 stated that V9 would normally call the MOD about elevated room air temperatures, but R2 wasn't on my side. On 6/24/25 at 4:01 PM, V19 (RN) stated that V19 worked on 6/21/25 from 3:00 PM to 11:00 PM and was working on side 2. V19 stated that R2 complained of R2 and R4's room being too warm, and V19 investigated by walking into R2's room which was warm with the AC unit not working. V19 stated that around 10:00 PM when the fire department staff entered the facility, V19 then called and notified V1 (Administrator). On 6/25/25 at 3:44 PM, V10 (CNA) stated that V10 worked on 6/21/25 from 3:00 PM to 11:00 PM, and V10 worked on side 2 and 3. V10 stated that at 3:00 PM on 6/21/25 during rounds, V10 observed R2 talking the nurse about the heat in R2's room. V10 stated V6 (LPN) checked on R2's room. V10 stated that some other resident rooms were not much cool but (V10) didn't look at the thermostat but it was like a tropical heat. V10 stated that around 9:30 PM to 10:00 PM, the fire department staff entered the facility. On 6/25/25 at 11:37 am, V3 (Housekeeper) stated that V3 is a housekeeper and when V1 needs an extra hand, I am maintenance. V3 stated that the one maintenance staff for the facility is V21 (Maintenance Director) but V21 is currently on vacation. V3 stated that V3's responsibilities are to mop and sweep all resident rooms and communal areas and cleans the bathrooms and shower rooms. V3 stated that V3 is also responsible to catalog the (air) temperatures in (resident rooms), and V3 does this by looking at the actual air temperature reading on the AC thermostats in each resident room. V3 stated that V3 is looking for readings of 72 to 74 degrees F. V3 stated that for air temperature readings greater than 74 degrees, V3 will tell V24 (Housekeeping Director) on Tuesdays, Thursdays and Saturdays when V24 is working and will tell V1 on the other days. V3 stated that V3 documents each air temperature reading from residents' rooms on the air temperature log. V3 stated that V3 will collect the resident room air temperature readings in the morning time and the air temperature readings normally rise throughout the daytime. V3 stated that V3 worked on 6/21/25 from 7:00 am to 3:00 PM, and it didn't start heating up until to 2 PM. After that 2 PM, I (V3) think its spiked. I didn't get no temps because I got them in the morning. I left at 3 PM. Me, I was feeling it (heat in the facility). V3 stated that V3 had addressed several residents' complaints of their rooms being too hot with their AC units leaking water. When asked if V3 notified V1, V21 (Maintenance Director) or V24 (Housekeeping Supervisor) on 6/21/25 of the leaking AC units or residents' complaints of feeling too hot in their rooms, V3 stated, I didn't tell anyone. On 6/25/25 at 1:40 PM, V2 (DON) stated that V2 was working as the MOD on 6/21/25 onsite in the facility from approximately 8:00 am to 6:00 PM. V2 stated that as the MOD, V2 is responsible for ensuring that residents are being taken care of and to oversee the functioning of the facility and staff. V2 stated that on 6/21/25, the heat index outside was 104 degrees F and that V2 placed a hold on residents leaving the facility on community passes due to the excessive hot weather. V2 stated that on 6/21/25, V2 did address R2 saying that it was too hot in R2 and R4's room by shutting the room window. V2 stated that V2 received no reports from the facility staff on 6/21/25 about the facility feeling too warm. V2 stated that V2 left the facility around 6:00 PM, and later V8 (LPN) phoned notifying V2 that someone called 911 about the facility being too warm. On 6/24/25 at 9:52 AM, V1 (Administrator) stated that on 6/21/25 while at home, V1 received a phone call from V19 (RN) stating that someone called the fire department saying that the rooms were too hot. V1 stated, I did not get a phone call, so I didn't know there was an issue. I was at home. Once I got the call that they were here, I got here within 10 minutes. V1 stated that V1 performed a tour with the fire department staff who was taking air temperature readings with their equipment with elevated air temperature readings is some resident rooms. V1 stated that with the directive of the fire department staff, V1 must move the residents from their rooms to a cooler room in the facility if the room air temperature was 85 degrees or higher. V1 stated that on the night of 6/21/25 to into 6/22/25, R2, R4, R6, R7, R8, R10, R11, R12, R13, R14, R15, R16, R18, R19, R21 and R25 were all relocated to different rooms in the facility, with R9 refusing to move. V1 stated that with the directive of the fire department staff, V1 must monitor the air temperature room readings hourly, and for resident rooms reading 80 to 84 degrees F, these residents must be monitored closely. This surveyor and V1 reviewed the hourly air temperature readings starting at midnight on 6/22/25, and V1 stated that V1 phoned the contracted air conditioning company, and early Sunday on 6/22/25, they ran a diagnostic test on the air conditioning system in the facility. V1 stated that when the air conditioning system was turned on by the contracted air conditioning company personnel on 6/2/25, only one AC pump was turned on instead of both AC pumps. V1 stated that some of the residents' room AC units were then overworking and malfunctioned. On 6/30/25 at 11:36 am, V1 confirmed that the resident census on 6/21/25 was 102 active residents. V1 stated that V21 is the Maintenance Director and has not been working (on vacation) since 6/17/25. V1 stated that V3 is a housekeeper and will change AC filters, but V3 does not perform maintenance repairs. V1 stated that staff will inform V1 or V21 of maintenance concerns, and V1 will make final decisions. In reviewing with V1 the facility policy for extreme high temperatures, this surveyor asked who the VP (Vice President) of Plant Operations or VP of Regional Operations is. V1 stated that V1 doesn't know and that V1 contacts the facility owners with extreme high temperature concerns in the facility. Facility temperature log, dated 6/22/25 from 12 am to 1 am, document, in part, air temperatures of four rooms at 82 degrees F; one room at 83 degrees F; three rooms at 84 degrees F, and one room at 85 degrees F. Facility temperature log, dated 6/22/25 from 1 am to 2 am, document, in part, air temperatures of three rooms at 82 degrees F; three rooms at 83 degrees F; and two rooms at 84 degrees F. Facility temperature log, dated 6/22/25 from 2 am to 3 am, document, in part, air temperatures of three rooms at 82 degrees F and one room at 83 degrees F. Facility temperature log, dated 6/21/25, documents only one temperature reading for each resident room. Facility floor plan reviewed showing that the facility has one floor (main level) where residents reside. Facility Resident Roster, titled Midnight Census Report and dated 6/21/25, indicates that 102 active residents are residing in the facility. Facility employee list documents, in part, one maintenance staff member, V21 (Maintenance Director). Online review of the outside weather on 6/21/25 documents that the high temperature was 95 degrees F at 2:53 PM. Facility policy titled Extreme High Temperature Guideline dated 4/3/2024, documents, in part, Purpose: To provide guidance to facility in times of unseasonably hot weather and/or cooling system malfunction. Responsible Party: Facility Staff. Should the temperature index for relative humidity and temperature in this facility rise above 80°, the facility shall implement the appropriate high temperature procedures. Should a specific area of the facility rise above 80°, it may be necessary to relocate residents to a cooler section of the facility . Department Specific Procedures: Nursing: . if necessary, transfer residents to areas of the facility that are better ventilated and cooler in temperature . Maintenance: monitor air temperatures at least every two hours between 8:00 AM and 10:00 PM in resident areas and every four hours between 10:00 PM and 8:00 AM temperatures should be taken at the warmest point identified through baseline monitoring on each floor or wing . Housekeeping and Laundry: . report any repairs to the supervisor or the director of maintenance. Administration: Alert all Extended Care V.P. of Plant Operations and the V.P. of Regional Operations regarding the high temperature situation if high temperature. (If) procedures do not sufficiently maintain resident safety. Facility policy titled Resident Rights Guidelines dated October 2023 documents, in part, . Guideline: our residents have certain rights and protections under federal law that help ensure appropriate care and services are provided . our facility will treat each resident with respect and dignity and care for each resident in a manner an (and) in an environment that promotes maintenance or enhancement of his or her quality of life . right to a safe, clean, comfortable, and home like environment . housekeeping and maintenance for a safe, sanitary, orderly, and comfortable interior . and safe temperatures. Facility policy titled Maintenance Policy dated January 2025 documents, in part, Policy: it is the policy of this facility to provide a safe, accessible, effective and efficient environment of care that is consistent with its mission, services and law and regulations. Policy Specifications: To ensure that the building (interior and exterior), grounds, and equipment are maintained in a safe operable manner. Responsibility: Maintenance Direct and Maintenance Personnel. Standards: . 14. Air-conditioning system shall be maintained and utilized as necessary to provide comfortable temperatures in all areas. Air temperature shall be maintained in a temperature range of 71 to 81 (degrees) F. Facility job description (undated) titled Director of Nursing documents, in part, . The primary purpose of your position is the provision of nursing care and treatments to residents. All services provided shall be in accordance with established nursing standards, policies, procedures, and practices of this facility and the requirements of this state . Major Duties and Responsibilities: . 1. Demonstrate understanding and utilize nursing policies and procedures in the administration of resident care. 2. Direct day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines. Ensure that all nursing personnel comply with the written policy and procedures established by the facility . 5. Follow facilities guidelines for reporting all activity during scheduled shift . 41. Responsible to supervise day-to-day activities of all nursing staff . 44. Ensure that the highest degree of quality care is provided at all times. Facility job description (undated) titled Charge Nurse Duties and Responsibilities documents, in part, to provide direct nursing care to residents and supervised the daily nursing activities of nursing staff in accordance with federal, state, and local standards, guide lined by regulations that govern the facility. Facility job description (undated) titled CNA Job Description documents, in part, that the CNA will report to the nurses and DON and must have qualifications to safely and successfully perform job-related functions that are required by federal, state, or local law. Facility job description (undated) titled Maintenance Supervisor documents, in part, Reports to: Administrator. Purpose: The purpose of this position is to: ensure that the facility environment, grounds and equipment is maintained in good, safe operating order . Maintain all established OSHA (Occupational Safety and Health Administration), State and Federal regulations regarding environmental . develop, implement and maintain, with facility administration approval, policies and procedures to assure compliance with all federal, state and local regulations . Duties/Responsibilities/Function: . Assure timely and consistent policy compliance with the following items: . 13. AC/Heating System Maintenance. Facility job description (undated) titled House Keeping Aid documents, in part, . provide housekeeping services to assure that a clean, orderly and home like environment is maintained in accordance with current federal, state and local regulations . Duties/Responsibilities/Function: . maintain all safety rules and regulations. Comply with all facility policies and procedures.

Based upon interview and record review the facility failed follow policy procedures, failed to document an incident report, and failed to implement the abuse prevention program for one of four residents (R1) reviewed for abuse. Findings include: On 2/4/25 at 2:25pm, surveyor inquired if V1 (Administrator/Abuse Coordinator) is in the facility. V2 (Director of Nursing/DON) stated She's on vacation since Friday (1/31/25). Surveyor inquired if abuse was recently reported in the facility. V2 responded Not in the past month. On 2/4/25 at 2:56pm, surveyor inquired about R1's reported concerns (V4 Social Service Director) stated Yesterday she (R1) had a complaint against one of the Nurses (V5 Registered Nurse/RN). I (V4) guess she (R1) thought she (V5) was yelling at her (R1). It was put down on a concern form and given to the DON (V2) yesterday. Surveyor inquired if an investigation was implemented V4 responded I know the DON spoke with the staff member (referring to V5) yesterday about the concern as soon as the Nurse (V5) came in. R1's (2/3/25) concern form states Nurse (V5 Registered Nurse) has been yelling at me (R1) every morning during med pass. Staff who followed up on the concern: (V2's name). On 2/4/25 at 3:37pm, surveyor inquired about staff requirements for alleged abuse. V2 (DON) stated If there's an abuse, we (staff) report it immediately to the abuse coordinator, if they're (V1) not here they (staff) would report to me (V2) then we investigate. Surveyor inquired what was implemented when R1's (2/3/25) concern form (including verbal abuse) was received V2 responded I counseled her (V5) about her tone of voice when she (V5) interacting with the residents and affirmed that V5 was not suspended. Surveyor inquired if anything else was implemented. V2 replied Now I will come and discuss it with the team. I took it back to Social Service in the meantime. We also switched the assignment we have another nurse taking care of her (R1). [Documenting an incident report and conducting interviews with R1, staff and/or other residents were excluded]. The (2/2017) abuse prevention program worksheet states this process is implemented where there is an allegation or reasonable cause to suspect that abuse, neglect, exploitation, or theft may have occurred. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. Regardless of the specific nature of the allegation, the investigation shall consist of: Completion of a written report on the status of the investigation within 24 hours of the occurrence. Interviews with any witness to the incident. An interview with the resident. Interviews with staff members having contact with the resident and accused individual during the period of the alleged incident. Interviews with other employees to determine if they have ever witnessed other incidents of abuse involving the accused individual. A review of circumstances surrounding the incident.

Based upon record review and interview the facility failed to follow the abuse prevention program and failed to report allegation verbal abuse and misappropriation of funds to the state surveying agency within regulatory requirements one of four residents (R1) reviewed for abuse. Findings include: 1.) R1's (1/9/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 2/4/25 at 3:22pm, surveyor inquired about concerns at the facility, R1 stated they're (staff) using my (R1) cash app on my phone at the vending machine. I'm (R1) not using the vending machine. R1's (1/27/25) concern form states resident believes that someone is logging into her phone and requesting money from her dad via her cash app and that someone has stolen $20 from this cash app and is using it for door dash. Upon investigation, it appears her account itself has been compromised. Staff member who received the original concern (V4 Social Service Director). Staff who followed-up on the concern: (V4). On 2/10/25 at 12:34pm, surveyor inquired about requirements for theft allegations. V1 (Administrator) stated If its money, I would call the police and say they have a theft (if its outside the vending machine). They (police) can come in and investigate. You should report it to the state surveying agency if they're (resident's) reporting a theft of something within 24 hours of notification. Surveyor inquired if V1 was made aware of R1's (1/27/25) theft allegation. V1 responded Not that one, not 1/27. Surveyor inquired if R1's (1/27/25) theft allegation was reported to the state surveying agency. V1 replied Not to my knowledge. On 2/11/25 at 12:10pm, V6 (Nurse Consultant) stated It was reported today to the State agency regarding the cash app, that someone was using her (R1) cash app (15 days after the allegation was received). 2.) R1's (2/3/25) concern form states Nurse (V5 Registered Nurse/RN) has been yelling at me (R1) every morning during med pass. Staff who followed up on the concern: (V2 Director of Nursing/DON). On 2/4/25 at 3:37pm, surveyor inquired when V2 received R1's (2/3/25) concern form. V2 stated the Social Service (V4) gave it to me mid-day yesterday and affirmed that V5 was counseled Yesterday about 3:30(pm) or so (roughly 24 hours ago). Surveyor inquired about the requirements for alleged abuse. V2 responded If there's an abuse, we report it immediately to the abuse coordinator, if they're not here they would report to me (V2) and affirmed that V1 (Administrator) is on vacation. Surveyor inquired about external reporting. V2 replied Based on the nature of the abuse we would report to the state surveying agency. Surveyor inquired what based on means. V2 replied Any abuse need to be reported to the state surveying agency if financial, physical, mental. Surveyor inquired if R1's (2/3/25) verbal abuse allegation was reported to the state surveying agency. V2 stated Did I report it? um no I've not report it. Surveyor inquired about the regulatory requirement for reporting abuse to the state surveying agency. V2 responded Any abuse need to be reported within the hour. R1's 2/3/25 (initial) incident report was submitted to the state surveying agency on [DATE] at 4:39 pm (after surveyor inquiry). The (2/2017) Abuse Prevention Program states when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee, shall notify (the state surveying agency's) regional office immediately. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the state surveying agency.

Based upon interview and record review the facility failed to follow the abuse prevention program and failed to conduct thorough investigations for one of four residents (R1) reviewed for abuse. Findings include: 1.) R1's (1/9/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 2/4/25 at 3:22pm, surveyor asked what transpired on 2/3/25? R1 stated the nurse was extremely mean to me. The one that was here at 5:30. She (V5 Registered Nurse/RN) kept saying wait in your room and was shouting at me. Surveyor inquired if the (2/3/25) incident was reported to facility staff. R1 responded I wrote a note to the Administrator that got sent to the DON (V2 Director of Nursing). R1's (2/3/25) concern form states Nurse (V5) has been yelling at me every morning during med pass. Resolution: per staff Nurse, resident is frequently asked for her medications and nicotine gum. Nurse reminded resident of the medication schedule. Resident needs frequent redirection and reminders of the plan of care. Nurse (V5) declined of yelling at the resident. Nurse was counseled on verbal communication and tone of voice when interacting with residents. Staff who followed up on the concern: (V2 DON). On 2/4/25 at 3:37pm, V2 (DON) stated If there's an abuse, we (staff) report it immediately to the abuse coordinator, if they're (V1 Administrator-Abuse Coordinator) not here they would report to me (V2) then we investigate. The investigation will include talking with the staff and talking with the person involved (interviewing other residents was excluded). Surveyor inquired about the (2/3/25) abuse investigation V2 affirmed that V1 is on vacation and V5 (Registered Nurse) was counseled. R1's (2/3/25) final report states staff and resident (not residents) interviewed therefore; surveyor requested the witness statements. A total of 10 (staff) Witness Statements were documented however the Date & Type of Event are excluded from the statements (Resident interviews were not received). On 2/11/25 at 11:15am, surveyor inquired about R1's (2/3/25) abuse investigation V2 (DON) stated We (staff) interviewed the resident (R1), and we interviewed the staff. We asked them (staff) if they witnessed the Nurse (V5) or anyone yelling or screaming at the resident (R1), and no one witnessed any of this. I (V2) also spoke with miss (R1) and asked her what took place. Surveyor inquired if any other residents were interviewed. V2 responded She (R1) doesn't have a roommate she's by herself in the room. Surveyor inquired where the alleged incident occurred. V2 replied Well, I believe it was early in the morning when she (R1) was asking for the medication. If I remember correctly, she was in her room and she was coming out asking the nurse for her medication. Surveyor inquired if R1 was in the hallway. V2 stated She (R1) did not tell me that. (V5) works overnight so I would have to ask her (V5) where she was when she was talking to miss (R1). Surveyor inquired (again) if any other residents (besides R1) were interviewed. V2 responded I have the statement from the Nurse, I have to get my statements because I don't know if I recall. On 2/11/25 at 11:23am, surveyor inquired if anyone besides R1 and staff were interviewed during 2/3/25 investigation. V1 (Administrator) stated I (V1) interviewed some of the resident's that were around at that time that were up. Surveyor inquired if written statements were obtained from the residents. V1 responded I don't have written statements. Surveyor inquired why the alleged resident statements were not documented. V2 replied Because I talked to them and didn't write it down. On 2/11/25 at 1:52pm, V3 (Assistant Director of Nursing/ADON) affirmed that she was assigned to R1 on 2/2/25 from 11pm to 7am (therefore in the facility during the alleged event). Surveyor inquired about V3's witness statement (which was not received). V3 stated I am not sure I filled it out. On 2/11/25 at 2:08pm, surveyor inquired about V8's (Receptionist) witness statement which excludes a date & type of event. V8 stated The ADON (V3) asked me to fill this out regarding a resident (R1), she (V3) didn't' give me a time, didn't give me an exact incident. Surveyor inquired when the witness statement was documented. V8 responded I can't remember the exact date. Surveyor inquired about V8's designated work hours. V8 replied It's 7 to 3pm therefore was not in the facility during time of the incident. On 2/11/25 at 2:19pm, surveyor inquired about V12's (Registered Nurse) witness statement which excludes a date & type of event. V12 stated I (V12) got it from the ADON she (V3) said to fill out the witness statement and put if I ever witness anybody in the facility being abused, she just said fill out the form. Surveyor inquired if V12 was aware of R1's abuse allegation. V12 responded From what I heard it was a Nurse was being verbally abusive, she (R1) had mentioned Nurse (V5) and affirmed she (V12) was made aware sometime after the statement was documented. Surveyor inquired if V5 speaks to people some kind of way. V12 replied Not patients but staff yes. I would say that she's (V5) from a different culture so the way that she says stuff is being rude. V12 affirmed she works dayshift (7am-3pm) therefore was not in the facility during time of the incident (5:30am). On 2/11/25 at 2:30pm, surveyor inquired about V14's (Registered Nurse) witness statement which excludes a date & type of event. V14 stated The ADON gave it to me. She (V3) gave us (staff) like in-service if anybody being abused and stuff like that, but I (V14) said no I didn't witness abuse towards (R1) or any resident. She just asked, have I ever witnessed abuse of any kind to (R1), and I said no. Surveyor inquired about the alleged incident. V14 responded She (V3) just asked me randomly have you ever, see abuse it's not attached to any date, or a time and I said no. Surveyor inquired when the witness statement was documented. V14 replied Last week Wednesday (2/5/25) or Thursday (2/6/25) therefore 2 or 3 days after the incident. Surveyor inquired if any residents reported that V5 was yelling at others. V14 responded Nobody has complained about her (V5) to me (V14), but I know in general she (V5) is loud. Like she talks loud to me and in general with others. I think maybe her voice is going loud, I don't know why. Surveyor inquired about V14's designated work hours. V14 responded I work 7(am) to 3 (pm) therefore was not in the facility during time of the incident. On 2/11/25 at 2:43pm, surveyor inquired about V7's (Activity Aide) witness statement which excludes a date and type of event. V7 stated The DON (V2 Director of Nursing) asked me if I ever witness any abuse in the facility and I said no. Surveyor inquired if V2 informed V7 why she (V2) was inquiring about abuse. V7 responded No. Surveyor inquired about V5's demeanor when she speaks. V7 replied She (V5) talk to people nice, I guess. All the Africans are loud when they talk to people (affirmed that V5 is African). They (Africans) loud talkers and you know you need to tell them to come down a little bit. Surveyor inquired about V7's designated work hours. V7 stated I start at 7:00 therefore was not in the facility during time of the incident. 2.) R1's (1/27/25) concern form states resident believes that someone is logging into her (R1) phone and requesting money from her dad via her cash app and that someone has stolen $20 from this cash app and is using it for door dash. Resolution: upon investigation, it appears her account itself has been compromised. Staff member who received the original concern (V4 Social Service Director). Staff who followed-up on the concern: (V4). On 2/4/25 at 2:56pm, surveyor inquired about R1's (1/27/25) theft allegation. V4 stated She (R1) reported that she believed that a resident (not staff) had logged into her phone and tried to use her cash card app, but she always has her (R1) phone with her. I (V4) believe that someone may have compromised the card (electronically), so I urged her to cancel the card which she did. They (residents) would have to have the password to her phone and a password to cash app to get into it and have access. Surveyor inquired about staff requirements for abuse allegations. V4 replied It (concern form) would be given to the abuse coordinator (V1 Administrator). On 2/10/25 at 12:34pm, surveyor inquired if V1 was made aware of R1's (1/27/25) theft allegation. V1 responded Not that one, not 1/27. On 2/11/25 at 12:10pm, V6 (Nurse Consultant) affirmed an investigation was conducted regarding R1's (1/27/25) theft allegation. The incident report, witness statements and/or documentation to that effect were not received during this survey. The (2/2017) Abuse Prevention Program states any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. The person in charge of the investigation will update the Administrator or person designated in the Administrator's absence during the progress of the investigation. The Administrator or a designee will keep the resident or resident representative informed of the progress of the investigation. If the Administrator was absent from the facility during the course of an abuse, neglect, exploitation, mistreatment, or misappropriation of resident property report and/or investigation, the Administrator shall be informed of the report and status of the investigation upon his or her return to the facility.

Based upon interview and record review the facility failed to follow policy procedures and failed to ensure that two of three residents (R1, R3) reviewed for medication administration remained free from significant medication errors. Findings include: 1.) R1's diagnoses include but not limited to seizures. R1's (1/9/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 2/4/25 at 3:22pm, surveyor inquired about concerns with medication administration at the facility. R1 stated The night Nurse doesn't want to give me Fluticasone (referring to Advair inhaler) until 9am and I need it when I wake up around 5 or 5:30. R1's (1/6/25) POS (Physician Order Sheets) include Advair Discus (Fluticasone propion-salmeterol) 1 puff inhalation every 12 hours and Divalproex 250mg (milligrams) delayed release every 12 hours. R1's (February 2025) MAR (Medication Administration Record) affirms Advair (Steroid Bronchodilator) is scheduled for 6am and 6pm administration however Late Administration is documented on 2/1/25, 2/2/25 and 2/3/25. R1's 2/1/25 (6am) Advair entry was documented at 7:41am. R1's 2/1/25 (6pm) Advair entry was documented at 7:09pm. R1's 2/2/25 (6pm) Advair entry was documented at 8:53pm. R1's 2/3/25 (6pm) Advair entry was documented at 8:13pm. R1's (February 2025) MAR also affirms that Divalproex (Anti-epileptic) is scheduled for 9am and 9pm administration however Late Administration is documented on 2/2/25, and 2/3/25. R1's 2/2/25 (9am) Divalproex entry was documented at 1:09pm (4 hours after the scheduled time). R1's 2/3/25 (9am) Divalproex entry was documented at 3:19pm (6.25 hours after the scheduled time). 2.) R3's diagnoses include Parkinson's disease and disorganized schizophrenia. R3's (1/17/25) BIMS determined a score of 15. On 2/5/25 at 1:29pm, surveyor inquired about concerns with medication administration at the facility. R3 stated The medicine doesn't come on time. Some of the time they (staff) are short and get upset and frustrated when we are asking questions about it. When they (staff) come, they say get up, get up. I (R3) try to get up and they say hurry up we are late, let's go. They try to rush me. R3's (1/13/25) POS includes Carbidopa-Levodopa 25-100mg 2 tablets TID (three times daily) diagnosis: Parkinson's disease and Quetiapine 50mg TID diagnosis: disorganized schizophrenia. R3's (February 2025) MAR affirms Carbidopa-Levodopa (Anti-Parkinson) is scheduled for 9am, 12pm and 8pm administration however Late Administration is documented on 2/4/25 and 2/5/25. R3's 2/4/25 Carbidopa-Levodopa (12pm) entry was documented at 1:24pm. R3's 2/5/25 Carbidopa-Levodopa (12pm) entry was documented at 1:40pm. R3's (February 2025) MAR also affirms Quetiapine (Antipsychotic) is scheduled for 9am, 12pm and 9pm administration however Late Administration is documented on 2/4/25 and 2/5/25. R3's 2/4/25 (12pm) Quetiapine entry was documented at 1:24pm. R3's 2/5/25 (12pm) Quetiapine entry was documented at 1:40pm. On 2/6/25 at 12:18pm, surveyor inquired about the regulatory requirement for medication administration V2 (Director of Nursing) stated An hour before and an hour after. The medication administration policy (updated: March 2022) states medications shall be administered one (1) hour before/after the medication schedule unless specifically ordered otherwise. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug.

Based on observations, interviews and record reviews, facility failed to follow their policy to ensure foods were labeled and dated in the dry food storage. This failure has the ability to affect all the residents in the facility. Findings include: On [DATE] at 09:26 AM, surveyor observed the dry food storage area. Food was kept on palates. The following food did not have dates on them: Bread, banana, potatoes, and frozen squash. V14 (Cook) stated that those should have dates on them. On [DATE] at 10:00 AM, V10 (Food Services Director) stated that all food is supposed to be labeled when they arrive. They are supposed to be labeled so that we do not use expired food when preparing food for the residents. On [DATE], at 10:15 AM, V11 (Dietician) stated that all food is supposed to be labeled when they arrive. V11 stated this is important so that we know when the food expire and should be thrown away. Facility's Labeling and Dating Foods policy (undated) documents in part: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.

Based on observation, interview and record review, facility failed to administer medications timely and failed to follow the facility's medication administration policy for 7 residents (R13, R48, R62, R64, R71, R90, R98) out of 7 residents reviewed for medication administration in a sample of 21 residents. Findings Include: On 12/09/2024 at 10:11AM V5 (Licensed Practical Nurse/LPN) was observed during medication administration. V5 had 7 residents (R13, R48, R62, R64, R71, R90, R98) that did not receive their scheduled 9:00AM medications. V5 stated, On a regular day, when I work a shift, I am usually done passing medications to all by residents by 10:15 AM. I try my best to finish my morning medication administration on time, but I work with many different residents who ask for things in a specific way. I always try to do my best to accommodate every resident's request and it takes more time to finish my medication administration by 10:00 AM. I keep my residents happy and accommodate their needs and that's why I can't finish the morning medication on time. Some residents want to talk to me and share things with me when I go in to administer their morning medications and I don't want to rush the residents and that is another reason why I am not done on time. On 12/10/2024 at 8:55 AM, V3 (Assistant Director of Nursing) stated, The medications that are scheduled at 9:00 AM, the nurse can give the medications starting at 8:00 AM, which is one hour before the scheduled time, and the nurse can give the medications up to 10:00 AM, which is one hour after the scheduled time. Anything that is administer past the 1-hour window of the scheduled time is considered late. If a nurse still has medications to pass after 10:00 AM, the nurse must go to the resident and explain why the medication is late. If a nurse needs help with the medication administration, they can call the director of nursing or myself (assistant director of nursing) for assistance. The physician must be notified when a resident is given medications past the regular window of 1 hour before/after the medication is scheduled. 1.) R13's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: hypertensive heart disease without heart failure, schizoaffective disorder, unspecified, pure hypercholesterolemia, unspecified, hypothyroidism, unspecified. Care plan (dated 08/01/2024) documents that R13 uses antipsychotic/mood stabilizing medication (clozapine and Depakote) due to schizoaffective disorder. Care plan documents that R13 has hypertension. R13's scheduled 9:00 AM medication as per the physician orders are: Atropine drops 1% amt: 1 drop; ophthalmic (eye) Benztropine tablet 1mg oral tablet Clozapine 100mg tablet 1 tablet Divalproex 500mg delayed release 1 tablet. Dorzolamide drops 2% 1 drop in both eyes Lisinopril 5mg tablet 1 tablet Timolol Maleate 0.5% drops Flomax 0.4mg capsule 1 capsule 2.) R48's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Type 2 diabetes mellitus without complications, major depressive disorder, single episode, unspecified, alcohol use, unspecified with intoxication, unspecified, bipolar disorder, unspecified, anxiety disorder due to known physiological condition. Care plan (dated 10/04/2024) documents that R48 receives antianxiety medication related to major depression and alcohol intoxication. The care plan documents that R48 receives antidepressant medication R/T Major Depression and alcohol intoxication. R48's scheduled 9:00 AM medication as per the physician orders are: Sertraline 50mg tablet 1 tablet. Glipizide 10mg tablet 1 tablet Gabapentin 300mg capsule 1 capsule 3.) R62's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Multiple sclerosis, major depressive disorder, recurrent severe without psychotic features, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, unspecified. R62's Care plan (dated 05/07/2024) documents that R62 has feelings of depression, isolative tendencies, hard time trusting others, anxiety, and history of engaging in substance abuse related to major depression disorder. R62's scheduled 9:00 AM medication as per the physician orders are: Propranolol 10mg tablet 1 tablet Sodium Chloride 1,000mg tablet 1 tablet Lexapro 20mg tablet 1 tablet Levetiracetam 500mg tablet 1 tablet Clonazepam 0.5mg tablet 1 tablet Gabapentin 300mg capsule 2 capsules Topamax 50mg tablet 1 tablet Wellbutrin XL extended release 150mg tablet, 1 tablet 4.) R64's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, major depressive disorder, recurrent, unspecified, other specified chronic obstructive pulmonary disease, schizoaffective disorder, unspecified, bipolar disorder, unspecified, gastro-esophageal reflux disease without esophagitis. Care plan (dated 09/11/2024) documents that R64 receives hypnotic medication related to major depression and generalize anxiety. R64's scheduled 9:00 AM medication as per the physician orders are: Amlodipine 5mg tablet 1 tablet Clonazepam 1mg tablet 1 tablet Escitalopram 10mg tablet 3 tablets [NAME] Thyroid 30mg tablet 1.5 tablet (45mg) Lipitor 10mg tablet 1 tablet 5.) R71's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease, unspecified, Major depressive disorder, recurrent, unspecified, Hypertensive heart disease without heart failure, Suicidal ideations. Care plan (dated 09/29/2024) documents that R71 receives antidepressant medication R/T Major depression. R71's scheduled 9:00 AM medication as per the physician orders are: Amlodipine 5mg tablet; 1 tablet Budesonide-formoterol HFA aerosol inhaler, 80-4.5mcg/actuation 2 puffs Escitalopram Oxalate 10mg tablet 1 tablet Escitalopram Oxalate 5mg tablet 0.5 tablet Lisinopril 20mg tablet 1 tablet Plaquenil 200mg tablet 1 tablet 6.) R90's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, generalized anxiety disorder, unspecified asthma, uncomplicated, hyperlipidemia, unspecified, major depressive disorder, recurrent, unspecified. Care plan (dated 01/30/2024) documents that R90 has shortness of breath (dyspnea) when lying flat related to asthma. R90's scheduled 9:00 AM medication as per the physician orders are: Clopidogrel 75mg tablet 1 tablet Venlafaxine capsule 150mg extended release 1 capsule. Rosuvastatin 10mg tablet 1 tablet Protonix 40mg tablet 1 tablet Metoprolol Succinate 25mg extended-release tablet 1 tablet 7.) R98's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Care plan (dated 08/15/2024) documents that R98 has a diagnosis related to hypertension. R98's scheduled 9:00 AM medication as per the physician orders are: Carvedilol 3.125mg tablet 1 tablet Clonidine HCL 0.1mg tablet 1 tablet Amlodipine 10mg tablet 1 tablet Amoxicillin 875mg tablet 1 tablet Baclofen 5mg tablet 0.5 tablet Bumetanide 1mg tablet 1 tablet Carvedilol 6.25mg tablet 1 tablet Clonidine HCL 0.1mg tablet 1 tablet Entresto 24-26mg tablet 0.5 tablet Isosorbide Dinitrate 10mg tablet 1 tablet Lantus U-100 unit/mL 15 units Loperamide 2mg capsule 1 capsule Metolazone 5mg tablet 1 tablet Metoprolol Succinate 25mg extended-release tablet 1 tablet. Rosuvastatin 40mg tablet 1 tablet Spironolactone 25mg tablet 1 tablet Gabapentin 100mg capsule 1 capsule Medication Administration Policy (dated 03/2022) documents in part: Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise.

Based on observation, interview, and record review, the facility failed to follow their policy to assess for self-administration of albuterol medication. This failure effected 2 residents (R58 and R79) out of 4 residents with chronic obstructive pulmonary disease (COPD) reviewed for self-administering medications in a total sample of 21 residents. Finding Include: 1.) R58's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: chronic obstructive pulmonary disease, muscle wasting and atrophy, not elsewhere classified, multiple sites, emphysema, unspecified, hypertensive heart disease without heart failure, cerebral infarction, unspecified. Care plan (dated 12/13/2023) documents that R58 has a diagnosis of COPD and exhibits the following symptoms, easily fatigued, periods of confusion due to oxygenation, anxiety and requires medication, oxygenation, shortness of breath placing resident at risk for death. R58's Physician Order (dated 12/12/2023) states: albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation; Special Instructions: For SOB (shortness of breath)/wheezing. Every 6 hours-PRN (as needed) Minimum Data Set (MDS) section C (dated 09/17/2024) documents that R58 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R58's cognition is intact. On 12/9/24 at 11:33AM, R58 stated, I have chronic obstructive pulmonary disease (COPD), and I don't have my rescue inhaler at my bedside. The nurses have my albuterol inhaler in the nursing cart. I asked different nurses on several occasions if I can keep the rescue inhaler at bedside in case I need it, and they all said no. I was never assessed by a nurse for self-administration of the rescue inhaler. The nurses just told me that I am not allowed to have it at my bedside and that's all, but they never did an evaluation of self-administration of the inhaler. On 12/9/2024, at 2:35 PM, V2 (Director of Nursing/DON) stated, R58 never expressed to me that he wanted his rescue albuterol at the bedside. The nursing staff never informed me. R58 needs to be evaluated by the nurse to see if he is capable of proper self-administration. Once the assessment shows that R58 is capable of proper self-administration, the nurse has to call the physician to get an order to keep the medication at bedside. It is important to note that the resident has to not only properly self-administer the medication but also follow the proper frequency of how often the medication is administered. R58 is alert and oriented x3. At this time, I cannot think of any reason that would prevent R58 from administering the medication in a safe manner. 2.) R79's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent, unspecified, hypertensive heart disease without heart failure, hyperlipidemia, unspecified, gastro-esophageal reflux disease without esophagitis. Care plan (dated 10/23/2024) documents that R79 has a diagnosis of chronic obstructive pulmonary disease (COPD) and exhibits the following symptoms; easily fatigued, periods of confusion due to low oxygenation, anxiety and requires medication, oxygenation, shortness of breath placing resident at risk for death. Minimum Data Set (MDS) section C (dated 10/29/2024) documents that R79 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R79's cognition is intact. On 12/09/2024 at 11:42AM, R79 stated, I have chronic obstructive pulmonary disease (COPD) and if I have an exacerbation of shortness of breath, I should have my rescue albuterol inhaler at bedside. I don't have the rescue inhaler because when I asked several different nurses if I can keep it with me, the nurses said that they are not allowed to leave any medications at bedside. If I have an exacerbation, by the time I call for assistance and by the time the nurse responds, I will be in trouble and that's why I should have my albuterol inhaler with me. I have told many different nurses at different times about wanting to keep my rescue inhaler and I was never assessed for self-administration of the inhaler. Nobody assessed me for proper self-administration, they just told me that I cannot have it. On 12/09/2024, at 11:52AM, surveyor performed an inspection of the nursing medication cart which contained the medications for R58 and R79. V8 (Licensed Practical Nurse) was present at the time that the surveyor inspected the medication cart. Surveyor observed that R58 and R79's albuterol sulfate HFA aerosol inhaler was being stored inside the nursing medication cart. On 12/9/24 at 2:43PM, V2 (DON) stated, R79 has COPD. To my knowledge, R79 did not request to have his rescue albuterol inhaler at bedside. We need to assess R79 for proper self-administration of the albuterol inhaler. Based on the outcome of the assessment, if R79 is able to self-administer the albuterol medication properly, then we have to call the doctor and get the order allowing the resident to have the medication at bedside. Medications are not left at bedside for safety purposes. If a resident wishes to keep the medication at bedside, the resident must be assessed, and the medication must be stored somewhere outside of the reach of other residents. R79 never mentioned to me that he wanted the rescue albuterol for his COPD at bedside. R79 is alert and oriented x3. At this time, I cannot think of any reason that would prevent R79 from self-administering the medication in a safe manner. R79's Physician Order (dated 10/23/2024) states: albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation: Every 6 Hours - PRN (as needed). Medication Administration Policy (dated 03/2022) documents in part: Residents who indicate a desire to self-administer medications will be assessed by the interdisciplinary care plan team using an assessment tool. Assessment results will be provided to the physician for approval. Residents will be allowed to self-administer medications only when the attending physician has written as order. Self-administered medications use and response will be monitored by licensed nurses. Self-Administration and Medication Storage Policy (dated 02/2014) states in part: To provide guidelines for self-administration of drugs/biologicals and their storage in the resident's room. Policy Specifications; (1.) Residents who request to self-administer drugs will be assessed at the time of admission or thereafter, to determine if the practice is safe, based on the results of the self-administration of medication form. (2.) The assessment results will be communicated with the attending physician and an order obtained to self-administer, if appropriate.

Based on observation, interview and record review, the facility failed to ensure a call light was within reach of one resident (R32) reviewed for the call light system. Findings include: 12/9/24 at 12:00 PM, observed R32's bed and call light placement. R32's bed was placed along one wall lengthwise. R32's call light was placed on the adjacent wall of the bed on the other side of the closet that was at the foot of the bed in the corner of the two walls. Surveyor asked R32 if R32 could reach the call light. R32 said I have to get up to get it. V2 (Director of Nursing/DON) joined surveyor in R32's room. V2 stated there is no way for R32 to reach the call light. 12/9/24 at 3:00 PM, V2 (DON) stated the purpose of call lights is to alert the staff that the resident needs help. The resident pulls the cord to activate the call light. The cord needs to be in the resident's reach. If R32 were in bed R32 could not reach the call light to alert staff that R32 needs help. R32 can call out if she needs help. 12/11/24 at 2:25 PM, V1 (Administrator) stated I expect the call lights to be within reach and the resident to be able to use them. When a staff person goes into the rooms, they should check the call light is within reach and functioning. Facility policy Answering the Call Light, August 2008, documents in part: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to properly store insulin medications and gastrostomy tube (g-tube) feeding extension tubing supplies. This failure impacted 2 residents (R14 and R53) who had expired insulin inside the medication cart during inspection. This failure also resulted in expired gastrostomy tube feeding extension tubing supplies being found in the medication storage room. Finding Include: On 12/09/24, at 12:49 PM, the 1st floor Medication Cart # 3 was inspected with V20 (Licensed Practical Nurse/LPN). R14's Novolog FlexPen U-100 Insulin (insulin aspart u-100) was found in drawer, marked with the open date of 07/24/2024, and marked with the expiration date of 08/21/2024. Surveyor found 3 10mL (milliliter) syringes marked with the expiration date of 09/30/2024. On 12/09/24 at 1:14 PM, surveyor inspected 1st floor medication cart #2 with V9 (LPN). Surveyor found R53's Basaglar Kwik Pen (insulin glargine injection) in the drawer, marked with the open date of 11/21/2024, and marked with the expiration date of 11/29/2024. Surveyor found a second Basaglar Kwik Pen (insulin glargine injection), marked with the open date of 11/23/2024 and no expiration date. On 12/10/2024, at 9:50 AM, the 1st floor medication storage room was inspected by the surveyor. The surveyor found 9 expired (Brand Name) Nutrition Delivery System Safety Spike Plus Pump Set (g-tube connection tubing) with the expiration date of 03/28/2024. Surveyor found 1 expired pre-filled 0.9% Normal Saline Flush (10mL) with the expiration date of 11/21/2024. Surveyor found 5 expired (Brand Name) System Continu-Flo Solution Set (g-tube connection tubbing) with the expiration date of 10/16/2024. Surveyor found 3 expired (Brand Name) System Continu-Flo Solution Set (g-tube connection tubbing) with the expiration date of 11/25/2024. On 12/09/2024, at 3:02 PM, V2 (Director of Nursing) stated, When the nurses open the insulin, they have to label the insulin with the date it is opened, and they must label the insulin with the date that it expires. Lantus insulin is good for 28 days. I like to read the manufacturer's instruction. If the manufacturer instruction says to discard after 30 days, then the insulin is labeled accordingly. Insulin in general is either good for 28 days or 30 days and must be discarded after the date it expired. On 12/10/2024, at 11:55 AM, V2 stated, Different nurses and the manager on duty are the ones who I delegate to clean the medication storage room, and to remove any access supplies that are not in use. Also, the nurses go through the medication storage room so that they can let me know if they need any supplies. My expectation is that the nurses who complete the inventory in the medication room will go through the supplies to ensure that the supplies are not expired. All the supplies in general, including the tubing, catheters, syringes, normal saline flushes, and all other supplies are not expired and that all the supplies in the medication storage room are current. When the nurses perform the inventory at the end of the month and as needed, they must remove any remove any supplies that are expired, and they must turn the expired supplies to the nursing office. The nursing carts are cleaned monthly and as needed. When the nurses clean the medication carts, they are expected to go through the entire nursing cart and make sure that medications and supplies are not expired. When the nurses find expired medication or supplies, they must remove the expired items from the medication cart and turn it into the nursing office. Storage of Medications Policy (dated 10/25/2014) documents in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. 1.) R14's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Asthma, type 2 diabetes mellitus with unspecified complications, unspecified dementia, mild, with other behavioral disturbance, gastro-esophageal reflux disease without esophagitis, disorder of urea cycle metabolism, unspecified. R14's Physician Orders (dated 08/01/2024) states: Novolog FlexPen U-100 Insulin (insulin aspart u-100): Per Sliding Scale If Blood Sugar is less than 80, call MD. If Blood Sugar is 181 to 220, give 1 Units. If Blood Sugar is 221 to 261, give 2 Units. If Blood Sugar is 262 to 300, give 3 Units. If Blood Sugar is 301 to 351, give 4 Units. If Blood Sugar is 352 to 400, give 5 Units. If Blood Sugar is greater than 400, give 6 Units. If Blood Sugar is greater than 400, call MD. 2.) R53's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Major depressive disorder, recurrent, unspecified, chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. R53's Physician Order (dated 07/09/2024) states: Basaglar KwikPen U-100 Insulin (insulin glargine); give 26 units at bedtime.

Based on observation, interview, and record review, the facility failed to ensure that a reusable blood pressure cuff device was properly cleaned and disinfected in between resident use for 3 residents (R17, R22, R62) out of 8 residents reviewed for infection control and prevention in a total sample of 21. Finding Include: 1.) R17's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: primary generalized (osteo)arthritis, schizoaffective disorder, unspecified, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Care plan (dated 02/07/2024) requires a therapeutic diet related to type 2 diabetes mellitus and hypertension. Minimum Data Set (MDS) section C (dated 08/05/2024) documents that R17 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R17's cognition is intact. 2.) R22's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, unspecified, hypermetropia, unspecified eye, unspecified psychosis not due to a substance or known physiological condition. Care plan (dated 10/23/2024) documents that R22 has diagnosis related to hypertension and hyperlipidemia. Minimum Data Set (MDS) section C (dated 10/23/2024) documents that R22 has a Brief Interview for Mental Status (BIMS) score of 13, indicating that R22's cognition is intact. 3.) R62's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Multiple sclerosis, major depressive disorder, recurrent severe without psychotic features, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, unspecified. R62's Care plan (dated 05/07/2024) documents that R62 has feelings of depression, isolative tendencies, hard time trusting others, anxiety, and history of engaging in substance abuse related to major depression disorder. Minimum Data Set (MDS) section C (dated 11/06/2024) documents that R62 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R62's cognition is intact. On 12/9/2024 at 9:29 AM, observed V5 (Licensed Practical Nurse) using a reusable blood pressure device to obtain R17's blood pressure, failing to clean and disinfect the device prior to collecting the resident's blood pressure. After V5 obtained R17's blood pressure, V5 was observed placing the blood pressure device on top of the nursing cart, failing to clean and disinfect the blood pressure cuff after resident use. On 12/9/24 at 9:47 AM, V5 was observed utilizing the blood pressure device to collect R62's blood pressure without cleaning and disinfecting the blood pressure device. On 12/9/24 at 9:55 AM, V5 was observed utilizing the blood pressure device to obtain R22's blood pressure without cleaning and disinfecting the device. On 12/9/2024 at 10:05 AM, V5 stated, I am supposed to clean and disinfect the blood pressure device before resident use and after resident. The device must be cleaned and disinfected in between residents but I did not do it. On 12/9/2024 at 3:10 PM, V2 (Director of Nursing) stated, Devices such as blood pressure monitoring machine must be disinfected before resident use and must be disinfected after resident use to prevent infection. On 12/10/2024 at 11:49 AM, V12 (Infection Control Preventionist) stated, The vital machines and the blood pressure puff should be disinfected after each resident use. The blood pressure machine should be disinfected in between each resident. Usually, the blood pressure cuff is the main part that should be disinfected in between each resident use. The purpose of disinfecting the blood pressure cuff after each resident use is to prevent the spread of infection from resident to resident. Cleaning and Disinfection of Resident-Care Items and Equipment Policy (revised 07/2014) documents in part: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment).

Based on observation, interview, and record review the facility failed to follow a resident's plan of care interventions for fall prevention and failed to provide the resident with a working call light for a resident high risk for falls in one (R1) of three residents reviewed for falls. Findings include: R1 is a [AGE] year-old female with a diagnosis including Schizophrenia, Chronic respiratory failure, Epilepsy, Nondisplaced fracture of seventh cervical vertebra, Subdural hematoma, Drug induced secondary parkinsonism and Type 2 diabetes. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) of 10/15. R1 uses a wheelchair for mobility. R1 is assessed as a high risk for falls (latest 3/25 fall assessment scored 21). R1 is care planned for including history of multiple falls. R1 is physician ordered to wear cervical collar until follow up appointment for further orders. R1 was placed on 1:1 supervision on 3/20/24. On 4/12/24 at 11AM R1 was observed in R1's room by herself. R1 was sitting up on the edge of bed trying to get up to transfer to her wheelchair. R1's wheelchair was 5 feet from R1's reach next to the wall opposite the side of bed. R1 almost fell to the floor. R1 had to be prompted by surveyor to remain sitting in her bed. R1 stated she had to go to the bathroom real bad. R1 attempted to stand several times and had to be prompted to stay sitting in bed. Help was called from surveyor. R1 did not have a soft helmet on. R1 did not have 1:1 supervision at time of observation. V3 (Licensed Practical Nurse/LPN) was called from office room across from R1's room. V3 had to retrieve R1's wheelchair and place it next to the bed and lock the wheels. V3 assisted R1 from a sitting position to the wheelchair. V3 then transported R1 to the women's bathroom in the corridor. R1's bed is located against the wall. The nurse call box was observed missing the cord and not usable. The square metal conduit leading to the nurse call box was observed pulled apart exposing sharp metal. This sharp metal edge was directly next to the middle of the mattress. On 4/12/24 at 11:05AM V3 (LPN) stated, I did not know that R1 needed assistance. I don't know what happened to the cord for the nurse call. I don't know where the CNA (Certified Nursing Assistant) is. On 4/12/24 V2 (Director of Nursing/DON) was asked to provide the interventions in place to prevent falls of R1. The following list was provided by V2: 2/23/24 Re orient the resident to her surroundings and ensure that the resident has on proper footwear. 2/22/24 Resident to be placed in common area during waking hours to be observed by staff for safety. 2/21/24 Resident was provided with a bed that lowers all the way down to the floor. Resident was also provided a padded floor mat. 1/27/24 Reeducate the resident to put on the brakes to her wheelchair before transfers. Reeducated resident on pulling call light and asking for staff assistance when necessary. 12/28/23 Reorient resident to her surroundings. Reeducate the resident on the importance of rising slowly from a seated position. Refer to physical therapy for evaluation and treatment. 12/27/23 Installed nonslip to seat of wheelchair. Resident referred to PT/OT for evaluation. 10/25/23 Provide an environment free of clutter and reeducate the resident to not use the bedside table for support. Keep personal items and frequently used items within reach. Keep call light in reach at all times. Provide an environment free of clutter. Encourage to assume a standing position only. The following shows R2's two most recent falls: Progress note dated 3/19/14 at 5:30AM staff member reported that R1 fell in the hallway. NOD (Nurse on Duty) immediately went to the scene. Head to toes assessment done, a laceration noted to left eyebrow with slight bleeding, area cleansed with normal saline, pressure dressing applied. V/S T 97.5, P 73, R 18, BP 143/77 O2 SAT 97% RA. R1 taken to her room and made comfortable in bed, Tylenol 650 mg given for comfort. Neuro checks initiated. At about 5:40AM ambulance called with ETA of 90 mins. Report given to RN (Registered Nurse) at hospital ER. V6 (Physician) notified, message left for family member and emergency contact. R1's Hospital record dated 3/19/24 shows R1 sustained abrasion of left eyebrow and closed nondisplaced fracture of seventh cervical vertebra. R1 returned to the facility on [DATE] with a soft collar around the neck. R1 had 4 sutures above left eyebrow. R1's progress note dated 3/20/24 shows including placed on 1:1 supervision for safety. R1's Progress note dated 3/28/24 12:32PM shows R1 is alert and verbally responsive, R1 was in the day room for lunch. Writer (V9 Licensed Practical Nurse/LPN) left for lunch in the basement, when heard name paged to come to the day room, V9 went immediately to the day room and noted R1 sitting up in her wheelchair. V9 was informed by staff that R1 slid from the wheelchair and hit her head. Where she fell from the previous fall was re-opened and bleeding. V9 then assessed R1, noted that the abrasion cut on the eye lid area of the face is bleeding and reopened. Clean, dry treatment was applied. MD notified with the order to send R1 to hospital for evaluation. Report given to RN (Registered Nurse) at hospital. All the head department made aware. Family member notified. Vital sign as follows BP 141/87, P77, R18, T 99.4, O2 sat 91% R/A. R1's Hospital record dated 3/28/24 showed laceration to left eyebrow requiring 5 sutures. Review of R1's fall care plan dated 3/28/24 includes: R1 provided with a soft helmet Start date 3/28/24. Low bed with padded floor mat on the one side of bed. (Other side is against wall) Start date 2/21/24. Keep call light within reach (assessable) at all times. Start date 7/1/23. On 4/12/24 at 12:40PM V4 (RN) stated R1 fell on [DATE] in the hallway from her wheelchair. We found her in the corridor outside her room. R1 stated she was trying to go to the washroom. No one saw her fall. We assessed her with an eyebrow abrasion and notifications to family and physician were made. R1 was sent to the hospital and returned the same day with a fracture to her neck vertebra. On 4/12/24 at 12:45PM V5 (Certified Nursing Assistant/CNA) stated I went to the corridor from the dining room and saw R1 on the floor next to her wheelchair. I got other staff to help her back to wheelchair. R1 stated she was trying to go to the bathroom. The nurse V4 (RN) also assisted helping R1 back in wheelchair. R1 assessed with an eyebrow abrasion. The doctor was called and ordered R1 to hospital. The emergency service came and took R1 to the hospital. On 4/12/24 at 12:54 PM V6 (Physician) stated R1 has had two significant falls recently. The last fall on 3/19/24 R1 sustained a nondisplaced fracture of the seventh cervical vertebra. R1 also sustained an abrasion of the left eyebrow. R1 will not follow any reeducation for fall prevention. She now has a sitter (1:1) since the last fall with the neck fracture. R1 refuses to follow interventions such as education of asking for assistance before transferring. R1 has a low bed and a floor mat also for interventions. R1 had a lot of strength and falls are not caused by weakness. R1 is reevaluated after each fall. She has had physical therapy for previous falls. We will continue to monitor. On 4/13/24 at 9:20AM V2 (DON) stated R1 has had new interventions after each fall. R1 now has 1:1 added after the 3/19/24 fall. On 4/13/24 at 9:55AM V6 (Physician) stated R1 having a nondisplaced fracture is a serious injury that could result in severe injury with additional falls. However, it is stable and not like a displaced fracture. More importantly is another fall with her previous subdural hematoma could result in a very serious injury. The facility is giving 1:1 which is rare in a long-term care facility. This is the best intervention in preventing additional falls. On 4/13/24 at 10:27AM V2 (DON) stated the following interventions were added after the following falls. On the 3/19 fall R1 was referred to physical therapy. On 3/20/24 1:1 intervention was added. On the 3/28/24 fall in the dining room R1 went to the hospital and sustained 5 stitches to left eyebrow which was a previous injury from 3/19/24 fall. The 3/19/24 fall resulted in an abrasion to the left eyebrow and non-displaced fracture to the neck. The soft helmet was an additional intervention added to R1 on 4/10/24 due to increased agitation and swinging her head. Note: (R1 fall care plan states soft helmet added 3/28/24). On 4/13/24 at 10:45AM V9 (LPN) stated R1 was in dining room. The staff were there, I was in day room to eat lunch. I was paged. They told me R1 fell I don't know how. The staff said she just fell to the floor, and they put her back in the chair. R1's left eyebrow was bleeding. I treated and called doctor. R1 went to the hospital. I don't know if R1 had 1:1 or whether her soft helmet was on her when she fell . On 4/13/24 at 11:05AM V10 (CNA) stated I heard R1 fell , and I came in the dining room. R1 was on the floor. R1 fell because she leaned forward. She didn't have her helmet on. R1 was bleeding from eye. R1 went to the hospital. Facility did not produce a fall prevention/supervision policy when requested on 4/13/24.

Based on observation, interview and record review the facility failed to prevent the spread of foodborne illnesses by improperly thawing meat and not securing bulk item scoops. This failure has the potential to affect all residents receiving oral nutrition. Findings include: On 1/28/2024 at 9:22am surveyor observed a large package of chicken in a steel pan thawing on the top shelf of the refrigerator. Surveyor also observed a roll of ground beef in a steel pan thawing on the bottom shelf in the refrigerator. On 1/28/2024 at 9:25am V15 (Dietary Manager) stated, both meats (referring to chicken and beef) are raw so how they thaw in the refrigerator should not matter. On 1/28/2024 at 9:30am surveyor observed the serving scoop for the oatmeal, rice and flour was inside of the large container for each item. On 1/28/2024 at 9:35am V15 stated, he was told last year that it was ok to put the serving scoop inside of the large bulk containers. On 1/31/20224 at 10:45am V26 (Dietician) stated, chicken should not thaw out over ground beef in the refrigerator because the two items have different internal temperatures. V26 further stated, the serving scoop should be kept on the outside of the bulk storage container contained in a bag to prevent any physical contaminants from getting into the sealed bag. Undated policy title Thawing Hazardous Food documents, in part, potentially hazardous food will be thawed in a safe and sanitary manner. Undated Handling Clean Equipment and Utensils documents, in part, utensils will be handled to prevent contamination, other stored utensils should be covered whenever possible and clean utensils will be stored in a clean location in a way that protects them from contamination. Job Description titled Food Service Supervisor documents, in part, to develop, implement and maintain, with facility administration approval, policies and procedures to assure compliance with all federal, state and local regulations and supervise and direct all food service components this includes, but not limited to proper food storage procedures.

Based on observations, interviews, and record reviews, the facility failed to ensure staff logged off the computer clinical record system prior to leaving the medication cart and failed to ensure empty medication dispensing cards which contained resident's health information were not left unattended. These failures affected 2 (R63 and R70) residents reviewed for confidentiality of records and has the potential to affect all the residents on Side 2 of the facility. Findings include: The (1/28/2024) census documented that there were 28 residents residing in rooms XXX - YYY. On 01/28/24 at 10:37am, R63's and R70's medications dispensing cards were facing upward and were left unattended on top of a medication cart. R63's medication dispensing card contained the name of medication, description, dose, frequency of the medication, route of administration, R63's room number, and Medical Doctor. R70's medication dispensing card contained the name of the medication, description, dose, frequency of the medication, route of administration, R70's room number and medical doctor. Also observed the computer screen, on the same medication cart, with residents' identifiers, was on and was left unattended. The computer screen was facing the hallway within the view of the surveyor. V4 (Registered Nurse) was exiting a resident's room and walked towards the medication cart. These observations were pointed out to V4. V4 stated, he (V4) was assigned to the medication cart. V4 also stated I (V4) started 3 weeks ago, and nobody showed me (V4) how to lock the computer screen. I (V4) know I (V4) need to lock the computer screen because of HIPAA (Health Insurance Portability and Accountability Act of 1996). And I (V4) also need to put the B**** C*** (medication dispensing cards) face down so nobody can see them for the same reason, due to HIPAA. Of note, there was only one residents' floor at the facility. On 01/29/24 at 12:31PM, V1 (Administrator) stated on Side 3 and Side 4, most residents are walking. They (residents) are ambulatory. On 01/29/2024 at 3:58pm, V2 (Director of Nursing) stated the medication cart should always be on visual field of the nurse when passing the medication. If they are going to leave the medication cart, make sure to lock the cart and the medication dispensing card should be inside the medication cart. If the medication dispensing card is empty, we remove the label and put them in the shredding bag. They cannot leave the medication dispensing card with the resident information and name of medication in plain view where other people can read it because of the HIPAA rules. On 01/29/2024 on 4:07pm, V2 stated whenever the nurse is not using the computer, the screen should be off to protect resident's information and also because of HIPAA. The computer should be off when left unattended. On 01/31/2024 at 10:05am, V2 verified on 01/28/2024 V4 was assigned on side 2 which include rooms XXX - YYY. On 01/31/2024 at 1:38pm, V2 stated there is only one residents' floor at the facility. R63's (01/17/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R63's mental status as cognitively intact. R63's (Physician Order report: 12/29/2023 - 01/29/2024) documented, in part Diagnoses: (include but not limited to) Neuromuscular dysfunction of bladder. Medication flow sheet. Prescription. Start Date: 05/01/2023. End Date: Open Ended. Description: Myrbetriq tablet extended release 24hr (hour); 50mg; amt (amount) 1 tab (tablet). (DX (diagnosis): neuromuscular dysfunction of bladder). R70's (01/09/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R70's mental status as cognitively intact. R70's (Physician Order Report: 12/29/2023 - 01/29/2024) documented, in part Diagnoses: (include but not limited to) Benign prostatic hyperplasia with lower urinary tract symptoms. Medications flow sheet. Prescription. Start Date: 09/08/2023. End Date: Open Ended. Description: bethanechol chloride tablet; 25mg; amt: 1 tab. (DX: benign prostatic hyperplasia with lower urinary tract symptoms). The (01/30/2024) email correspondence with V2 documented, in part It is the facility expectation for the staffs to abide by the HIPAA rules when providing care to the residents. The computer screen must be off when not in use by the Nurse. The used medications dispensing cards should not be left unattended and they should be discarded appropriately by placing the labels to be shredded. The (undated) RN (Registered Nurse) job description documented, in part Purpose: the primary purpose of this position is to: Provide licensed nursing care to resident on assigned unit in accordance with current federal, state and local standards, guidelines and regulations. DUTIES/RESPONSIBILITIES/FUNCTION. 26. Ensures HIPPA HIPAA (Health Insurance Portability and Accountability Act of 1996). Compliance is maintained at all times. 27. Understands the importance of logging on and off the computer clinical record system and will consistently maintain all computer protocols. The (undated) Residents' Rights for people in Long-Term Care Facilities documented, in part Your rights to privacy. You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. The (03/2014) HEALTH INFORMATION MANAGEMENT - RESIDENT INFORMATION PRIVACY PROTECTION documented, in part To assure that all resident - identifiable information maintained by the facility shall be confidential and disclosed only to authorized individuals. Policy specifications: 1. Resident record information will be made available only to legitimate requestors, those individual/parties, both inside and external to the facility having an authorized need-to-know.

Based on observation, interview, and record review the facility failed to ensure two licensed nursing personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect three residents on side two medication cart who were prescribed controlled substances and eight residents on side one medication cart who are prescribed controlled substances. Findings include: On 01/30/2024 at 11:38 am review on side 2 medication cart with V22 (RN/Registered Nurse) surveyor observed the shift-to shift controlled substances check form for January 2024. The Nurse's Initials off box was blank for January 12, 2024 (3pm-11pm shift). The Nurse's Initials on box was blank January 15, 2024 (7am-3pm shift). The Nurse's Initials on box was blank January 15, 2024 (11pm-7am shift). On 01/30/2024 at 1:04pm review of the side 1 medication cart with V24 (RN) surveyor observed the shift-to-shift controlled substances check form for January 2024. The Nurse's Initials on box was blank for January 1, 2024 (11pm-7am shift). The Nurse's Initials on box was blank for January 3, 2024 (3pm-11pm shift). The Nurse's Initials on box was blank for January 5, 2024 (7am-3pm and 3pm-11pm shifts). The Nurse's Initials off box was blank for January 5, 2024 (3pm-11pm and 11pm-7am shifts). The Nurse's Initials on box was blank for January 6, 2024 (11pm-7am shift). The Nurse's Initials off box was blank for January 7, 2024 (7 am-3pm shift). The Nurse's Initials off box was blank for January 9, 2024 (3 pm-11pm shift). The Nurse's Initials on box was blank for January 11, 2024 (11 pm-7am shift). The Nurse's Initials off box was blank for January 12, 2024 (7am-3pm shift). The Nurse's Initials on box was blank for January 17, 2024 (3pm-11pm and 11pm-7am shifts). The Nurse's Initials off box was blank for January 17, 2024 (11pm-7am shift). The Nurse's Initials off box was blank for January 18, 2024 (7am-3pm shift). The Nurse's Initials on box was blank for January 18, 2024 (11pm-7am shift). The Nurse's Initials on/off boxes were blank for January 19, 2024 (11pm-7am shift). The Nurse's Initials off box was blank for January 20, 2024 (7am-3pm shift). The Nurse's Initials on box was blank for January 22, 2024 (7am-3pm shift). The Nurse's Initials off box was blank for January 22, 2024 (3pm-11pm shift). The Nurse's Initials off box was blank for January 24, 2024 (11pm-7am shift). The Nurse's Initials off box was blank for January 26, 2024 (3pm-11pm shift). The Nurse's Initials on box was blank for January 26, 2024 (11pm-7am shift). The Nurse's Initials off box was blank for January 27, 2024 (7am-3pm shift). The Nurse's Initials on box was blank for January 29, 2024 (11pm-7am shift). The blank spaces on the facility's-controlled substances check form indicate the controlled substances were not reconciled at the end and beginning of the shift on specified days. On 1/30/2024 at 11:38am V22 (RN) stated, the shift-to-shift controlled substances check form is signed on the day and shift you are working. V22 stated the nurse who is coming into work is to count the controlled substances with the nurse who is leaving. V22 stated, the nurse who is coming in to work and the nurse who is leaving for the day both count the number of controlled substance tablets in the bingo card. V22 stated the reason why the nurses are counting the number of controlled substance tablets in the bingo cards is to verify that the number of controlled substance tablets is correct. V22 stated if the count for the controlled substances tablets is not correct, then the nurses must notify the Director of Nursing. On 1/31/2024 at 12:23pm V2 (Director of Nursing) stated, when a nurse comes on duty the nurse will do a count of the controlled substance tablets and liquid with the nurse going off duty. V2 stated, the nurses are to initial the shift-to-shift controlled substances check form which indicates that the count for the controlled substances is correct. V2 stated, it is my expectation that the nursing staff are following the protocol regarding signing the controlled substance shift to shift count sheets. On 1/31/2024 reviewed the facility's policy titled Controlled Substances with an effective date of 10/25/2014 and a revision date of 09/01/2016, which documents, in part: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (two) and other controlled substances. 9. Nursing staff will count controlled medications at the end of each shift. The Nurse coming on duty and the Nurse going off duty will make the count together. They will document and report any discrepancies to the Director of Nursing Services. On 1/31/2024 reviewed the facility's policy titled Controlled Substance Storage with an effective date of 10/25/2014. This policy documents, in part: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. E. At each shift change a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses. On 1/31/2024 reviewed the facility's undated RN (Registered Nurse) job description which documents, in part: 12. Ensure that appropriate documentation/charting is completed as required and in accordance with established policies and procedures. 15. Ensure that narcotic records are accurate for your shift. Immediately notify the DON (Director of Nursing)/ADON (Assistant Director of Nursing) of any identified drug discrepancies. On 1/31/2024 reviewed the facility's undated LPN (Licensed Practical Nurse) job description which documents, in part: 10. Ensure that narcotic records are accurate for your shift, immediately notify the DON (Director of Nursing)/ADON (Assistant Director of Nursing) of any identified drug discrepancies.

Based on observation, interview and record review the facility failed to ensure two medication carts out of the three medication carts reviewed were free of loose tablets. This deficient practice has the potential to affect 27 residents who receive medications from side two medication cart and 22 residents who receive medications from side one medication cart. Findings include: On 1/30/2024 at 11:38AM surveyor accompanied by V22 (RN/Registered Nurse) inspected the side 2 medication cart. The following was observed: V22 pulled all the medication bingo cards from the drawers containing medication bingo cards and placed the medication bingo cards on the top of the medication cart. V22 pulled a total of (2) 1/2 white tablets, 6 white tablets, 1 brown tablet, 3 pink tablets and 1 yellow tablet from the bottom of the drawers of the side 2 medication cart. On 1/30/2024 at 11:45am V22 (RN) stated the nurses are supposed to clean the medication cart drawers. V22 stated the cleaning of the medication cart is to be done every day, the nurse should clean the medication cart before going off duty for the day so that the nurse coming on duty has a clean cart. On 01/30/2024 at 1:04 pm surveyor accompanied by V24 (RN) inspected the side 1 medication cart. V24 pulled all the medication bingo cards from the drawers containing medication bingo cards and placed the medication bingo cards on the top of the medication cart. The surveyor observed V24 pull (8) 1/2 white tablets, 1 1/2 orange tablets, 1 ruby colored tablet, 1 pink tablet, 1 gold tablet, 1 tan tablet and 1 yellow tablet from the bottom of the drawers of the side 1 medication cart. On 01/30/2024 at 1:15pm V24 (RN) stated I would have to ask the Director of Nursing who is responsible for cleaning the medication cart, I work for the agency. On 1/31/2024 at 12:23pm V2 (DON/Director of Nursing) stated the nurses are responsible for cleaning the medication carts out. V2 stated the medications carts should be cleaned out every shift. V2 stated it is my expectation that the nurses keep the medication carts clean. V2 stated there should not be any loose tablets/pills in the medication carts at any time. V2 stated if the nurses remove the tablets/pills from the bingo cards appropriately, there should not be any loose tablets in the medication carts. On 01/31/2024 reviewed the Facility's document, with an effective date of 10/25/2014 and a revision date of 05/01/2018 titled ID1: Storage of Medications which documents in part, I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperature and humidity. On 01/31/2024 reviewed the facility's undated RN (Registered Nurse) job description which documents in part, Duties/Responsibilities/Function 28. All other duties as assigned.

Based on observation, interview and record review the facility failed to ensure the container of the multi blood glucose test strips were labeled with the open date. This failure has the potential to affect 15 residents who receive blood glucose monitoring. Findings include: On 1/29/24 at 11:40am, with V13 (Licensed Practical Nurse/LPN), during medication pass, an opened container of the multi blood glucose test strips with no open date labeled was observed in the medication cart. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. On 1/30/24 at 10:56am, with V16, (LPN), during observation of medication cart storage, an opened container of the multi blood glucose test strips with no open date labeled was observed. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. When asked if there should be an open date on the container of the multi blood glucose test strips, V16 stated, No. V16 referenced the manufacturing manual inside the container of multi blood glucose test strips title (Blood Glucose Monitoring System) Blood Glucose Test Strips documents, in part, the bottle should be labeled once first opening and use within 3 months of first opening or the expiration date on the label, whichever comes first. On 1/31/24 at 10:10am, V2 (Director of Nursing) stated, It is a good practice to put the open date on the blood glucose test strip bottle once opened, to be aware of the expiration date. When asked if the nurse should perform a blood sugar reading using a multi blood glucose test strip from an undated container, V2 stated, the nurse must Follow manufacturer's recommendation for expiration once the bottle is opened. Facility policy undated and title Obtaining a Fingerstick Glucose Level, documents, in part, If using the blood glucose monitoring system (meter with test strips), use test strips before their expiration date. Facility presented document report titled, Insulin, with a date of 1/30/2024. This document report lists the 15 residents who receive blood glucose monitoring.