Every finding on record at Woodland Post-Acute

Based on interview and record review, the facility failed to maintain an acceptable parameter of nutritional status such as usual body weights for one of 24 sampled residents (Resident 50) when Resident 50's severe weight losses (more than 5% weight variance in one month, more than 7.5% weight variance in 3 months and more than 10% weight variance in 6 months) were not consistently identified, interventions were not evaluated for effectiveness, and the physician and responsible party (RP) were not notified of the change in Resident 50's condition.These failures had the potential to cause further nutritional decline and resulted in Resident 50 experiencing the following severe weight losses:- 6/5/25 to 7/1/25: 9 lbs (pounds, a unit of measurement) or 6.6% in a month;- 9/1/25 to 10/3/25: 7 lbs (5.1%) in a month;- 11/2/25 to 12/2/25: 6.8 lbs (5.3%) in a month;- 6/5/25 to 12/2/25: 15.6 lbs (11.5%) in six months; and- 10/3/25 to 1/1/26:13.6 lbs (10.5%) in three months.During a review of Resident 50's admission records, the records indicated Resident 50 was admitted to the facility in April 2024 with diagnoses that included polyneuropathy (simultaneous malfunction of many nerves throughout the body), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), hypothyroidism (thyroid gland fails to produce enough hormones), dysphagia (difficulty swallowing), and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). Resident 50's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/17/25, indicated Resident 50 had intact cognition (having sufficient mental capacity, including judgment, memory, and reasoning).During a review of Resident 50's care plan, initiated on 4/4/24 and revised on 1/7/26, the care plan indicated, .Impaired nutritional and hydration status.Meal intake less than 75%, Refusal of meals, .Non compliant to diet, gets outside food .Recommend MD [medical doctor] consult/Appetite stimulant [compounds that increase hunger and promote weight gain] r/t [related to] poor po [by mouth] intake .Refer to RD [Registered Dietitian] &/or IDT [Interdisciplinary Team] for significant weight loss, poor hydration, poor meal intakes .During a review of Resident 50's Weights and Vitals [measurements of basic body functions] Summary, the summary indicated the following weights:- 6/5/25 - 136 lbs- 7/1/25 - 127 lbs- 8/2/25 - 129 bs- 9/1/25 - 137 lbs- 10/3/25 - 130 lbs- 11/2/25 - 127.2 lbs- 12/2/25 - 120.4 lbs- 1/1/26 - 116.4 lbsDuring a review of Resident 50's RD monthly weight review note, dated 7/2/25, the note indicated Resident 50 had a weight loss of 9 lbs or 6.6% within a month. The note indicated, .Unintentional wt [weight] loss r/t poor po intake .Discussed [Resident 50] in idt meeting [Resident 50] refuses 1:1 [one on one] nsg [nursing] assist with meals .Intervention .Recommend Appetite stimulant r/t poor po intake .During a review of Resident 50's clinical records, the records indicated there was no documented evidence that the appetite stimulant was not ordered by the physician per RD's recommendation to address Resident 50's weight loss from June 2025 to July 2025, and there was no documented evidence for the reason why the recommendation was not followed.During a review of Resident 50's physician progress note, dated 7/6/25, the note indicated, .Review of Systems.General: Denies fever, chills, or weight loss . The note indicated no reference to Resident 50's weight loss and why the RD's recommendation was not followed.During a review of Resident 50's RD monthly weight review note, dated 10/8/25, the note indicated Resident 50 had a weight loss of 7 lbs or 5.1% in a month. The note indicated, .Recommend MD [medical doctor] consult r/t abnormal labs.During a review of Resident 50's clinical records, the records indicated that a significant change in condition was not initiated for Resident 50's weight loss from September 2025 to October 2025. There was also no documented evidence that the physician and Resident 50's RP was notified of the weight loss.During a review of Resident 50's Dietary Profile documented by the Dietary Supervisor (DS), dated 11/4/25, the profile indicated, .resident weight fluctuates up and down but remains stable in this quarter, no dietary changes this quarter .During a review of Resident 50's physician progress note, dated 11/15/25, the note indicated, .Review of Systems.General: Denies fever, chills, or weight loss. The note indicated no reference to Resident 50's weight loss.During a review of Resident 50's clinical records, the records indicated there was no documented evidence that Resident 50's weight loss of 6.8 lbs or 5.3% within a month between November 2025 and December 2025 was reviewed by the RD or the IDT. The notes also indicated that there was no documented evidence that the RD or the IDT reviewed Resident 50's significant weight loss of 15.6 lbs or 11.5% within six months from June 2025 to December 2025. There was no documented evidence that the interventions initiated for Resident 50 were evaluated or changed as needed during the weight losses, no significant changes in condition initiated, and there was no documented evidence that the physician and the RP were notified of the weight losses.During a review of Resident 50's physician progress note, dated 12/7/25, the note indicated, .Review of Systems.General: Denies fever, chills, or weight loss. The note indicated no reference to Resident 50's weight loss within the last month (November 2025-December 2025) and within the last six months (June 2025-December 2025).During a review of Resident 50's RD monthly weight review note, dated 1/7/26, the note indicated Resident 50 had a weight loss of 13.6 lbs or 10.5% within three months. The note indicated, .Unintentional wt loss r/t poor po intake.Goal: wt maintenance.Intervention.Recommend appetite stimulant possible megace [a hormone used to treat significant weight loss and loss of appetite].During a review of Resident 50's physician progress note, dated 1/11/26, the note indicated, .Review of Systems.General: Denies fever, chills, or weight loss. The note indicated no reference to Resident 50's weight loss within the last month (November 2025-December 2025) and within the last six months (June 2025-December 2025). There was also no documented evidence on why the RD's recommendation for appetite stimulant was not followed.During a review of Resident 50's Dietary Profile, dated 2/23/26, the profile indicated, .Usual Body Weight.125 TO 135 POUNDS.EATS ONLY 25% TO 50% OF ALL HER MEALS, RESIDENT LOST 9 POUNDS SINCE NOVEMBER .During a review of Resident 50's clinical records, the records indicated that a significant change in condition was not initiated for Resident 50's significant weight loss from October 2025 to January 2026. There was also no documented evidence that the physician and the responsible party were notified of the weight loss.During a concurrent interview and record review on 3/19/26 at 4:25 p.m. with the RD, the RD stated that she provides recommendations as soon as the residents' weights were available and these recommendations are followed through by the nursing department. The RD reviewed Resident 50's weight record from June 2025 to January 2026 and acknowledged that Resident 50 had weight losses and recommended appetite stimulant. The RD confirmed Resident 50 did not receive the appetite stimulant and it was for the doctor to decide if Resident 50 will receive the appetite stimulant. The RD stated she was not aware of what happened after she provided the recommendations. The RD further stated that the facility monitors residents' weekly weights for significant weight changes and confirmed weekly weight monitoring was not done for Resident 50 during the times Resident 50 had a significant weight loss. The RD stated there was no documented evidence that the staff attempted to check Resident 50's weights weekly or if Resident 50 refused the weight checks. The RD stated weekly weight monitoring was important for a resident having significant weight loss to make sure that the resident was not deteriorating.During a concurrent interview and record review on 3/20/26 at 10:54 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON and ADON reviewed Resident 50's weight records from June 2025 to January 2026 and acknowledged that Resident 50 had multiple weight losses from June 2025 to January 2026. The DON confirmed the RD recommended appetite stimulant for Resident 50 on 7/2/25 and on 1/7/26, and the DON stated that if the RD recommended the appetite stimulant for Resident 50, the nurses should have communicated the recommendation to the physician to do a review. The DON confirmed that there were no appetite stimulants ordered for Resident 50, there was no documented evidence that the RD's recommendations were communicated to the physician and no documentation on the reason why the RD's recommendations were not followed. The DON stated, .this could be contributing to [Resident 50's] decline. The DON also acknowledged that Resident 50 did not have significant change in conditions initiated for the significant weight losses and confirmed that there was no documented evidence that the physician and Resident 50's RP was notified of the significant weight losses. The DON also confirmed that there was no weekly weight monitoring done for all of Resident 50's significant weight losses and stated, .that wasn't recommended by RD and nobody thought about it. The DON confirmed there was no documented evidence that Resident 50 refused the weekly weights or if the weekly weight monitoring was attempted. The DON stated weekly weights were important for residents who have significant weight loss because weights were indicators for functional decline and change in condition.During a concurrent interview and record review on 3/20/26 at 12:40 p.m. with the Nurse Practitioner (NP), the NP confirmed Resident 50's severe weight losses were not indicated in Resident 50's physician progress notes. The NP stated she should have documented Resident 50's severe weight losses and why the RD's recommendation to give appetite stimulant was not started. The NP added that staff should have checked Resident 50's weekly weight during the events of significant weight losses to monitor Resident 50 better.During a review of the facility's policy and procedure (P&P) titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised 9/2017, the P&P indicated, .4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.Cause Identification.1. The physician will review for medical causes of weight gain,.and weight loss before ordering interventions.6. The physician (or staff, based on a discussion with a physician) will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status.Treatment/Management.2. The physician will authorize appropriate interventions, as indicated.b. The physician will document if cause-specific interventions could not be identified or are not feasible.Monitoring.1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss.) .During a review of the facility's P&P titled Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an):.d. significant change in the resident's physical/emotional/mental condition.4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:.b. There is a significant change in the resident's physical, mental, or psychosocial status.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.During a review of the facility's P&P titled Nutrition & Weight Management Policy, revised 10/2025, the P&P indicated, .The facility provides care and services to each Resident to ensure the Resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.Procedural/Compliance Guidelines:.1. Utilize a systematic approach to optimize each Resident's nutritional status:.c. Develop and implement pertinent approaches.d. Monitor the effectiveness of interventions and revise them as necessary.5. Ongoing Monitoring/Revision:.a. Monitor Resident's condition and care plan interventions on an ongoing basis.i. Monitoring weight using consistent methods.b. Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted.c. Notify physician and Responsible Party of: i. Significant changes in weight, intake, or nutritional status, such as: a. 5% or more weight variance in one month; b. 7.5% or more weight variance in 3 months; c. 10% or more weight variance in 6 months.d. Nutritional recommendations may be made by the Dietitian &/or Interdisciplinary Team.Consult with physician or designated practitioner for corresponding orders as indicated.

Based on interview and record review, the facility failed to ensure required members of the Quality Assurance Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee were present during meetings for a census of 82 when the Medical Director (MD) did not attend the QAPI meetings quarterly.This failure had the potential to negatively impact the quality of resident care.During a review of the facility's quarterly QAPI meeting sign-in sheets, dated 7/29/25 and 1/26/26, the sign-in sheets indicated names and signatures of QAPI committee members who attended the QAPI meeting. The sheets did not indicate that the MD was present during the meetings.During an interview on 3/20/26 at 2:33 p.m. with the Administrator (ADM), the ADM confirmed the MD did not attend the QAPI meeting on 7/29/25 because he was out of the country. The ADM further stated the MD did not assign a designee to attend the meeting. The ADM also stated that the MD was present via telephone during the QAPI meeting on 1/26/26 but forgot to sign on the sign-in sheet. The ADM stated there was no documentation that indicated the MD was present via telephone. The ADM stated it was important for the MD to be present during the QAPI quarterly meetings because the MD was the head of the clinical aspect, and that the MD should be aware of the clinical issues happening in the building.During a review of the facility's Annual QAPI & Patient Safety Plan, dated 2/21/26, the plan indicated, .The QAPI Committee is composed of the Facility Administrator, Director of Nursing, Medical Director, and at least 3 other members of the facility Leadership Team, direct care staff, and external consultants as appropriate .The facility QAPI Committee meets at least quarterly.

Based on observation, interview, and record review, the facility failed to prepare and store food in a safe and sanitary method in accordance with professional standards when:1.The Dietary Aide (DA) did not properly calibrate a thermometer, and2.The cutting boards had crevices, and3. A dietary staff did not wear a beard net in the kitchen, and4.Resident's food in resident refrigerator was not labeled with correct use by date.These failures placed residents at risk for food borne illnesses. 1. During a concurrent observation and interview on 3/18/26 at 10:20 a.m. with the Dietary Aide (DA) and the Dietary Manager (DM), the DA stated she calibrates the thermometers twice a week. Reviewed log of thermometer calibrations that indicated the thermometers had been calibrated to 32 degrees Fahrenheit every morning. The DA stated she only checks the cold temperature not the boiling point. Observed the DA place five thermometers in a glass container with ice but did not add water to make a slush of ice and water. The DA pushed the thermometers into the ice. The DA waited three minutes before reading the temperature. Requested policy for calibrating the thermometers from the DM. During concurrent interview and record review on 3/18/26 at 10:47 a.m. with the DM, the DM provided In-service: Checking Accuracy and Calibrating a Thermometer that indicated a slush should be formed when calibrating the thermometers. The DM acknowledged that the DA did not make a slush when she checked the thermometer calibration and that may put residents at risk if food is not at correct temperature. The DM requested the DA recalibrate the thermometers. A review of the facility's Policy and Procedure (P&P) titled In-service: Checking Accuracy and Calibrating a Thermometer, not dated, indicated .Food thermometers are to be check [sic] for accuracy and calibrated, if needed, on a regular basis .Food safety of all food handled in the kitchen is at stake. If the thermometers are not accurate, the food temperatures are not accurate, and the food may not be safe to serve .Fill a container .with crushed ice. Ice must be crushed . Add clean cold tap water to the container until a slush is formed. Place the thermometers in the ice bath and wait one minute .Read the temperature of all the thermometers in the ice bath without taking them out. The temperature should be 32 degrees F [Fahrenheit] . 2. During a concurrent observation and interview on 3/18/26 at 10:42 a.m. with the DM, observed two out of four cutting board with crevices. The DM stated the crevices are from cutting meat on the cutting boards with sharp knives. The DM acknowledged that the cutting boards can have bacteria in the crevices. A review of the facility's P&P titled Food Preparation and Service, revised 10/17, indicated . Food and nutrition service employees shall prepare and serve in a manner that complies with safe food handling practices . A review of 2022 Food Code U.S. Food and Drug Administration, 1/18/23, Chapter 4 Section 4-501.12 indicated .Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced . 3. During a concurrent observation and interview on 3/18/26 at 9:47 a.m. with the Dietary Supervisor (DS), observed the DS in kitchen with a closely trimmed beard. The DS was not wearing a net or covering over his beard. The DS stated he does not need to wear a beard net unless the beard is really big. Requested policy. A review of the facility's P&P titled Food Preparation and Service, revised 10/17, indicated .Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices . Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . A review of the 2022 Food Code U.S. Food and Drug Administration, 1/18/23, Chapter 2 Paragraph 2-402.11 (A) indicated .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep hair from contacting exposed FOOD, clean EQUIPMENT, UTENSILS, AND LINENS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . 4. During an interview on 3/18/26 at 10:53 a.m. with the DM, the DM stated the residents' refrigerator is located in station 2. The DM stated the kitchen staff clean the resident refrigerator. During a concurrent observation and interview on 3/18/26 at 4:15 p.m. with Licensed Nurse (LN) 9, observed resident refrigerator in locked central supply room. Observed package of individually wrapped cheese and unopened package of salami in a zip loc bag labeled with resident's name, date received 1/23/26, and discard date of 6/28/26. The expiration date on package of cheese was 6/28/26, but the expiration date for the salami was 4/9/26. The discard date on the zip loc bag, 6/28/26, did not reflect the earlier expiration date for the salami. LN 9 stated the nurses label and date the food for the residents and the kitchen staff clean out the refrigerator. During an interview on 3/18/26 at 4:24 p.m. with the DM, the DM stated both the cheese and the salami in the resident refrigerator were unopened and the expiration dates is what they use. The DM acknowledged both items were in the same bag with same discard by date. During a concurrent observation and interview on 3/19/26 at 8:02 a.m. with LN 6, LN 6 confirmed the resident refrigerator contained a zip loc bag with individually wrapped cheese and an unopened package of salami in it and labeled with a received by date of 1/23/26 and use by date of 6/28/26. LN 6 confirmed that the cheese had expiration date of 6/28/26 and salami had expiration date of 4/9/26. LN 6 stated items are kept for three days and then discarded. LN 6 stated, Don't know why they did that (put in same bag). Supposed to be three days. Different dates are confusing. A review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors, revised 10/25, indicated .it is the facility policy to honor a Resident's Right to have food brought in by family or other visitors .however, food must be handled and stored in a way to facilitate safety .Prepared food items brought in from outside sources should be labeled and dated .Facility may refrigerate labeled/dated prepared items in designated unit or pantry refrigerator . As a general guideline, prepared food is recommended to be consumed within 3 days of preparation .Unit/pantry refrigeration units shall be cleaned weekly by designated staff . A review of the 2022 Food Code U.S. Food and Drug Administration, 1/18/23, Chapter 3 Subparagraph 3-501.17 (B) (2) indicated .The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by- date based on FOOD safety .

Based on observation, interview, and record review, the facility failed to ensure foods were prepared to meet the needs of the residents when the Dietary Aide (DA) did not follow the recipe when preparing a pureed food.This failure had the potential to result in decreased nutritional value or decreased meal satisfaction for residents who receive a pureed diet. A review of the facility's pureed spaghetti recipe for winter menu 2026, indicated .Place portions of regular cooked spaghetti needed into a food processor. Process to a fine texture. For every 5 portions needed, add 1 cup of hot water and 1 tbsp [tablespoon] margarine and nonfat dry milk powder. Process until smooth, pudding consistency is achieved. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds . During a concurrent observation and interview on 3/18/26 at 9:48 a.m. with the Dietary Aide (DA), who stated she is also a cook, and the Dietary Manager (DM), observed the DA prepare the pureed spaghetti for the lunch meal. Observed the DA add correct ingredients and process to smooth pudding consistency. Then observed DA turn food processor on for approximately five seconds and turn off the food processor. When asked how long she reprocessed the food for, the DA stated she turned on the food processor for five seconds. The DA stated she did not reprocess for thirty seconds. The DA stated she did not time it and only reprocessed long enough to make sure it did not have any lumps. The DA acknowledged she did not follow the recipe instructions exactly. The DM, who observed the food preparation, acknowledged that the DA did not follow the recipe for reprocessing length of time A review of the facility's Policy and Procedure (P&P) tilted Food Preparation, dated 2018, indicated .Food shall be prepared by methods that conserve nutritive value, flavor, and appearance .The facility shall use approved recipes, standardized to meet the resident census . Recipes are specific as to portion, yield, method of preparation, amount of ingredients, and time and temperature guide .

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately stored and not available at bedside for three of 24 sampled residents (Resident 5, Resident 50, and Resident 68) when:Eye drops were observed on top of Resident 68's bedside table;An orange tablet was observed in an unlabeled medication cup on top of Resident 5's bedside table; and,An unlabeled medication cup containing white powder was observed on top of the dresser in Resident 50's room.These failures had the potential for Resident 5, Resident 50, and Resident 68 to receive medications with unsafe or reduced potency from improper storage.During a review of Resident 68's admission records, the records indicated Resident 68 was admitted to the facility in December 2024 with diagnoses that included sciatica (pain that travels along the path of the sciatic nerve) and muscle weakness. Resident 68's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/9/25, indicated Resident 68 had intact cognition.During an observation on 3/17/26 at 10:25 a.m. in Resident 68's room, Resident 68 was observed lying in bed, eyes closed, respirations unlabored, and did not respond to questions. Four plastic ampoules of eyedrops were observed inside a clear plastic cup, and a bottle of eye drops was observed beside the plastic cup on top of Resident 68's bedside table.During a concurrent observation and interview on 3/17/26 at 10:42 a.m. with the Director of Nursing (DON) in Resident 68's room, the DON confirmed the bottle of eyedrops and four ampoules of eyedrops inside Resident 68's room. The DON stated the eyedrops were not supposed to be at bedside.During a concurrent observation and interview on 3/17/26 at 10:45 a.m. with Licensed Nurse 7 (LN 7) in Resident 68's room, LN 7 confirmed the observation of eyedrops inside Resident 68's room and stated she was not aware of the eyedrops at bedside. LN 7 stated it was important not to keep medications at bedside so that residents will not overuse the medication. LN 7 further stated the eyedrops can cause blindness if not used properly. The LN 7 added that Resident 68 was not allowed to administer her own medications and might put the eyedrops in the mouth or nose.2. During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in May 2023 with diagnoses that included gastroesophageal reflux disease (GERD -happens when stomach aid flows back up into the esophagus and causes heartburn), anxiety disorder (a group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation), depression (persistent feeling of sadness and loss of interest), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). Resident 5's MDS, dated [DATE], indicated Resident 5 had intact cognition.During an observation on 3/17/26 at 9:24 a.m. in Resident 5's room, Resident 5 was not present in the room, and an orange tablet was observed in an unlabeled medication cup on top of the bedside table.During a concurrent observation and interview on 3/17/26 at 9:36 a.m. with Resident 5 and LN 7 in Resident 5's room, LN 7 confirmed the orange tablet in the medication cup at bedside. LN 7 stated she did not give the tablet to Resident 5, and the tablet looked like Tums (antacid used to relieved heartburn, indigestion, and upset stomach caused by too much stomach acid). Resident 5 stated the tablet was Tums and was given by the nurse from the previous night for acid reflux. LN 7 stated that the medication was not supposed to be at bedside. LN 7 further stated that there could be side effects if Resident 5 kept more medication than she was supposed to. LN 7 added that staff needed to make sure that the resident took the medication.3. During a review of Resident 50's admission records, the records indicated Resident 50 was admitted to the facility in April 2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), attention-deficit hyperactivity disorder (ADHD - a condition characterized by inattention, hyperactivity and impulsivity), and adjustment disorder (strong emotional and behavioral symptoms that happen after a stressful event). Resident 50's MDS, dated [DATE], indicated Resident 50 had intact cognition.During an observation on 3/17/26 at 10:15 a.m. in Resident 50's room, Resident 50 was observed lying in bed, awake but refused to answer questions. An unlabeled medication cup containing white powder was observed on top of Resident 50's dresser at bedside.During a concurrent observation and interview on 3/17/26 at 10:50 a.m. with LN 7 in Resident 50's room, LN 7 confirmed the unlabeled medication cup containing white powder on top of Resident 50's dresser. LN 7 stated Resident 50 did not have any wounds and stated she did not know what the powder was.During an interview on 3/20/26 at 10:54 a.m. with the DON, the DON stated staff are not supposed to keep medication at bedside because .We don't know when the resident is going to take the medication. The DON further stated there was a possibility that the residents might not take the medication properly. The DON added that staff need to observe when the residents take medication and make sure that the residents took the medication.During a review of the facility's policy and procedure (P&P) titled MEDICATION STORAGE IN THE FACILITY, dated 4/2008, the P&P indicated, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized .During a review of the facility's P&P titled PREPARATION AND GENERAL GUIDELINES, dated 10/2017, the P&P indicated, .15) The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures to ensure accurate acquiring, receiving, dispensing, and administering of drugs for four of 24 sampled residents (Resident 8, Resident 93, Resident 17, and Resident 9) when: 1. Resident 93's medication was not available for administration as ordered;2. There was no accurate accountability of controlled medications (high potential for abuse or addiction) for three residents (Resident 93, Resident 8, and Resident 17); and3. Resident 9's medications were not administered as ordered. These failures increased the potential for Resident 93 and 9 to experience adverse effects from not receiving medications and the potential for abuse, misuse, and diversion for controlled medications.1. A review of the admission Record indicated Resident 93 was admitted [DATE] with diagnoses including acute osteomyelitis (sudden, severe infection of the bone) of left ankle and foot and sepsis (a life- threatening blood infection). A review of Resident 93's Order Summary Report indicated Resident 93 had an order for Prasugrel (antiplatelet or blood thinner- medication used to prevent blood clots) HCL (hydrochloride) 10 milligram (mg, unit of measurement) give 1 tablet by mouth one time a day for Antiplatelet therapy on 3/6/26. A review of Resident 93's Medication Administration Record (MAR) indicated the Prasugrel was documented as 8 or medication not available for 10 days on 3/7, 3/8, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, 3/16, and 3/17/26. A review of Resident 93's Administration Note for the Prasugrel order from 3/7 to 3/17 did not indicate the physician was notified of the medication not available for administration. A review of Resident 93's Physician Progress Note dated 3/16/26 by the Nurse Practitioner indicated, .pharmacy reports prasugrel not covered consider cardiology consult for alternative therapy. The patient was referred to Cardiology. A review of Resident 93's Communication Form dated 3/16/26 indicated Prasugrel was not covered by insurance and pharmacy will not dispense. The pharmacy made recommendations indicating 2 other medications and this form was acknowledged by the Nurse Practitioner and the response was Refer to Cardiology. During a medication pass observation on 3/18/26 starting at 7:23 a.m. with Licensed Nurse 6 (LN 6), Resident 93's Prasugrel 10 milligram was not available for administration. During an interview on 3/18/26 at 7:35 a.m. with the LN 6, the LN 6 stated the Prasugrel was not available, and the medication was ordered on 3/6/26. During a concurrent interview and record review on 3/19/26 at 11:18 a.m. with the Director of Nursing (DON) and the Resource Nurse (RN), Resident 93's MAR was reviewed with the DON. The DON stated he was made aware on 3/18/26 of Resident 93's Prasugrel medication not available because of insurance coverage. The DON further stated he called the pharmacy and the medication was delivered around 12:50 p.m. yesterday (3/18/26). The RN explained the process when a medication was ordered, the licensed nurse (LN) will check if the medication is available in the emergency (e)- kit. The LN will notify the physician if the medication is not available in the e-kit and follow up with the pharmacy. The RN stated when she reviewed Resident 93's clinical records, RN did not see documentation the physician was notified. The RN further stated the facility cannot locate the notice of non-covered/high-cost form from the pharmacy. During a telephone interview on 3/20/26 at 2:09 p.m. with the Pharmacy Consultant (PC), the PC stated Resident 93's notice of non-coverage for Prasugrel was faxed to the facility on 3/6/26. The PC further stated the physician saw Resident 93 on 3/12 and there was no documentation this provider did a clinical intervention to switch to another medication. The PC added if a medication is not given three times or more, the physician should be notified. A review of the facility's policy and procedure (P & P) effective October 2017 and titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES indicated, .Medications are administered in accordance with written orders of the attending physician. A review of the facility's P & P effective January 2022 and titled, ORDERING AND RECEIVING MEDICATIONS FROM THE DISPENSING PHARMACY indicated, .A licensed nurse .Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. 2a. A review of Resident 93's physician order dated 3/7/26 indicated Oxycodone-Acetaminophen (controlled pain medication) 5-325 mg give 1 tablet every 4 hours as needed for moderate to severe pain. A review of Resident 93's Controlled Drug Record (CDR) and Medication Administration Record (MAR) indicated the following: - on 3/8/26 at 10:20 a.m., the CDR indicated 1 tablet of Oxycodone 5-325 mg was taken out, the MAR indicated the Oxycodone was not given; - on 3/10/26 at 8:50 p.m. [2050], the CDR indicated 1 tablet of Oxycodone 5-325 mg was taken out, the MAR indicated the Oxycodone was not given; and, - on 3/17/26 at 5 a.m. [0500], the CDR indicated 1 tablet of Oxycodone 5-235 mg was taken out, the MAR indicated the Oxycodone was not given. During a concurrent interview and record review on 3/20/26 at 9:11 a.m. with the Director of Nursing (DON), Resident 93's CDR and MAR were reviewed. The DON acknowledged the discrepancies in the CDR and MAR on 3/8, 3/10, and 3/17 for Resident 93. 2b. A review of Resident 8's physician orders dated 1/6/26 indicated the following: - Hydrocodone- Acetaminophen 5-325 mg (milligram, unit of measurement) give 1 tablet every 6 hours as needed for moderate pain; and, - Hydrocodone-Acetaminophen 5-325 mg give 2 tablets every 6 hours as needed for severe pain. A review of Resident 8's CDR and MAR indicated the following: - on 2/21/26, the CDR indicated 3 tablets of Hydrocodone 5-325 mg were taken out; the MAR indicated a total of 4 tablets of Hydrocodone 5-325 were given (2 tablets at 7:34 a.m. and 2 tablets at 3:39 p.m.); - on 2/27/26 at 7:40 a.m., the MAR indicated 2 tablets of Hydrocodone 5-325 were given, the CDR indicated Hydrocodone was not taken out; - on 3/2/26 at 6:41 a.m., the CDR indicated there was 1 tablet of Hydrocodone taken out, the MAR indicated Hydrocodone was not given; and, - on 3/3/26 at 6:41 a.m., the MAR indicated there was one tablet of Hydrocodone given, the CDR indicated Hydrocodone was not taken out. During a concurrent interview and record review on 3/20/26 at 9:21 a.m. with the DON, Resident 8's CDR and MAR were reviewed. The DON acknowledged the discrepancies in the CDR and MAR on 2/21, 2/27, 3/2, and 3/3 for Resident 8. During a follow up interview on 3/20/26 at 9:30 a.m. with the DON, the DON stated his expectation when a controlled medication is taken out for administration, it should be documented in the CDR and in the MAR. The DON further stated there is a potential for medication error and diversion. 2c. A review of Resident 17's physician order dated 1/23/26 and discontinued 2/13/26 indicated Oxycodone HCl 5 mg give 1 tablet every 12 hours as needed for moderate to severe pain. A review of Resident 17's CDR for the Oxycodone HCl 5 mg indicated recount and there were 29 pills remaining. The Oxycodone bubble pack indicated there were 30 pills delivered and there were 29 pills left. The CDR did not indicate the date and time when the Oxycodone #30 was taken out from the bubble back. During a concurrent interview and record review on 3/20/26 at 9:47 a.m. with the DON and Assistant Director of Nursing (ADON). The DON stated he was the one who signed the Resident 17's CDR and he received 29 tablets of the Oxycodone. Resident 17's CDR and MAR were reviewed with the ADON, the ADON stated the #30 oxycodone pill was not accounted for in the CDR, the MAR indicated Oxycodone was administered on 2/13/26. The ADON stated her expectation when LNs take out a controlled medication is to document in the electronic MAR and CDR to prevent any errors or discrepancy. A review of the facility's P & P effective April 2008 and titled, CONTROLLED MEDICATIONS indicated, .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR) .Date and time of administration .Amount administered . 3. During a review of Resident 9's admission records, the records indicated Resident 9 was admitted to the facility in December 2024 with diagnoses that included acute kidney failure (reversible kidney damage), hydronephrosis (swelling of kidneys caused by buildup of urine due to obstruction or blockage in the urinary tract), and abnormal findings in blood chemistry (measure substances in the blood to evaluate organ function, metabolic balance, and overall health). Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/7/26, indicated Resident 9 had intact cognition. During a review of Resident 9's Medication Administration Records (MARs) from January 2026 to March 2026, the MARs indicated an order for Ferrous Gluconate (used to treat or prevent iron deficiency anemia, not having enough healthy red blood cells, by aiding the body in producing red blood cells) 324 mg (milligrams, a unit of measurement) once a day for prophylaxis related to abnormal findings of blood chemistry. The MARs indicated Resident 9's Ferrous Gluconate doses were not available and were not administered for 19 non-consecutive days in January 2026, 18 non-consecutive days in February 2026, and 9 non-consecutive days in March 2026. During a review of Resident 9's MAR for March 2026, the MAR indicated an order for Folic Acid (vitamin needed by the body to manufacture red blood cells) 1 mg once a day for prophylaxis related to abnormal findings of blood chemistry. The MAR indicated Resident 9's folic acid doses were not available and were not administered on 3/16/26 and 3/17/26. During a review of Resident 9's progress notes, there was no documented evidence that the physician was notified of the missed doses for ferrous gluconate and folic acid. During an interview on 3/19/26 at 3:11 p.m. with Licensed Nurse 8 (LN 8), LN 8 stated ferrous gluconate was available in the medication cart and supply was available as floor stock. LN 8 also confirmed Resident 9's folic acid was refilled on 3/15/26 and was available in the medication cart since. During a concurrent interview and record review on 3/20/26 at 10:54 a.m. with the DON, the DON confirmed ferrous gluconate doses were not given in multiple days from January to March 2026 and the same staff was signing on the missing doses. The DON stated supply of ferrous gluconate was available in the medication room and stated that there was a possibility that the staff did not know where the supply was located. The DON also confirmed folic acid comes in bubble packs and confirmed Resident 9's folic acid was refilled on 3/15/26. The DON confirmed that Resident 9's folic acid was available but not given. The DON further stated if the staff cannot find the medication, they should be aware that every floor had medication carts, and if not available, staff should notify the physician whether the medication was over the counter or not. During a review of the facility's policy and procedures (P&P) titled PREPARATION AND GENERAL GUIDELINES, dated 10/2017, the P&P indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.2) Medications are administered in accordance with written orders of the attending physician .

Based on observation, interview, and record review, the facility failed to provide care and treatment according to professional standards of practice for three of 24 sampled residents (Resident 93, Resident 8 and Resident 9) when: 1.Resident 93's PICC line (peripherally inserted central catheter, a type of IV, intravenous line, that is used to deliver fluids or medications into a vein) was not flushed (injection of normal saline solution into an IV catheter to clear the line) prior to and after IV antibiotics (used to treat bacterial infections) were administered; 2. The physician was not notified of Resident 8's blood sugar reading greater than 400 mg (milligrams)/dl (deciliter); and, 3. Resident 9's IV antibiotic was not administered as ordered and the physician was not notified of Resident 9's unavailability of IV access. These failures had the potential for Resident 93 to experience complications including PICC line failure or infection, Resident 8 to experience complications from hyperglycemic (high blood sugar) episodes, and resulted in Resident 9 experiencing delays in the administration of IV antibiotic treatment. 1. A review of Resident 93's admission Record indicated Resident 93 was admitted to the facility in March 2026 with multiple diagnoses including acute osteomyelitis (infection in the bone) of left ankle and foot, sepsis (body's immune response to infection that damages vital organs), and diabetes (high blood sugar levels due to body not producing enough insulin or insulin is not effective). A review of Resident 93's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 3/9/26, indicated Resident 93 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 93 was cognitively intact. A review of Resident 93's Non-Acute Care Physician Transfer Orders, dated 3/6/26, indicated .Medications nafcillin [an antibiotic medication] (nafcillin 2 g [gram] injection) .12 grams over 24 hours via infusion pump. 10 mL [milliliter] NS [Normal Saline-water and salt solution with 9% salt concentration] flush before and after infusion . A review of Resident 93's Order Summary Report indicated order dated 3/6/26, Nafcillin Sodium Injection Solution .Use 4 gram intravenously three times a day for antibiotic . A review of Resident 93's Order Summary Report indicated order dated 3/18/26, Flush PICC with 10 ml of normal saline before and after IV medication administration three times a day . A review of Resident 93's Medication Administration Record [MAR], for 3/1/26 to 3/31/26, indicated Flush PiCC Line Lumens with 10 ml of normal saline before and after IV medication administration three times a day-Start Date 03/18/2026 . The MAR did not reflect the PICC line was flushed before and after medication administration prior to 3/18/26. During an interview on 3/17/26 at 9:16 a.m. with Resident 93, Resident 93 stated he has a PICC line and is receiving IV antibiotics three times a day. Resident 93 stated last night (3/16/26), the nurse did not flush his line before giving the antibiotic, between the two bags of IV antibiotics, or after the antibiotic was completed. Resident 93 stated he knew the line needed to be flushed before and after antibiotics were given. During a subsequent interview on 3/19/26 at 12:08 p.m. with Resident 93, Resident 93 stated the nurse who did not flush his PICC line on 3/16/26 apologized to him on 3/18/26 for not flushing the PICC line on 3/16/26. During an interview on 3/19/26 at 12:27 p.m. with Licensed Nurse (LN) 2, LN 2 stated the process for administering IV antibiotics is to check the orders, check the rate, flush the line, administer the medication, and flush the line when medication is done. During a concurrent interview and record review on 3/20/26 at 2:09 p.m. with the Director of Nursing (DON), the DON acknowledged there was no order for Resident 93's PICC line to be flushed before and after IV antibiotic administration until 3/18/26. The DON acknowledged there was no order for PICC line flushing between 3/6/26 and 3/17/26. The DON stated the process for IV antibiotic administration is to perform hand hygiene, clean hub of line, flush line to assess the line, and verify the medication. The DON stated after the antibiotic is given the line should be flushed again. The DON stated, Should be an order for PICC line flushing to maintain patency and safety. A review of the Facility's Policy and Procedure (P&P) tilted General Policies for IV Therapy, dated 3/23, indicated .Physician's orders are required for initiating intravenous/subcutaneous therapy. All orders must include name, dose, frequency, duration of therapy, route of administration and diagnosis . Intermittent IV medications should be separated by saline flushes . A review of the P&P titled Medication Administration-General Guidelines, effective 10/17, indicated .Medications are to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Medications are administered in accordance with written orders of the attending physician . 2. A review of Resident 8's admission Record indicated Resident 8 was admitted to the facility in January 2026 with multiple diagnoses including multiple rib fractures, Prader-Willi syndrome (a genetic condition causing physical, mental and behavioral problems, including being hungry all the time), diabetes, and urinary retention (unable to fully empty the bladder). A review of Resident 8'a MDS, Cognitive Patterns, dated 2/21/26, indicated Resident 8 had a BIMS score of 9 out of 15 that indicated Resident 8 was moderately cognitively impaired. A review of Resident 8's order, dated 1/25/26, indicated .Insulin Lispro Injection Solution [fast acting type of insulin] 100 UNIT/ML .Inject as per sliding scale [a scale used to determine how much insulin to give to correct elevated blood sugar] Subcutaneously [just under the skin] two times a day .Notify MD [Medical Doctor] if BG [Blood glucose, sugar] < [less than] 70 or > [greater than] 400 . A review of Resident 8's Care Plan, initiated 1/28/26, Imbalanced Blood Glucose level r/t [related to] insufficient insulin control AEB [as evidenced by] abnormal Blood Glucose readings .Goal .Resident will have no signs of hypo [below normal] or hyperglycemia through the next review date. Resident will maintain blood glucose readings within target range (60-130 mg/dl fasting less than 180 mg/dl post meal) .Interventions Administer Insulin / Lispro .within 15 minutes before meals or per sliding scale orders . A review of Resident 8's MAR, for 3/1/26 to 3/31/26, indicated a blood sugar on 3/1/26 at 4:30 p.m. of 499 mg/dl, on 3/5/26 at 4:30 p.m. of 528 mg/dl, and on 3/16/26 at 4:30 p.m. of 410 mg/dl. A review of Resident 8's clinical record did not reflect MD had been notified of elevated blood sugar of 528 on 3/5/26 or of blood sugar of 410 on 3/16/26. The clinical record did not reflect a Change of Condition Assessment had been initiated for the elevated blood sugars on 3/1/26, 3/5/26, and 3/16/25. During a concurrent interview and record review on 3/19/26 at 3:14 p.m. with the LN 1, LN 1 acknowledged Resident 8's blood sugar was 499 mg/dl on 3/1/26, 528 mg/dl on 3/5/26, and 410 mg/dl on 3/16/26. LN 1 stated if blood sugar was greater than 400 mg/dl then the nurse should have called the MD. LN 1 stated a Change in Condition Assessment should have been done for a hyperglycemic episode. LN 1 stated there was no Change in Condition Assessment done on 3/1/26, 3/5/26, or 3/16/26 for the hyperglycemic episodes. After a review of Resident 8's progress notes with LN 1, LN 1 acknowledged that there was no documentation of notification to MD of Resident 8's elevated blood sugars on 3/5/26 and 3/16/26. LN 1 stated the MD should have been notified of Resident 8's elevated blood sugars greater than 400 mg/dl on 3/5/26 and 3/16/26. LN 1 stated if the MD was not notified Resident 8 was at risk of not getting enough insulin or diabetic shock. During an interview and concurrent record review on 3/20/26 at 2:09 p.m. with the DON, the DON acknowledged Resident 8's elevated blood sugars greater than 400 mg/dl on 3/1/26, 3/5/26, and 3/16/26. The DON stated it would have been appropriate for a Change in Condition Assessment to have been completed for the elevated blood sugars. The DON acknowledged that no Change in Condition Assessments were done for elevated blood sugars on 3/1/26, 3/5/26, and 3/16/26. The DON acknowledged that there was no documentation that the MD had been notified on 3/5/26 and 3/16/26 of the elevated blood sugars. The DON stated the MD should have been notified of blood sugars greater than 400 mg/dl because may need new orders. A review of the facility's P&P titled Change in a Resident's Condition or Status, revised 5/17, indicated .Our facility shall promptly notify the resident, his or her Attending Physician, and representative .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) .specific instruction to notify the Physician of changes in the resident's condition .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A review of the facility's P&P titled Charting and Documentation, revised 7/17, indicated .All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical. functional or psychosocial condition shall be documented in the resident's medical record .the following information is to be documented in the resident medical record .Changes in the resident's condition . Documentation of procedures and treatments will include .The assessment data and /or any unusual findings .Notification of family, physician or other staff . A review of the facility's P&P titled Insulin Administration, dated 2022, indicated .Monitor blood sugar as ordered by physician . 3. During a review of Resident 9's admission records, the records indicated Resident 9 was admitted to the facility in December 2024 with diagnoses that included benign prostatic hyperplasia (BPH - enlargement of the prostate gland), acute kidney failure (reversible kidney failure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (excessive, persistent, and uncontrollable worry or fear), neuromuscular dysfunction of bladder (Neurogenic bladder - happens when electrical signals between nervous system and bladder function are interrupted), and resistance to multiple antibiotics (occurs when bacteria evolve to survive drugs designed to kill them). Resident 9's MDS, dated [DATE], indicated Resident 9 had intact cognition. During a review of Resident 9's care plan, revised 1/9/25, the care plan indicated, .At risk for recurrent bladder infection.Administer prescribed medication. During a review of Resident 9's physician progress note, dated 3/16/26, the note indicated, .[Resident 9] presents today for the evaluation of urinary tract symptoms.Assessment and Plan.Pharmacy called back stated due to [Resident 9's] crcl [creatinine clearance – measures how efficiently kidneys filter waste from the blood] Meropenem [an antibiotic] is better, Notified nurse to change to Meropenem 1 GM (gram, a unit of measurement) IV. During an interview on 3/17/26 at 10:42 a.m. with Resident 9, Resident 9 stated he had UTI (Urinary Tract Infection) and had been waiting for his IV medication all day. During a review of Resident 9's MAR for March 2026, the MAR indicated a physician order for Meropenem 1 GM IV every eight hours for UTI. The MAR further indicated Resident 9's Meropenem was not signed as administered on 3/16/26 at 10 p.m. and 3/17/26 at 6 a.m. During a review of Resident 9's nurses note, dated 3/17/26 at 6:14 a.m., the note indicated, .[Resident 9] was to begin IV ABX [antibiotic] therapy yesterday however, IV medication was not available in EKIT [emergency kit]. IV medication did not arrive till 0400 [4 a.m.]. Endorsed to AM shift medication is located in med room with all IV supplies. AM shift nurse said she will locate an RN when time on the MAR. During a review of Resident 9's nurses note, dated 3/17/26 at 2:25 p.m., the note indicated, .[Resident 9] on charting for IV ATB therapy. Resident sent out to ER for PICC insertion at 1200 [12 p.m.].all meds administered and taken. During a concurrent interview and record review on 3/20/26 at 10:54 p.m. with the DON and the Assistant Director of Nursing (ADON), the DON confirmed Resident 9's Meropenem was ordered on 3/16/26 and Resident 9 did not have an access to receive the antibiotic. The ADON stated Resident 9's meropenem was not delivered because the pharmacy requested laboratory report before dispensing the medication. The ADON confirmed that Resident 9's meropenem was delivered on 3/17/26 at 4 a.m. but was not administered on the scheduled time at 6 a.m. on 3/17/26 because Resident 9 did not have an access. The DON and ADON confirmed that there was no documented evidence that the physician was notified that Resident 9 did not have an IV access to administer the IV antibiotic. The DON confirmed that the failure to notify the physician about the absence of IV access caused a delay in the administration of the IV antibiotic. The DON stated that staff should be asking the physician for the order for an IV access and stated that was not the case for Resident 9. During a review of the facility's policy and procedure (P&P) titled PREPARATION AND GENERAL GUIDELINES, dated 10/2017, the P&P indicated, .2) Medications are administered in accordance with written orders of the attending physician.3. If a dose seems excessive.or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification is documented in the nursing notes and elsewhere in the medical record as appropriate. During a review of the facility's P&P titled Charting and Documentation, revised 7/2017, the P&P indicated, .7. Documentation of procedures and treatments will include care-specific details, including:.f. Notification of.physician.if indicated.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of 24 sampled residents (Resident 11) when: Resident 11 was prescribed a psychotropic medication (drug that treats mental illnesses such as anxiety, by altering brain chemistry) Lorazepam (a benzodiazepine used to treat anxiety disorders. Common side effects include dizziness, drowsiness, and weakness) without adequate monitoring.This failure had the potential for Resident 11 to experience drowsiness, dizziness, or weakness increasing Resident 11's risk for falls.During a review of Resident 11's Facesheet (a one-page medical document summarizing a patient's key demographic, insurance, and clinical data) indicated, Resident 11 was admitted to the facility in February 2026.During a review of Resident 11's Order Summary Report dated 3/19/26, Report indicated, an order for: LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 2 hours as needed for mild anxiety Active 2/17/26, LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 2 tablets by mouth every 2 hours as needed for moderate anxiety Active 2/17/26, and LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 3 tablets by mouth every 2 hours as needed for severe anxiety Active 2/17/26.Order Summary Report indicated, no monitoring orders for the use of Lorazepam were ordered at the time of 2/17/26.During a review of Resident 11's Care Plan dated 3/19/26, Care Plan indicated, no interventions or monitoring of the medication Lorazepam were listed when it was ordered on 2/17/26.During an interview on 3/19/26, at 1:51 p.m., with Licensed Nurse (LN) 3, LN 3 stated, [Resident 11] has orders for Lorazepam for anxiety. LN 3 stated, she did not see any monitoring orders for the Lorazepam. LN 3 stated, The monitoring order should be put in at the same time as the medication order.During an interview on 3/20/26, at 9:58 a.m., with Director of Nursing (DON), DON stated, the nurses are supposed to add the order for behavioral monitoring when the med [medication] is ordered. They did not.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use dated 2021, the P&P indicated, A psychotropic drug is any medication that affects brain activities associated with mental process and behavior, which includes but is not limited to antipsychotics, anxiolytics [anxiety medications], hypnotics [medications to help fall sleep] and antidepressants.4. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All residents receiving medications used to treat behaviors should be monitored for: a. Efficacy b. Risks c. Benefits d. Harm or adverse consequences.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of care for one of 24 sampled residents (Resident 74) when: 1. Resident 74's nebulizer (a small machine that turns liquid medicines into mist to deliver medication) tubing was not replaced every 7 days; and,2. Resident 74's oxygen use was not accurately documented. These failures had the potential to result in respiratory infection and undetected deterioration of respiratory function for Resident 74. A review of the admission Record indicated Resident 74 was readmitted early February 2026 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and acute respiratory failure (lungs cannot get enough oxygen into the blood) with hypercapnia (too much carbon dioxide in the blood). A review of Resident 74's Medication Administration Record (MAR) for March indicated the following physician orders:-Ipratropium- Albuterol solution (used to treat breathing difficulties) 3 milliliter inhale orally every 4 hours as needed for shortness of breathing (SOB) or wheezing via nebulizer with a start date of 2/4/26; and,-Oxygen at 2L/min (liters/minute, unit of measurement) via nasal cannula (a thin flexible tube with two prongs that go inside the nostrils to deliver oxygen) as needed for oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) less than 92% or SOB as needed with a start date of 2/19/26. A review of Resident 74's care plan initiated 4/20/22 indicated, At risk for shortness of breath or respiratory distress related to dx [diagnosis] of COPD. The interventions included, Oxygen therapy as MD [Medical Doctor] ordered. During a concurrent observation and interview on 3/17/26 at 9:25 a.m., inside Resident 74's room, a nebulizer tubing was stored in a clear bag. The nebulizer tube and the bag was dated 3/8/26. Resident 74 stated he had been using his oxygen at night. During a concurrent observation and interview on 3/17/26 at 1:11 p.m. with Licensed Nurse 3 (LN 3) inside Resident 74's room. The LN 3 stated Resident 74 had been using 2L/min of oxygen at night. The LN 3 stated there was no date in the oxygen tubing and LN 3 did not know when the oxygen tubing was changed. The LN 3 further stated the nebulizer tubing was dated 3/8/26 and it should have been changed 2 days ago. During an interview on 3/19/26 at 11:51 a.m. with the Director of Nursing (DON) and the Resource Nurse (RN), the RN stated the oxygen tubing, and the nebulizer tubing should be changed every 7 days. During a follow up observation and interview on 3/20/26 at 8:22 a.m. in Resident 74's room. Resident 74 was lying in bed, and he was not using oxygen. Resident 74 was asked if he was using his oxygen, Resident 74 responded, at nighttime. During an interview on 3/20/26 at 8:30 a.m. with the Activities Director (AD) in Resident 74's room. The AD talked to Resident 74 in his native language. The AD asked Resident 74 if he was using the oxygen and the nebulizer treatment. Resident 74 stated he had been using the oxygen every night due to shortness of breathing and the nebulizer treatment in the morning. Resident 74 denied being short of breath at this time. During a concurrent interview and record review on 3/20/26 at 10:05 a.m. with the DON, Resident 74's oxygen orders, MAR, and the oxygen saturation summary were reviewed. The DON stated Resident 74's order of oxygen at bedtime was discontinued on 2/4/26 and there was no routine oxygen order for March. The DON further stated Resident 74's oxygen saturation on 3/19/26 was 94% with oxygen via nasal cannula and it was not documented in the MAR. The DON stated his expectation was for licensed nurses to document the use of oxygen in the MAR since oxygen is a medication. A review of the facility's policy and procedure dated 11/15/2023 and titled, Respiratory Therapy - Prevention of Infection indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Infection Control Considerations Related to medication Nebulizers .Discard the administration set-up every seven (7) days .The following information should be recorded in the resident's medical record .The date and time the respiratory therapy was performed .The name and title of the individual(s) who performed the respiratory therapy .All assessment data obtained during the treatment.

Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) had an annual performance review for one of five sampled CNA staff (CNA 3).This failure had the potential for CNA 3 to provide inadequate care to residents.During a concurrent interview and record review on 3/19/26, at 12:14 p.m., with Director of Staff Development (DSD) CNA 3's personnel file was reviewed. CNA 3's personnel file indicated, he was hired on 2/4/25. Personnel file indicated, no annual performance review was completed. DSD stated, I am not sure how we track when they [annual performance reviews] are due. DSD stated, he did not see an annual performance review in the file, and there should be one in the personnel file. During a review of the facility's Employee Handbook dated 2023, Handbook indicated, Performance Evaluations, Performance feedback should be on-going between supervisors and employees. However, we established annual, documented reviews as a standard to formalize an interactive conversation about what is going well, where there could be improvements, goals for career growth and set objectives to work towards.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations dated 2024, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually.10. The completed performance evaluation will be sent by the director or supervisor to the HR Director to be placed in the employee's personnel file.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%)) when two medications out of 31 opportunities were not given in accordance with the physician's orders for two residents (Resident 93 and Resident 79). This failure resulted in a medication error rate of 6.45%.1a. A review of the admission Record indicated Resident 93 was admitted [DATE] with diagnoses including acute osteomyelitis (sudden, severe infection of the bone) of left ankle and foot and sepsis (a life- threatening blood infection). A review of Resident 93's Order Summary Report indicated Resident 93 had an order for Prasugrel (antiplatelet or blood thinner- medication used to prevent blood clots) HCL (hydrochloride) 10 milligram (mg, unit of measurement) give 1 tablet by mouth one time a day for Antiplatelet therapy on 3/6/26. During a medication pass observation on 3/18/26 starting at 7:23 a.m. with Licensed Nurse 6 (LN 6), Resident 93's Prasugrel 10 milligram was not available for administration. During an interview on 3/18/26 at 7:35 a.m. with LN 6, the LN 6 stated the Prasugrel was not available, and the medication was ordered on 3/6/26. During a concurrent interview and record review on 3/19/26 at 11:18 a.m. with the Director of Nursing (DON) and the Resource Nurse (RN), Resident 93's MAR was reviewed with the DON. The DON stated he was made aware on 3/18/26 of Resident 93's Prasugrel medication not available because of insurance coverage. 1b. A review of the admission Record indicated Resident 79 was originally admitted March of 2020 with diagnoses including cerebral infarction (a type of stroke, loss of blood flow to a part of the brain) and gastro-esophageal reflux disease (GERD, chronic condition where stomach acid flows back into the food pipe). A review of Resident 79's Order Summary Report indicated an order dated 3/5/25 for Prevacid (decreases stomach acid) delayed release 30 mg 1 capsule every 12 hours for heartburn GIVE ON EMPTY STOMACH FOR BEST ABSORPTION. During a medication pass observation on 3/18/26 starting at 7:49 a.m. with LN 3, the LN 3 prepared medications for Resident 79 including the Prevacid. During a concurrent observation and interview on 3/18/26 at 8:06 a.m. with LN 3, the LN 3 administered Resident 79's medications. The LN 3 stated Resident 79 had his breakfast, and the meal trays were passed between 6:30 to 7 a.m. During a follow up interview on 3/18/26 at 8:12 a.m. with LN 3, the LN 3 stated Prevacid ideally should be given on an empty stomach, the medication was scheduled every 12 hours at 8 a.m. and at 8 p.m. During a concurrent interview and record review on 3/18/26 at 9:21 a.m. with LN 3, Resident 79's physician order was reviewed. The LN 3 stated Resident 79's Prevacid order indicated GIVE ON EMPTY STOMACH FOR BEST ABSORPTION. During an interview on 3/19/26 at 11:34 a.m. with the DON and the RN. The RN acknowledged Resident 79's Prevacid order indicated to give before meals for best absorption. A review of the facility's policy and procedure effective October 2017 and titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES indicated.medications are administered in accordance with written orders of the attending physician .Medications are administered within 60 minutes of scheduled time .except before or after meal orders, which are administered based on mealtime.

Based on interview and record review, the facility failed to ensure a written agreement was obtained for services furnished by outside resources for one of 24 sampled residents (Resident 10) receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). This failure had the potential to result in the lack of accountability in the dialysis services. A review of the admission Record indicated Resident 10 was admitted October of 2025 with diagnoses including atherosclerotic heart disease (build up of fat or cholesterol in the heart's arteries causing them to narrow and harden) and end stage renal disease (ESRD, irreversible kidney failure). A review of Resident 10's physician order dated 3/6/26 indicated, HEMODIALYSIS AT [Dialysis company name and address] .MWF [Monday, Wednesday, Friday] .During an interview on 3/19/26 at 4:36 p.m. with the Administrator (ADM), the ADM stated he would look for the agreement between the facility and the dialysis clinic. During a follow up interview on 3/20/26 at 12:04 p.m. with the ADM, the ADM stated the facility had no agreement with the dialysis clinic. The ADM further stated the importance of the agreement is to make sure Resident 10 receives dialysis care.A review of the facility's policy and procedure revised October 2025 and titled, Hemodialysis Care and Coordination indicated, This facility shall provide the necessary care and treatment, consistent with professional standards of practice, physician orders .to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) accurately reflected the resident's health status for one of 24 sampled residents (Resident 50) when Resident 50's MDS Section K Swallowing/Nutritional Status was not accurately documented.This failure had the potential to result in Resident 50 not receiving treatments and services consistent with Resident 50's needs.During a review of Resident 50's admission records, the records indicated Resident 50 was admitted to the facility in April 2024 with diagnoses that included dysphagia (difficulty swallowing), hypothyroidism (thyroid gland does not make and release enough hormone into the bloodstream), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). Resident 50's MDS, dated [DATE], indicated Resident 50 had intact cognition.During a review of Resident 50's MDS Section K Swallowing/Nutritional Status, dated 12/17/25, the MDS indicated Resident 50's weight was 120 lbs. The MDS further indicated Resident 50 did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months.During a review of Resident 50's Weights and Vitals Summary, the following weights were recorded:- 6/5/25 - 136 lbs- 11/2/25 - 127.2 lbs- 12/2/25 - 120.4 lbsDuring a joint interview on 3/20/26 at 3:19 p.m. with the Minimum Data Set Consultant (MDSC) and the Minimum Data Set Nurse (MDSN), the MDSN stated she answered Resident 50's MDS Section K on 12/17/25 and answered No when asked if Resident 50 had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDSC reviewed Resident 50's weights and confirmed Resident 50 had a weight loss of 5.5% within the last month of the assessment from 11/2/25 to 12/2/25 and had a weight loss of 11.7% within the last six months of the assessment from 6/5/25 to 12/2/25. The MDSN stated she should have selected Yes when asked about Resident 50's weight loss. The MDSN stated MDS accuracy was important so that the facility can implement good interventions.During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated, .2. A significant change of condition is a major decline or improvement in the resident's status that: .d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument [RAI, a structured assessment system designed to ensure each resident's needs, strengths, preferences, and goals are accurately identified and addressed] .9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by .regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual .During a review of the CMS (Centers for Medicare and Medicaid Services) RAI instruction Manual, dated 10/2025, the manual indicated, .SECTION K: SWALLOWING/NUTRITIONAL STATUS .Intent: The items in this section are intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration .The assessor should collaborate with the dietary staff to ensure that items in this section have been assessed and calculated accurately .Coding Instructions .Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician .If the resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status .

Based on observation, interview, and record review the facility failed to implement infection prevention and control practices for two of 24 sampled residents (Resident 15 & Resident 19) when:The facility did not implement Enhanced Barrier Precautions (EBP: an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of carrying multidrug-resistant organisms) for Resident 15 andFacility staff left soiled linens and trash on Resident 19's bed.These failures had the potential to spread communicable disease to an at risk population.1.During an observation on 3/17/26, at 10:21 a.m., Resident 15's room did not have any isolation precautions signs. Multiple care staff were observed entering and exiting Resident 15's room without wearing PPE (Personal protective equipment). During an observation on 3/18/26, at 8:35 a.m., Resident 15's room did not have any isolation precautions signs.During a review of Resident 15's Facesheet (a summary document, most commonly used in healthcare as a patient's top-level summary, including demographic data, insurance, and medical history) facesheet indicated, Resident 15 was admitted to the facility on [DATE], with diagnoses including but not limited to Chronic Kidney Disease, Benign Prostatic Hyperplasia with lower urinary tract symptoms (BPH enlarged prostate).During a review of Resident 15's Order Summary Report dated 3/19/26, Report indicated, an order for Foley Catheter [a flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag] order start date 1/22/26.During a review of Resident 15's Order Summary Report dated 3/17/26, Report indicated no order for Enhanced Barrier Precautions.During a review of Resident 15's Minimum Data Set (MDS: a federally mandated assessment tool) Section H, dated, 12/29/25, MDS-H indicated resident had an indwelling catheter.During an interview on 3/20/26, at 3:08 p.m., with Infection Preventionist (IP), IP stated, she did not think Resident 15 had a catheter. IP stated, let me look in his record. IP stated, she sees in Resident 15's medical record that he did have a catheter. IP stated, if a resident has a catheter they should be placed on enhanced barrier precautions. IP stated, the order for EBP was entered on 3/17/26, there was no order before then.2. During an observation on 3/17/26, at 8:40 a.m., in Resident 19's room, soiled linens, a soiled brief, and soiled gloves were noted to be left on Resident 19's bed. No staff were noted in Resident 19's room.During an interview on 3/17/26, at 8:47 a.m., with Director of Nursing (DON), in Resident 19's room, DON stated, he sees the soiled linens and trash on the bed. DON stated, from an infection prevention standpoint I would say no it [soiled linens and trash] shouldn't be left on the bed, it should be thrown away right after.During an interview on 3/17/26, at 8:53 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, she left the soiled linens and trash on Resident 19's bed because she did not get her trash cart before assisting Resident 19. CNA 4 stated, she left a dirty brief and soiled linens on the bed while she went to get the trash/linen cart.During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precaution, dated 2024, the P&P indicated, To maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Enhanced Barrier Precautions (EBP) used in conjunction with the standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing to reduce transmission.1. Facility staff shall post a 'visual alert' by the resident's door indicating high-contact resident care activities requiring the use of gowns and gloves for Residents with the following criteria that placed them at higher risk: .c. Indwelling medical devices with or without secretions or excretions even if the resident is not known to be infected or colonized with a MDRO (such as central lines, urinary catheters).

Based on observation, interview, and record review, the facility failed to obtain informed consent (process to ensure resident is fully informed of the potential risks and benefits) for one of twenty-four sampled residents (Resident 49) when Resident 49 was administered a psychotropic medication (medication that affects the mind, emotions, and behavior) prior to obtaining an informed consent. This failure had the potential to result in Resident 49 not being fully aware of the medication's benefits, risks, and side effects. A review of Resident 49's admission Record indicated Resident 49 was admitted to the facility in December 2025 with multiple diagnoses including cerebrovascular accident (stroke- loss of blood flow to the brain causing brain cell death), displaced fracture of left olecranon process (elbow fracture), bipolar disorder (mental health condition that causes extreme mood swings), and depression (mood disorder that causes persistent feeling of sadness and loss of interest). Resident 49's admission Record indicated Resident 49 was his own Responsibility Party (RP).A review of Resident 49's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 12/13/25, indicated Resident 49 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 10 out of 15 that indicated Resident 49 had moderate cognitive impairment.A review of Resident 49's SBAR [Situation Background Assessment Recommendation} Communication Form ., dated 2/10/26, indicated .Other change in condition suicidal ideation .resident loosely wrapped call light cord around neck .A review of Resident 49's order, dated 2/18/26, indicated .Depakote Oral tablet Delayed Release [mood stabilizer medication for treatment of bipolar disorder] 250 MG [milligrams] (Divalproex Sodium) Give 1 tablet by mouth two times day for Bipolar Disorder . A review of Resident 49's Care Plan .Alteration in mood and behavior pattern R/T [related to] Bipolar disorder Depression phase M/B [manifested by] expression of Suicidal Ideation . date initiated 2/12/26, indicated .Interventions .Promote independence and decision making . A review of Resident 49's Psychotherapeutic Drug Informed Consent, signed 3/13/26, indicated .Mood Stabilizer .Depakote .250mg . BID [twice a day] .Duration Indefinite .Date Ordered 03/10/2026 . A review of Resident 49's Medication Administration Record [MAR], for 3/1/26 to 3/31/26, indicated .Depakote Oral Tablet Delayed Release 250 MG . Give 1 tablet by mouth two times a day for Bipolar Disorder -Start Date- 02/19/2026 .D/C Date -03/10/2026 . A review of Resident 49's MAR, for 3/1/26 to 3/31/26, indicated . Depakote Oral Tablet Delayed Release 250 MG . Give 1 tablet by mouth two times a day for Bipolar Disorder use gloves to handle- Start Date- 03/10/2026 .During an interview on 3/20/26 at 9:37 a.m. with the Social Services Director (SSD), the SSD stated Resident 49 had order for Depakote on 2/18/26. The SSD acknowledged that Resident 49's Psychotherapeutic Drug Informed Consent was not signed until 3/13/26. The SSD stated informed consent should be obtained prior to administering the medication.During an interview on 3/20/26 at 11:09 a.m. with the Nurse Practitioner (NP), the NP stated Resident 49 was started on medication Abilify (an antipsychotic medication used to treat bipolar disorder and major depressive disorder) in late January 2026 but was changed to Depakote after an episode of suicidal ideation on 2/10/26. The NP stated medication was changed to Depakote, a mood stabilizer, because Abilify may cause suicidal thoughts. When asked when the informed consent for Depakote was obtained, the NP stated she was not sure.During a concurrent interview and record review on 3/20/26 at 2:09 p.m. with the Director of Nursing (DON), the DON acknowledged Resident 49 had order for Depakote on 2/18/26 but did not have an informed consent signed until 3/13/26. The DON stated the physician obtains the consent then it is verified and signed by the provider. The DON stated the informed consent should have been obtained when Resident 49 was started on the medication. The DON stated if taking medication without an informed consent Resident 49 may not have been aware of the side effects. The DON stated, He was not fully informed. A review of the facility's Policy and Procedure (P&P) titled Informed Consent Policy, revised 1/24, indicated .Policy: .It is the policy of this Facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs .Psychotropic Drug- Any medication used to control behavior or treat a disordered thought process .The Facility informs Attending Physicians of the informed consent process and their responsibilities according to the regulations .When processing a new order or an increase in psychotropic drugs, the following must be done .Obtain informed consent from resident or responsible party . When an order for a psychotropic drug .is obtained the Licensed Nurse verifies with the Attending Physician that informed consent has been obtained. The Licensed Nurse documents this verification on the Informed Consent Form .A review of the facility's P&P titled Psychotropic Medication Use, effective 6/21, indicated .A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics and antidepressants .It is the responsibility of the attending health care practitioner to inform the resident and /or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per the facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to the initiation of the psychotropic medication .The Facility shall verify informed consent prior to the administration of a psychotropic medication for a resident .

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 34 and Resident 62) were assisted with Activities of Daily living (ADL- normal daily functions required to meet basic needs) when fingernails were long and unclean. These failures had the potential for Resident 34 and Resident 62 to sustain injury and/or infection. 1a. A review of the admission Record indicated Resident 34 was admitted June of 2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), affecting right dominant side and cerebral infarction (a type of stroke, loss of blood flow to a part of the brain). Resident 34's Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status of the resident) dated 12/11/25 indicated Resident 34 had moderate cognitive impairment with a score of 12. A review of Resident 34's care plan initiated 6/14/24 indicated Resident 34 had self care deficit requiring assistance or is dependent in personal hygiene. The care plan intervention included to provide verbal, visual and physical cues as indicated. During an observation on 3/17/26 at 10:22 a.m. with Resident 34 in his room. Resident 34 was lying in bed, and his fingernails were long with blackish substance underneath the nails. During a follow up observation and interview on 3/19/26 at 10:22 a.m. with Resident 34 in his room. Resident 34 stated yes when he was asked if his fingernails were long and if he wanted his fingernails to be trimmed. During a concurrent observation and interview on 3/19/26 starting at 10:30 a.m. with Certified Nursing Assistant 1 (CNA 1), in Resident 34's room. The CNA 1 stated Resident 34's fingernails needed trimming, filing, and cleaning. The CNA 1 further stated yes when she was asked if there were blackish substance underneath resident's nails. The CNA 1 added it is part of resident care to make sure the fingernails are trimmed and clean. 1b. A review of the admission Record indicated Resident 62 was admitted December of 2022 with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (progressive loss of kidney function caused by diabetes) and cognitive communication deficit. Resident 62's BIMS dated 12/9/25 indicated Resident 62 had severe cognitive impairment with a score of 2. A review of Resident 62's care plan initiated 1/10/22 indicated Resident 62 had self care deficit in ADL including personal hygiene. The care plan interventions included, Assist in personal hygiene as needed. During a concurrent observation and interview on 3/17/26 at 11:06 a.m., Resident 62 was lying in bed, had long fingernails with blackish substance underneath his nails. Resident 62 was unable to state how long he had been in the facility. During a follow up observation and interview on 3/19/26 at 8:48 a.m., Resident 62 was lying in bed, resident showed his hands upon request. Resident 62's fingernails were long with blackish substance underneath his nails. Resident 62 stated I guess so when he was asked if his fingernails were long and dirty. During a concurrent observation and interview on 3/19/26 starting at 11:01 a.m. with CNA 2, in Resident 62's room. The CNA 2 stated Resident 62's fingernails were long and dirty. The CNA 2 further stated Resident 62 is diabetic, and for diabetic residents the licensed nurse trims the nails. During an interview on 3/19/26 at 11:58 a.m. with the Director of Nursing (DON) and the Resource Nurse (RN), the RN stated the staff needs to trim and clean the nails of residents after a shower. During an interview on 3/20/26 at 1:16 p.m. with the Medical Records (MR), the MR stated Resident 34 and Resident 62 had no care plan for refusal of nail care. A review of the facility's policy and procedure (P & P) revised February 2018 and titled, Fingernails, Care of indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care aid in the prevention of skin problems around the nail bed .Unless otherwise permitted, do not trim the nails of diabetic residents .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .Notify the supervisor if the resident refuses the care. A review of the facility's P & P revised 10/2025 and titled, Supporting Activities of daily Living (ADLs) Policy indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .Hygiene .grooming .

Based on interview and record review, the facility failed to follow their Policy and Procedures to process a refund for one of four sampled residents (Resident 1) when the resident's share of cost (the amount of money an individual is responsible to pay towards their medical related services, supplies, or equipment before Medi-Cal will begin to pay) was not returned to the family within 60 days upon Resident 1's death.This failure had the potential to result in fiduciary abuse and a violation of Resident 1's rights. Findings:A review of Resident 1's admission Record indicated; Resident 1 was admitted to the facility in 2020 with a diagnoses that included Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). The admission Record further indicated Resident 1 was their own responsible party. A review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 14 which indicated Resident 1 had full understanding. During an interview with the Business Office Manager (BOM) on [DATE] at 10:57 a.m., the BOM stated the Business Office records indicated $187.97 was owed to Resident 1's family. The BOM further stated, I didn't know why the money has not been returned. During a concurrent interview and record review with the BOM on [DATE] at 12:17 p.m., the BOM stated, Our policy indicated the money should have been returned to the family within 60 days of Resident 1's death. During an interview with the Administrator (ADM) on [DATE] at12:32 p.m., the ADM stated, The expectation is that we follow our policy and if the policy says we should have returned the money within 60 days, then we are at fault. During a concurrent interview and record with the ADM and BOM on [DATE] at 12:37 p.m., the ADM and BOM verified Resident 1 expired on [DATE] and as of [DATE], Resident 1's money has not been returned within the 60 days as per there policy. A review of the Business Office records indicated Resident 1 had a Share of Cost overpayment owed back to them of $187.97 for the month of [DATE]. A review of the Outstanding Account report indicated, the BOM had first corresponded with the complainant on [DATE] at 2:42 p.m. The BOM noted complainant, Asked about refund for Share of Cost. A review of the facility policy titled, A/R Refunds Policy and procedure dated 6/2023 indicated, Overpayments shall be refunded no later than 60 days from when the overpayment was identified, according to CMS 6037-F Final Rule .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled Residents (Resident 1) despite Resident 1's admitting diagnosis of stimulant (drugs that increase the activity of the central nervous system) use and a positive illicit drug test results from the urine drug screening during the recent hospitalization. This failure placed Resident 1 at risk for undetected drug use or relapse, undetected overdose that could result in medical emergency and had the potential for delayed delivery of care and mental health decline. Findings: Resident 1 was admitted to the facility mid-2025 with a diagnoses of deep skin infection caused by bacteria and other stimulant abuse. A review of Resident1's Brief Interview for Mental Status (BIMS), dated 5/15/25, the BIMS indicated Resident 1 had a score of 15 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 1's Order Summary Report (OSR), dated 5/14/25, the OSR indicated, .Resident has mental capacity to make decisions. A review of Resident1's Nurses Notes (NN), dated 6/30/25 at 5:15 a.m., the NN indicated, .Resident has been outside mostof [sic] day with significant other. Resident brought back inside .this writer did ask if Resident had taken anything while outside d/t [due to] hx [history] of meth [methamphetamine, highly addictive central nervous system stimulant, high potential for abuse] abuse and significant other at the facility . A review of Resident1's NN, dated 6/30/25 at 9:28 a.m., the NN indicated, Upon receiving shift report from the night nurse it was noted that pt [patient] from Room (number) had spent most of the previous evening outside with her significant other .Due to the elevated temperature and per pt request, pt was sent outto [sic] hospital @ [at] 0923 for further evaluation report was given to (name of hospital). A review of Resident 1's hospital History and Physical (H&P), dated 6/30/25, the H&P indicated, Patient appears intoxicated [under the influence of a substance] and not able to add any history voluntarily .positive for meth and fentanyl [potent synthetic opioid that has high risk of overdose]. A review of Resident 1's hospital Discharge Summary (DS), dated 7/2/25, the DS indicated, Discharge Diagnosis: Diagnosis this visi .Toxic encephalopathy (neurologic disorder) and Polysubstance abuse (using more than one drug or substance) .U-Tox [Urine Drug Screening] positive for meth and fentanyl . A review of Resident 1's NN, dated 7/2/25 at 1:50 p.m., the NN indicated, Resident returned from [name of hospital] at 1:45 pm via gurney . However, there was no indication of Resident 1's positive drug screening for methamphetamine and fentanyl. A review of Resident1's NN, dated 7/5/25 at 10:59 a.m., the NN indicated, Resident is always hanging outside the smoking area after hours . A review of Resident1's NN, dated 7/6/25, at 5:49 a.m., the NN indicated, After reviewing the DC (Discharge) Summary, it is noted that Resident's tox screen was positive for Meth and Fentanyl. Spoke with the Resident and Resident stated that she has been actively using . A review of Resident1's Medical Record (MR) included there was no documented evidence that care plan had been developed for Resident 1's stimulant use during initial admission and after Resident'1 recent urine drug screening tested positive for meth. During an interview with the License Nurse (LN) 1 on 7/8/25 at 12:49 p.m., LN 1 stated that if a Resident drug screening came back positive, the MD [Medical Director], DON [Director of Nursing] and ADM [Administrator] needed to be notified at once. LN 1 added the facility needed to have a care plan for the Residents and to provide education about the complications of drug use. During an interview with the Physical Therapist (PT) at 7/8/25 at 2:16 p.m., the PT stated, Partner comes here regularly to visit her, and they are smoking together all the time. The PT added staff do not accompany Resident 1 and the spouse when they were outside. The PT also stated, I have seen him before to visit her and stayed for a long time. The pt added, there was no care plan implemented regarding the situation and stated, nurses have not relayed any plans to me. During an interview with the Activities Director (AD) on 7/8/25 at 2:47 p.m., The AD stated the spouse was at the facility every day. The AD added Resident 1 and the spouse were mostly staying outside smoking in the patio and they were unsupervised by staff. The AD stated, (Resident 1's Name) can go out anytime and it won't be supervised. Independent smokers can go out and smoke anytime. It is a home-like environment. During a concurrent interview and records review with the Social Service Director (SSD) on 7/8/25 at 2:54 p.m., The SSD confirmed that she was aware of Resident 1 stimulant use during admission and stated, She said she used to do that with the husband in the car. the SSD also confirmed that there was no care plan in effect for Resident 1's substance use. When asked if Resident 1 could have used a stimulant in the facility, the SSD stated, It was a possibility based on Resident 1's recent drug screening. During an interview with Resident 1 on 7/8/25 at 3:15 p.m., when asked about her recent urine drug screening, Resident 1 stated, I used two weeks ago. Resident 1 confirmed that she used meth in the premises of the facility and stated, I used it outside around the corner [facility], there's no staff there. Resident 1 added that her spouse regularly visited her. During an interview with the DON on 7/8/25 at 3:26 p.m., the DON confirmed that Resident 1 was allowed to go outside unsupervised around the premises of the facility. When asked if the facility had initiated a plan for Resident 1's substance use, the DON stated, 'I am not sure if a plan was started. The DON stated, The facility should have started a risk management and IDT (Interdisciplinary Team) meeting, and that monitoring should have been implemented because of Resident 1's substance abuse history. The DON also added that a care plan should have been started and stated, It was important for nurses to know what's going on with her [Resident 1] and to have a plan of care, so they know what they need to do with the situation and that everybody was aware of the situation. The DON also stated that she expected the nurses to review the Resident's discharge papers from the hospital, which included the history and physical. The DON later confirmed that the facility did not follow up with the Resident and did not have a care plan in effect to Resident 1's substance use. During a review of the facility's policy and procedure (P&P) titled, Care of Resident with Substance Use Disorder, dated 11/30/22, the P&P indicated, PROCEDURE .2. An individualized care plan with person-centered intervention will be developed .addressing the risk of overdosing .and drug - seeking behavior, including leaving the facility without notifying staff . 3. A resident identified with known history of substance abuse will be monitored for signs and symptoms of possible use, such us frequent leaves of absence with or without facility knowledge . 4. The facility shall make efforts to prevent substance use while in the facility . 5. Interdisciplinary Team (IDT) members will conduct a meeting with the resident and/or the residents legal representative .

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents (Resident 1) when an allegation of abuse was not reported per facility policy. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document, dated 1/15/25 and received by the Department on 1/15/25, indicated an allegation of suspected dependent adult/elder abuse had been made related to an employee to resident verbal and physical abuse between Registry Staff 1 (RS 1) and Resident 1. During an interview, on 1/17/25 at 12:49 p.m., Licensed Nurse 1 (LN 1) confirmed that the allegation was reported to her on 1/9/25 and she did not report it to the Administrator who is the Abuse Prevention Coordinator (APC). During an interview, on 1/17/25 at 1:33 p.m., Certified Nursing Assistant 1 (CNA 1) confirmed she heard the allegation of abuse on 1/9/25 at the nurse ' s station and acknowledged that it was not reported to the APC. During an interview on 1/17/25 at 2:18 p.m., CNA 2 confirmed that she heard the allegation of abuse on 1/9/25 and confirmed that it was not reported to the APC. During an interview, on 1/17/25 at 4:23 p.m., Director of Nursing (DON) stated it was the facility ' s policy to report an allegation of abuse to the Department within 2 hours. The DON confirmed the 1/9/25 allegation had not been reported to the Department until 1/15/25. During a review of the facility ' s policy and procedure titled, Abuse Reporting and Investigation, dated 1/10/24, the policy indicated To promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies .All allegations of abuse, neglect, mistreatment .shall be reported to the APC .All violations involving abuse .shall be reported .to local CDPH .within 2 hours after the allegation is made or reported .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care which met professional standards when he was involved in an employee to resident abuse allegation, and it was not documented by nursing and social services department. This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing and psychosocial needs for Resident 1. Findings: A review of Resident 1 ' s admission record indicated he was last admitted in late 2024 with diagnoses including encephalopathy (brain dysfunction) and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/24, indicated Resident 1 had severe memory impairment. A Skilled Services Documentation, dated 1/8/25 and 1/15/25, indicated no documented evidence of abuse allegation. Further review of document indicated no body check was done on Resident 1, no documented evidence of physician notification, and no documented evidence of nursing progress note on psychosocial well-being. Progress notes, dated 1/8/25 to 1/15/25, indicated no documented evidence of social services follow up for Resident 1. A care plan, dated 1/15/25, indicated that Resident 1 had a psychosocial wellbeing problem .recent verbal abuse from agency staff .Interventions .Assist Resident to process feelings .outcome . During an interview, on 1/17/25 at 12:49 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated that a report was made to her on 1/9/25 of allegation of verbal and physical abuse between Registry Staff 1 (RS 1) and Resident 1. LN 1 confirmed there were no nursing assessment or nursing documentation done. During an interview, on 1/17/25 at 4:03 p.m., with Social Services Director (SSD), SSD confirmed that there were no follow up interviews, psychosocial support and interventions done with Resident 1 after facility was made aware of abuse allegation. During a concurrent record review and interview, on 1/17/25 at 4:23 p.m., the Director of Nursing (DON) stated she considered an employee-to-resident abuse allegation as a change of condition for the resident. DON's expectation was the LN needed to do an assessment with a body/skin check and 72 hour monitoring post incident. The DON further stated the MD needed to be notified. DON confirmed that there was no nursing assessment, no notification to MD and no follow up social services documentation regarding the abuse allegation involving Resident 1. During a review of Social Services Director ' s job description, the document indicated .job position is to .assure that the .emotional and social needs of the resident are met .interview residents/families .involve the resident/families in social services . During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program, revised 12/1/22, the policy indicated, The facility shall examine the alleged victim for any physical signs of injury, including, but not limited to, psychological and psychosocial effect. During a review of the facility ' s P&P titled, Abuse Reporting and Investigation, dated 1/10/24, the policy indicated All allegations of abuse .will be reported to .the resident ' s Attending Physician. During a review of the facility ' s P&P titled, Change of Condition, revised March 2018, the policy indicated .the nurse shall assess and document .staff will monitor and document the resident/patient ' s progress .and the physician will adjust .accordingly.