Orange Healthcare & Wellness Centre, Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility document review, the facility failed to ensure the Arbitration Agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) was explained in a form, manner, and language the residents or their representatives understood for two of three residents (nonsampled Residents 23 and 72) reviewed for the Arbitration Agreement. * The facility allowed Residents 23 and 72 who had no mental capacity to understand and make medical decisions, to enter and sign the Arbitration Agreement. This failure posed the risk for the residents to not have a clear understanding of the arbitration process.Findings: 1. Medical record review for Resident 23 was initiated on 1/9/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 11/2/25, showed Resident 23 had no mental capacity to understand and make decisions. Review of Resident MDS dated [DATE], showed Resident 23 had severe cognitive impairment. Review of Resident 23's Arbitration Agreement dated 8/12/25, showed Resident 23's signature. Further review of the Arbitration Agreement showed . by signing this contract you are agreeing to have all claims, including claims other than a claim for medical malpractice, decided by arbitration and you are giving up your right to a jury or court trial and you agree that no party shall adjudicate any claim on a class action basis. 2. Medical record review for Resident 72 was initiated on 1/9/26. Resident 72 was admitted to the facility on [DATE]. Review of Resident 72's H&P examination dated 10/12/25, showed Resident 72 had no capacity to understand and make decisions. Review of Resident 72's Arbitration Agreement dated 10/24/25, showed Resident 72's signature. Further review of the Arbitration Agreement showed . by signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. On 1/9/26 at 0953 hours, an interview and concurrent facility document review for Residents 23 and 72 was conducted with the admission Director. The admission Director verified the above findings and stated Residents 23 and 72 had no capacity to understand and make decisions to sign the Arbitration Agreement and the facility staff should have contacted the residents' representatives to explain the Arbitration Agreement for Residents 23 and 72. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 100) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice visit calendar was available in Resident 100's medical record. * The facility failed to integrate Hospice A's plan of care into Resident 100's care and failed to accurately reconcile the physician's orders. These failures posed the risk of the delay in the communication and provision of hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Care of Residents dated 1/1/12, showed if the resident and/or surrogate decision maker decides to utilize hospice care, attending physician will be contacted to make final determination. The hospice and facility will collaborate on a care plan for the residents. Facility and hospice staff will collaborate on a regular basis concerning the residents' care. Review of Hospice A Patient Agreement for Skilled Nursing Inpatient and related Hospice Services dated 9/6/23, under the section Plan of Care showed a written care plan established, maintained, reviewed and modified, if necessary, at intervals established by the interdisciplinary group. A plan of care includes (a) an assessment of each Hospice patient and needs, (b) an identification of the hospice services to be provided in response to assessment, including management of discomfort and symptoms relief, and (c) details concerning the scope and frequency of the Hospice services and facility services needed to meet the patient's and family's needs. The Hospice will develop a coordinated plan of care that is consistent with the state licensure, and Medicare and Medicaid requirements for the provision of Hospice services and is responsive to the unique needs of the Hospice patient who needs who resides in a skilled nursing facility and his/her expressed desire for Hospice care. Further review of the Hospice A Patient Agreement for Skilled Nursing Inpatient and related Hospice Services showed all physician orders communicated to facility on behalf of hospice in connection with the plan of care shall be in writing and signed by the applicable attending physician or hospice physician. Hospice shall maintain all adequate records of all physician orders communicated in connection with the plan of care. Medical record review for Resident 100 was initiated on 1/6/26. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's Order Summary Report showed the following physician's orders:- dated 5/31/25, to admit the resident to Hospice A under routine level of care.- dated 8/18/25, to administer morphine sulphate ( pain medication) oral solution 20 mg per 5 ml to give 0.25 ml ( i.e.1 mg) by mouth every two hours as needed for severe pain, and to hold if the respiration rate less than 12 or sedated. b. Review of Resident 100's medical record failed to show the Hospice A calendar for December 2025 and January 2026 to show the schedule when the hospice staff were visiting Resident 100. c. Review of the Resident 100's plan of care failed to show the hospice care plan was incorporated in the facility's plan of care for the resident. d. Review of the Hospice A medication list for Resident 100 showed a physician's order for morphine concentrate 20 mg/ml oral, to administer 5 mg every two hours as needed for shortness of breath and pain. On 1/8/26 at 0837 hours, an interview was conducted with LVN 6. LVN 6 stated Resident 100 was on under hospice care, and the staff from the hospice visited Resident 100. When asked how often the hospice staff visited Resident 100, LVN 6 stated the hospice aid visited twice a week and the skilled nursing visit was once a week. However, LVN 6 did not know the exact days when the hospice staff came to visit Resident 100. On 1/8/26 at 0846 hours, an interview and concurrent medical record review of Resident 100's medical record was conducted with LVN 7. LVN 7 verified the hospice calendar for December 2025 and January 2026 for Resident 100 was not available in the resident's medical record and the facility's care plan did not incorporate the resident's hospice care plan. LVN 7 stated he was unable to locate the hospice care plan in Resident 100's medical record. LVN 7 also verified the physician's order for the morphine sulfate medication was not accurately reconciled from the hospice medication list. LVN 7 stated the hospice order was for morphine sulfate 20 mg/mL, and to administer 5 mg (0.25 ml). However, the concentration ordered by the facility was 20 mg per 5 ml, which meant when administering 0.25 ml, the resident would only receive 1 mg instead of 5 mg as ordered. LVN 7 stated this could lead to poor pain control for Resident 100. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure appropriate infection control practices were followed.* The facility failed to test the water supply, and inspect the HVAC filters per the facility's water management program.* The clean linen cart for transferring clean linen in the laundry room had frayed edges and peeling layered duct tape and a non-cleanable surface. * The facility failed to ensure one of three blood glucose monitors (a portable device to measure blood sugar levels at home using a tiny blood sample) was cleaned and disinfected according to the manufacturer's instructions after the blood glucose monitor was used on Residents 3, 33, and 40. These failures resulted in the risk for the spread of microorganisms potentially contaminated areas throughout the facility. Findings:
1. Review of the facility's Legionella (type of bacteria) Water Management plan showed the following:
- Maintaining a disinfectant residual of 0.1 mg/liters of free chlorine can help prevent Legionella growth in the water system. The facility will measure the residual disinfectant monthly. - To prevent Legionella growth, the best pH for water is between 6 and 7. The facility will measure the water pH level monthly. - Monitor ventilation systems to ensure optimal performance for removal pf particulates, and elimination of excess moisture. The facility will inspect all HVAC filters monthly.
Review of the facility's Water Management Plan Monthly pH/Chlorine Testing Log for 2025 showed checkmarks for monthly chlorine and pH testing. The log failed to sure what the testing results were, and whether the results were an acceptable range.
Review of the facility's electronic Logbook Documentation showed the HVAC filters were inspected and filters changed quarterly on 1/30, 4/23, 7/30, and 10/28/25. The facility was unable to locate the documentation to show the filters were inspected monthly.
On 1/8/26 at 1052 hours, an interview and concurrent facility document review was conducted with the Director of Maintenance and Property Management. The Property Management reviewed the electronic maintenance logbook and stated the HVAC air filters were changed quarterly (every three months) and verified there were no documentation to show the filters were inspected monthly.
On 1/8/26 at 1307 hours, a follow up interview and concurrent facility document review was conducted with the Director of Maintenance and Property Management. The Director of Maintenance and Property Management verified the monthly pH/Chlorine testing log failed to show the testing results, and if the results were an acceptable range.
2. On 1/8/26 at 0938 hours, a laundry room observation was conducted with Housekeeper 1. A wheeled linen cart frame with a flexible tarp-like bag was observed. The linen cart's edges were frayed and torn in places and one area had multiple layers of red duct tape, which was also peeling. Housekeeper 1 stated the cart was used to transport clean dry linen from the dryer to the folding table. When asked what she used to disinfect the cart and clean the linen folding table, Housekeeper 1 stated she used wipes, but was unable to locate any wipes in the laundry room.
On 1/8/26 at 0950 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance verified the clean linen cart's tarp-like surface and frayed edges/tape were not cleanable surfaces.
On 1/8/26 at 1343 hours, an observation and concurrent interview was conducted with the Director of Maintenance. The Director of Maintenance provided a container of Clorox Healthcare Germicidal Bleach Wipes and stated the wipes were the product used to disinfect the laundry room clean linen cart. The front of the container showed it was to be used on treated, hard, nonporous surfaces.
3. Review of the facility's P&P on Blood Glucose Monitoring dated 5/2/23, showed to clean the monitoring device after each use as noted in the manufacturer's instructions.
Review of the Manufacturer's Instructions of the Assure Blood Glucose Monitoring system dated 9/2024 (www. akrayusa.com) showed the cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Only wipes with EPA registration numbers listed in http://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants have been validated for use in cleaning and disinfecting the blood glucose meter.
On 1/8/26 at 0558 hours, a medication administration observation was conducted with LVN 5. LVN 5 was observed cleaning the glucometer after checking Resident 3, 33, and 40's blood sugar with an alcohol pad (70 % alcohol). LVN 5 verified the glucometer was wiped clean with the alcohol pads.
On 1/8/26 at 0732 hours, an interview was conducted with the IP. The IP stated the glucometers must be cleaned and disinfected using the Super Sani-Cloth wipes (germicidal, bactericidal, tuberculocidal, and virucidal disposable wipes).
On 1/9/25 at 1508 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 104) was safe to self-administer medications. * Resident 104 was observed with one unidentified medication tablet and an unlabeled white bottle containing various medication tablets on his bedside table. Resident 104 had no assessment and physician's order addressing Resident 104's self-administration of the medications. This failure had the potential for the resident to administer the medications inaccurately, and the risk of adverse reactions from the medications. Findings: Review of the facility's P&P titled Medication - Self Administration revised [DATE], showed the following:- Residents will be assessed and monitored for their ability to self-administer medications. This must include physician approval, which will be documented in the resident's medical record.- The licensed nurse completes the Self Administration of Medications Assessment, which evaluates the resident's: cognitive function, physical ability, medication knowledge, compliance history, knowledge of proper storage and safety, and knowledge of administration of each route.- A written physician's order is required before a resident begins self-administration- The licensed nurse will inspect the contents of the medication containers for evidence that the resident may not be able to self-administer medications (i.e. non-drug items stored in pill containers, different medications mixed together, medications which have expired or appear to be deteriorating.- Any concerns will be communicated to the physician and IDT immediately.- All self-administered medications must have complete pharmacy labels or intact, readable labels if they are over the counter medications. On [DATE] at 0955 hours, during the initial tour of the facility, Resident 104 was observed in bed with a loose medication tablet and a white unlabeled medication bottle on his bedside table. Resident 104 stated the medications in the bottle were his supplements which was brought in by his wife. Resident 104 stated he administered the supplements himself. Medical record review for Resident 104 was initiated on [DATE]. Resident 104 was admitted to the facility on [DATE]. Review of Resident 104's H&P examination dated [DATE], showed the resident had no capacity to understand and make decisions due to cognitive impairment. Review of Resident 104's Order Summary Report for [DATE] failed to show a physician's order to self-administer the medications. Further review of Resident 104's medical record failed to show an assessment was conducted to determine if Resident 104 was safe to self-administer the medications. On [DATE] at 1004 hours, an observation of Resident 104 and concurrent interview was conducted with LVN 3. Resident 104 was observed in bed with the bedside table positioned across his bed. The resident's bedside table was observed with a loose medication tablet and a white unlabeled medication bottle. LVN 3 stated the loose medication tablet on the resident's bedside table looked like one of Resident 104's supplements that his wife provided and the facility dispensed. However, LVN 3 stated she did not know where the medication tablet came from. LVN 3 stated she did not know what medications were in the white unlabeled medication bottle. On [DATE] at 1010 hours, a follow up interview was conducted with LVN 3. LVN 3 stated she did not know what medications were in the white unlabeled medication bottle or where it came from. LVN 3 stated she was in the resident's room earlier to administer Resident 104's medication and did not question the medication bottle on Resident 104's bedside table. On [DATE] at 1015, an observation of Resident 104 and concurrent interview was conducted with the DON. The DON stated sometimes the resident's wife brought in the supplements for Resident 104 without notifying the facility staff. The DON stated the facility had several discussions with the wife to stop bringing in the supplements for the resident. The DON was observed opening the white unlabeled medication bottle and was unable to verify the contents of the bottle. The DON stated there was a risk of the unknown medication tablets interacting with the medications the facility was administering to the resident. The DON verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of three residents (Resident 7) reviewed for close records. * The facility failed to notify Resident 7 and/or their representative in writing regarding the transfer and reasons for the transfer, and the facility's bed hold policy when Resident 7 was transferred to the acute care hospital. In addition, the facility failed to send the copy of notice of transfer discharge to Ombudsman (a neutral advocate who investigates and resolves complaints for residents in healthcare settings like long-term care facilities). These failures had the potential for the resident and/or their representative to be unaware about the transfer and reason(s) of transfer, and their rights to request a bed hold and return to the first available bed should the resident's acute care hospital stay exceeded the seven-day bed-hold period.Findings: a. Review of the facility's P&P titled Notice of Transfer/discharge date d October 2017 showed to provide the resident and responsible party with a written notice of transfer/discharge prior to or at the time of discharge/transfer and their appeal right. Before the transfer or discharge occurs, the facility must notify the resident and, if known, the responsible party, and ombudsman after transfer and reason for the transfer, and document in the resident's clinical record. Review of the facility's P&P titled Bed Hold dated July 2017 showed the facility notified the resident and/or representative, in writing, of the bed hold, option, anytime the resident is transferred to an acute care hospital or requests therapeutic leave. Closed medical record review for Resident 7 was initiated on 1/8/26. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated 5/15/25, showed Resident 7 had the capacity to understand and make decisions. Review of Resident 7's Physician Order dated 1/2/26, showed to transfer Resident 7 to the acute care hospital for confusion, agitation, tachycardia (high heart rate) and for bed hold for seven days, if admitted . Review of Resident 7's progress notes dated 1/2/26 at 1803 hours, showed Resident 7 was transferred to the acute care hospital and Resident 7 was admitted to the acute care hospital due to acute kidney injury (sudden, rapid loss of kidney function, where the kidneys can't filter waste, leading to buildup in the blood), urinary tract infection (bacterial infection in the urinary system, i.e. kidneys, ureters, bladder and urethra) and sepsis ( a life-threatening medical emergency where the body's extreme, overactive response to an infection damages its own tissues, organs, and systems, leading to potential organ failure and death). Review of Resident 7's Notice of Proposed Transfer and discharge date d 1/2/26, showed the transfer location as the acute care hospital and the reason for the transfer was for Resident 7's welfare and Resident 7's needs could not be met in the facility. Under the section for the resident or resident representative signature failed to show any entry. In addition, the Notice of Proposed Transfer and Discharge form did not show if the copy of the form was sent to the Ombudsman. Further review of Resident 7's medical record did not show if a written notice of the transfer/discharge was provided to Resident 7 or their representative when Resident 7 was transferred to the acute care hospital on 1/2/26. In addition, the resident's medical record did not show if the copy of notice of transfer/discharge was sent to the Ombudsman. b. Review of the Resident 7's Bed hold Agreement showed the facility has a bed hold policy and will hold the bed for up to seven days if the resident is transferred to a general acute care hospital or goes on therapeutic leave often of no more than. overnights per calendar days, as long as resident or the representative notifies the facility within 24 hours after transfer leave that they wish to have the facility hold the resident's bed. Resident who are not eligible for Medi-cal/caid are responsible for the cost of the bed hold days not to exceed the patient's daily rate for care. Insurance may or may not cover such charges. You have the options of requesting a bed hold to keep the bed vacant and available for return to the facility. The bed hold begins the day the resident leaves the facility. The bed hold agreement was signed by Resident 7's representative on 9/28/25. Further review of the Bed Hold Agreement did not show if the Bed Hold notice was provided to Resident 7 and/or their representative when Resident 7 was transferred to the acute care hospital on 1/2/26. On 1/9/26 at 1052 hours, an interview and concurrent closed medical record review was conducted with RN 3. RN 3 verified Resident 7 was transferred to the acute care hospital on 1/2/26. RN 3 verified Resident 7's representative was informed regarding the bed hold notice upon the resident's admission to the facility, however, RN 3 was not able to find the documentation to show if the facility's bed hold policy was provided to Resident 7 or their representative in writing when Resident 7 was transferred to the acute care hospital on 1/2/26. RN 3 verified Resident 7's Notice of Proposed Transfer and Discharge form dated 1/2/26 did not have Resident 7's or their representative's signature. RN 3 stated she was not sure how the facility provided the transfer/discharge notices, and the bed hold policies in writing, when the resident was not able to sign the document and the resident representative was not available at the time of the transfer. In addition, RN 3 verified the copy of the Notice of Proposed Transfer and Discharge form for Resident 7 was not sent to the Ombudsman, when he was transferred to the acute care hospital on 1/2/26. On 1/9/26 at 1108 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified the above findings and stated the facility did not mail the written notice of the transfer/discharge and notice of bed hold to the resident or their representative, when residents were transferred to the acute care hospital. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a baseline care plan for one of 19 final sampled residents (Resident 118). * Resident 118's removal of her indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine from the bladder) and interventions in place for monitoring for bladder function were not included in the resident's baseline care plan. This failure had the potential for the resident's plan of care not being communicated to the IDT and a potential delay in identifying a bladder dysfunction. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 4/24/25, showed the baseline care plan must include the minimum information necessary to properly care for each resident, and should include resident specific health and safety concerns to prevent decline or injury, and identify their needs for assistance with ADL care. Review of the facility's P&P titled Indwelling Catheter - Insertion, Maintenance and Discontinuation of revised 7/22/25, showed after removal of the indwelling urinary catheter, the resident's care plan will be updated as necessary. Medical record review for Resident 118 was initiated on 1/6/25. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Summary Report showed a physician's order dated 1/6/25, to monitor for the signs and/or symptoms of urinary retention (inability to fully empty the bladder) for 72 hours status post indwelling urinary catheter removal. Review of Resident 118's Baseline Care Plan failed to address the resident's urinary catheter, including when it was removed, and monitoring the resident for urinary retention. On 1/7/26 at 0947 hours, an interview was conducted with Resident 118. Resident 118 stated after her indwelling urinary catheter was removed yesterday morning, she had a hard time voiding. Resident 118 stated she has had a hard time getting used to holding her urine in and when she had the urge to void, she needed to rush to the toilet. On 1/7/26 at 1157 hours, interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 118's medical record and stated the resident's indwelling urinary catheter was discontinued yesterday morning, and the facility staff were to monitor the resident for bladder retention, like discomfort and distention, for 72 hours. The DON verified the resident's baseline care plan failed to address the resident's indwelling urinary catheter discontinuation and the interventions in place to monitor and assist the resident. The DON stated the resident's baseline care plan should have been updated yesterday, after the indwelling urinary catheter was removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident (Resident 20) reviewed for activities. * The facility failed to provide an ongoing activity program for Resident 20 in accordance with the comprehensive assessment, interests, and physical, mental, and psychosocial well-being to ensure the resident maintained their highest mental, physical, and psychosocial well-being. This failure had the potential for the resident to experience feelings of social isolation.Findings: Review of the facility's P&P titled Activities Program dated 5/22/25, showed the facility provides an Activity Program designed to meet the needs, interests, and preferences of each resident. The facility will be staffed and equipped to encourage the participation of each resident, to fully stimulate and support physical and mental capabilities, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. On 1/6/26 at 8030 hours, during the initial tour to the facility. Resident 20 was in his room and was asked if he was attending the facility's recreational activities. Resident 20 stated It is a joke, one to two times a week they play music. I went there sometimes but not my music. They don't have what I like. Resident 20 further stated the activity staff did not go to his room. Resident 20 had the Activities Calendar affixed to his room wall. Resident 20 stated maybe they're just satisfying the state guidelines, they put that up. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 9/25/25, showed Resident 20 could make his own decisions. Review of Resident 20's Activity Evaluation dated 9/25/25, showed Resident 20's activity preferences were as follows: fishing and playing golf, listening to pop, country, and rock and roll, prefer to watch news sports weather talk shows, some game shows like Trivia, Jeopardy, Who wants to be a Millionaire, and comedy movies, reads non-fiction, fiction, and biology books. Review of Resident 20's Quarterly Activity Progress Note dated 12/26/25, showed the Activities Department would encourage/assist/remind Resident 20 to join/participate to the group activity of interest, provide contact room rounds to offer activity material, and socialization as needed or as tolerated. Review of Resident 20's Activities Look Back Report from November to January 8, 2026, showed the following documentation:- on 11/18/25: active 1:1 (one staff to one resident) participation - books /reading materials, education/current topics/ trivia;- on 11/29/25: passive 1:1 participation- books /reading materials;- on 12/9/25: passive 1:1 participation- education/current topics/ trivia;- on 12/13/25: active1:1 participation- books /reading materials;- on 12/27/25: active1:1 participation- books /reading materials; and- on1/3/26: active1:1 participation- books / reading materials, education/current topics/ trivia. On 1/8/26 at 943 hours, an interview and concurrent medical record review was conducted with the Activity Director. The Activity Director stated Resident 20 hardly came to activities and was visited three times a week by the activity staff. Review of Resident 20's Activity Look Back Report was conducted with the Activity Director, which showed Resident 20 had activity staff visits and participated six times from 11/18/25 through 1/3/26, with no documentation of refusals. The Activity Director stated she was not checking the activity staff to make sure the room visits were being done. When asked if the activity staff knew Resident 20's plan of care were, the Activity Director stated, I'm hoping they do. On 1/8/26 at 1000 hours, an interview and concurrent medical record review was conducted with Activity Assistant 1. Activity Assistant 1 stated she conducted the room visits for the residents using the following schedule:- on Mondays and Tuesdays: the residents in Nursing Stations 1 and 2;- on Tuesdays: the residents in Nursing Station 3;- on Wednesdays: the residents in Nursing Stations 1 and 2; and- on Thursdays: the residents in Nursing Station 3.Review of the Activity Look back Report with Activity Assistant 1 showed Resident 20 was visited and participated six times from 11/18/25 through 1/3/26. Activity Assistant 1 verified the above findings and stated the room visits for Resident 20 should have been two to three times a week. Activity Assistant 1 stated she was not sure what had happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one final sampled resident (Resident 116) and one nonsampled resident (Resident 120) reviewed for the accident hazards were provided the necessary care and services. * The facility failed to ensure CNA 1 remained awake while providing supervision for Residents 116 and 120, who were on high observation alert due to falls. This failure posed a risk for the residents to sustain further falls and/or injuries.Findings: On 1/8/26 at 0518 hours, during a tour of the facility, an observation of CNA 1 was conducted inside Residents 116 and 120's room. Upon entering the residents' room, CNA 1 was observed with her head down on the nightstand next to Resident 120 (bed A). The privacy curtain was closed with no visual of Resident 116 (Bed B). The surveyor knocked on the wall in attempt to wake CNA 1 but was not successful. Resident 120 was observed awake and moving around in bed and Resident 116 appeared to be sleeping. The surveyor then contacted RN 1 to wake up CNA 1. RN 1 entered the residents' room and tapped CNA 1 on the arm. CNA 1 sat up but did not turn around. RN 1 then tapped CNA 1 on the arm again and CNA 1 stood up to speak with the surveyor as RN 1 exited the residents' room. On 1/8/26 at 0520 hours, an interview was conducted with CNA 1. CNA 1 stated she was asleep. CNA 1 stated she was assigned to provide supervision for Residents 116 and 120 because they were trying to get out of bed unassisted. CNA 1 also stated she was unable to maintain a visual of Resident 116 with the privacy curtain closed. On 1/8/26 at 0541 hours, an interview was conducted with RN 1. RN 1 stated the facility staff assigned to provide supervision for the residents should be sitting by the residents' closet where they would have visual of both residents, or have the privacy curtain open if they chose to sit at the table. RN 1 also stated the facility staff assigned to provide supervision for the residents were not supposed to be sleeping while watching the residents. a. Medical record review for Resident 116 was initiated on 1/8/26. Resident 116 was admitted to the facility on [DATE]. Review of Resident 116's H&P examination dated 1/1/26, showed Resident 116 had the capacity to understand and make decisions. The H&P also showed the physician advised to send Resident 116 to the emergency room for evaluation of fall on 12/31/25. b. Medical record review for Resident 120 was initiated on 1/8/26. Resident 120 was admitted to the facility on [DATE]. Review of Resident 120's H&P examination dated 1/1/26, showed Resident 120 was able to make their own decisions. The H&P also showed the resident had a fall on 1/1/26 at 0400 hours. On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON stated Residents 116 and 120 had physician's orders for high observation because they were new residents in the facility and both residents fell on the day they were admitted to the facility. The DON stated when the facility staff were assigned to watch two residents on high observation, the facility staff could sit wherever they wanted, as long as they could visually see both residents. The DON stated the facility staff should not be sitting at the nightstand if they could not see both the residents. The DON also stated the facility staff should never be sleeping in the residents' room and it was a safety issue for the residents for the facility staff to be sleeping. On 1/9/26 at 1445 hours, an interview was conducted with the Administrator. The Administrator stated Residents 116 and 120 were on high observation because they both fell the day they were admitted to the facility. The Administrator stated the facility staff assigned for high observation should be doing frequent checks of the residents they were assigned to and should never be sleeping.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to obtain the appropriate admission PICC line measurements for one of one final sampled resident (Resident 119) reviewed for the central lines (a long, flexible tube inserted into a large vein in the neck, chest, arm, or groin, ending near the heart, to provide long-term access for delivering fluids, nutrition, and medications). * The facility failed to ensure Resident 119's arm circumference and the PICC line's external catheter were measured upon the resident's admission to the facility. This failure had the potential to delay identifying potential complications of the central line. Findings: Medical record review for Resident 199 was initiated on 1/6/16. Resident 119 was admitted to the facility on [DATE]. Review of Resident 119's IV Administration Record for December 2025 showed a physician's order dated 12/19/25, to measure the resident's arm circumference and PICC lie external catheter lumens every week. The record showed a box for the measurements to be completed on 12/19/25 (the resident's admission date), which was not completed. Further review of Resident 119's medical record failed to show the resident's arm circumference and external catheter length measurements were completed upon the resident's admission to the facility. On 1/8/26 at 0909 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the arm circumferences and PICC line external catheter lengths measurements were obtained for all the newly admitted residents with PICC lines upon their admission to the facility, and weekly thereafter. RN 3 further stated the changes in the measurements would help identify central line catheter issues, like tubing migration. RN 2 verified Resident 119's medical record failed to show the admission PICC line arm circumference and external catheter length measurements were obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Resident 11) reviewed for pain management. * The facility failed to accurately record Resident 11's highest pain level for the shift, as well as document the nonpharmacological interventions (NPI) implemented prior to administering the PRN (as needed) pain medication. These failures put the resident at risk of their pain level not being documented accurately and receiving unnecessary pain medication without the NPI in place. Findings: Medical record review for Resident 11 was initiated on 1/6/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report showed a physician's order dated 10/2/25, showed to monitor the resident's pain level every shift (on a scale of 0-10, with 0 being no pain, and 8-10 being sever pain) and document the NPI provided. Review of Resident 11's MAR for January 2026 showed the following:- On 1/1/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet (a controlled pain medication) 5-325 mg medication was administered at 1122 hours, for a pain level of 8. - On 1/1/26, during the evening shift, the resident's pain level was documented as 0. However, two tablets of the Percocet 5-325 mg medication was administered at 1530 hours, for a pain level of 8. - On 1/2/26 day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1002 hours, for a pain level of 8, and at 1422 hours, for a pain level of 9. - On 1/2/26 evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1830 hours, for a pain level of 9. - On 1/2/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/3/26 at 0630 hours, for a pain level of 8. - On 1/3/26 during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1038 hours, for a pain level of 8, and at 1440 hours, for a pain level of 9. - On 1/3/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1840 and 2240 hours, for a pain level of 9. - On 1/4/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1030 hours, for a pain level of 7, and at 1444 hours, for a pain level of 9. - On 1/4/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1845 hours, for a pain level of 9. - On 1/4/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/5/26 at 0526 hours, for a pain level of 8. - On 1/5/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 0957 hours, for a pain level of 8. - On 1/5/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1730 and 2130 hours, for pain levels of 8. - On 1/5/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/6/26 at 0530 hours, for a pain level of 8. - On 1/6/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1838 hours, for a pain level of 7. - On 1/6/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/7/26 at 0417 hours, for a pain level of 8. On 1/7/26 at 1159 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for the pain and NPI documentation in the resident's MAR for each shift, the licensed nurses should document the highest pain level for the entire shift, as well as all the NPI implemented prior to administering the pain medication. The DON verified the above shifts with a 0 pain level documented and the NA for the NPI were incorrect and should have reflected the resident's highest pain level. The DON also verified there was no documentation to show the NPIs were implemented prior to administering the PRN pain medication (except for 1/2/26, during the evening shift).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure there was adequate staffing for the 2300 to 0700 hours shift to meet the physical and psychosocial needs for two of 19 final sampled residents (Residents 20 and 118) and two nonsampled residents (Residents 43 and 81). * The facility failed to ensure Resident 20's call light was answered in a timely manner for assistance in toileting and transfers to and from the bed between the hours of 0200 - 0500 hours on 1/4 and 1/5/26. * The facility failed to ensure Residents 43 and 81 received timely staff assistance during the 2300-0700 hours shift. * The facility failed to timely answer Resident 118's call light to address her toileting needs without the resident experiencing distress over the staff's response time. These failures had the potential for the residents to not be provided with care consistent with professional standards of practice and care as outlined in their person-centered plans of care.Findings:
Review of the facility's P&P titled Nursing Department- Staffing, Scheduling and Posting dated July 2018 showed the facility was to ensure adequate number of nursing personnel are available to meet resident needs. The facility will employ Nursing staff that will be on duty in at least the number and with the qualifications required to provide necessary nursing services for residents admitted for care. In staffing an adequate number of Nursing Service personnel, scheduling will be done as needed to meet the residents' needs, and such information will be posted as required.
1.a. On 1/6/26 at 0845 hours, an observation and concurrent interview was conducted with Resident 81. Resident 81 was lying in his bed with a feeding tube connected to his abdomen. Resident 81 stated he was dependent on staff assistance and had a concern with facility staffing during the night shift. Resident 81 stated he did not get the assistance he needed timely during the night shift. Resident 81 stated he was admitted to the facility at around 1900 hours on 12/31/25. The assigned CNA put him on the bed and covered him with the blanket the resident got from the acute care hospital and left. Resident 81 further stated he did not remember getting assistance until the next morning on 1/1/26. Resident 81 stated he remembered pressing the call button multiple times but did not remember getting assistance that night. Resident 81 further stated on 1/4/26 at around 2000 hours, the assigned CNA assisted the resident to change his incontinence brief. Resident 81 stated after around 30 minutes, he needed to be changed again and pressed the call button to ask for staff assistance. Resident 81 stated he did not get any assistance until midnight, almost three hours after he needed assistance. Resident 81 stated he did not feel good to have to wait for the staff for a long time to change his wet incontinence brief. Resident 81 further stated he knew he waited three hours because he looked at the clock so he knew how long he waited.
Medical record review for Resident 81 was initiated on 1/6/26. Resident 81 was admitted to the facility on [DATE].
Review of Resident 81's MDS assessment dated [DATE], showed Resident 81 was cognitively intact and required staff assistance for his activities of daily living.
Review of Resident 81's H&P examination dated 1/1/26, showed Resident 81 could make his needs known and could make his own decisions.
b. On 1/6/26 at 1012 hours, an observation and concurrent interview was conducted with Resident 43. Resident 43 was lying in her bed. Resident 43 stated the facility did not have enough staff during the 2300-0700 hours shift. Resident 43 stated she had to wait more than an hour to get assistance at night. Resident 43 stated she remembered an incident when she had to wait for more than 25 minutes to get her colostomy bag changed. Resident 43 stated she remembered because her colostomy bag was full and it was hurting her when she was waiting for the staff to help her. Resident 43 stated she knew she waited more than 25 minutes for assistance because she looked at the clock in front of her.
Medical record review for Resident 43 was initiated on 1/6/26. Resident 43 was admitted to the facility on [DATE].
Review of Resident 43's Order Summary Report showed an order dated 12/26/24, to provide colostomy care every shift.
Review of Resident 43's H&P examination dated 6/11/25, showed Resident 43 had the capacity to understand and make medical decisions.
Review of Resident 43's MDS assessment dated [DATE], showed Resident 43 was cognitively intact and dependent on facility staff for her activities of daily living.
On 1/9/26 at 1142 hours, the Administrator and the DON were informed and acknowledged the above findings.
2.a. Review of the facility's P&P titled Communication- Call system dated 11/1/12, showed the purpose of the call system is to provide a mechanism for residents to promptly communicate with Nursing Staff. The Nursing Staff will answer the call bells promptly, in a courteous manner.
Medical record review for Resident 118 was initiated on 1/6/25. Resident 118 was admitted to the facility on [DATE].
Review of Resident 118's Order Summary Report showed a physician's order dated 1/6/25, to monitor for sign and/or symptoms of urinary retention for 72 hours status post indwelling urinary catheter removal.
Review of Resident 118's H&P dated 12/26/25, showed the resident had the capacity to understand and make medical decisions.
On 1/7/26 at 0947 hours, an interview was conducted with Resident 118. Resident 118 stated after her indwelling urinary catheter was removed yesterday morning, she had a hard time voiding. Resident 118 further stated she now has a hard time getting used to holding in her urine. Resident 118 stated when she has the urge to void, she needs to rush to the toilet.
On 1/8/26 at 0511 hours, an interview was conducted with CNA 2. CNA 2 stated she had 18 residents to care for that night. CNA 2 stated about half of her residents did not sleep all night, and many were incontinent and need assistance toileting. CNA 2 stated the residents complain about the call light response time, but some residents were time consuming and she gets overwhelmed.
On 1/8/26 at 0521 hours, an interview was conducted with RN 1. RN 1 stated they did get resident complaints during the 2300-0700 hours shift. RN 1 stated the facility currently has five CNAs and two 1:1 sitters (staff assigned to a specific resident for direct supervision) for 88 residents. When asked if the nurses help answer call lights, RN 1 replied the LVNs were pretty busy. RN 1 stated the facility has 88 residents for two LVNs and tries to provide assistance with answering the call lights. RN 1 stated he did rounds and on his last round he answered two call lights while the assigned CNA was busy with another resident.
On 1/8/26 at 0542 hours, an observation and concurrent interview was conducted with Resident 118. Resident 118 was awake watching TV in her bed. Resident 118 stated she dreads having to go to the bathroom because she was afraid she was going to have an episode of incontinence and will need to wait 15-20 minutes for the staff to respond to her call light and assist her with toileting. Resident 118 stated the staff just could not get to her timely.
b. On 1/6/26 at 0830 hours, during the initial tour of the facility, Resident 20 stated the call light response was not answered timely. Resident 20 stated he went to the bathroom, used the call light for assistance and the staff did not show up. Resident 20 stated he self-transferred and went to bed. Resident 20 further stated there was only one CNA to help the residents because the other one was on break.
Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE].
Review of Resident 20's H&P examination dated 9/25/25, showed Resident 20 could make his needs known and could make his own decisions.
On 1/8/26 at 0615 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 20 asked for assistance in toileting one to four times during the shift. Resident 20 was assisted to the shower chair to the toilet and transferred back to the bed. CNA 4 was informed Resident 20 stated he was calling and no one came after 30 minutes, so he self-transferred to the wheelchair then to the bathroom and back to the bed. CNA 4 stated they were not aware of this and the resident did not say anything.
On 1/8/26 at 0700 hours, an interview was conducted with CNA 5. CNA 5 stated they usually did not wait to answer the call lights because the sound was annoying. CNA 5 stated they checked the resident to see if the call light was on.
On 1/9/25 at 1520 hours, the Administrator was informed of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure medications were available, administered, and accounted for appropriately for one of five final sampled residents reviewed for unnecessary medication (Resident 116) and for one of two IV E-kit medication kits. * Resident 116's insulin was not available to be administered as ordered. * The facility failed to ensure the IV E-kit in Medication Room A was replaced timely. * The facility failed to ensure the IV E-kit pharmacy log in Medication Room A was accurately completed when accessed by RN 1. These failures resulted in medication not being available to be administered to the residents as well as inaccurate accounting of the emergency medication supply. Findings:
1. Review of the facility's P&P titled Provider Pharmacy Requirements revised January 2025 showed the pharmacy will provide timely services 24 hours a day, seven days a week. All new medication orders will be available for administration on the day they are ordered.
Medical record review for Resident 116 was initiated on 1/6/26. Resident 116 was admitted to the facility on [DATE].
Review of Resident 116's Order Summary Report showed a physician's order dated 12/31/25, for Novolog to be administered subcutaneously before meals and at bedtime per the sliding scale (a dose based on the resident blood sugar level).
Review of Resident 116's MAR for January 2026 showed on 1/1/26 at 0630 hours, Resident 116's blood sugar was 200 mg/dl. The entry was coded with a 9 for other/see progress notes.
Review of Resident 116's Progress Note dated 12/31/25 at 1954 hours, showed the resident was admitted at 1841 hours.
Review of Resident 116's Orders – Administration Progress Note dated 1/1/26 at 0646 hours, showed the Novolog insulin medication (antidiabetic) was pending delivery (more than 11 hours after the resident was admitted ).
On 1/7/26 at 1535 hours, an observation of the facility's Refrigerated E-kit showed the E-kit included Novolin R insulin and Humalog insulin (antidiabetic medication).
On 1/8/26 at 1423 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for new admissions, medications should be delivered by the pharmacy within four to six hours, and the E-kits may be utilized as well. The DON reviewed Resident 116's medical records and verified the Novolog insulin medication should have been available to be administered on 1/1/25 for the 0630 dose. The DON stated even though Resident 116's ordered insulin was not available in the E-kits, the nurse should have contacted the physician for a temporary physician's order for one of the available insulins until the supply was delivered by the pharmacy.
2. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2025 showed the following:
- an emergency supply of medications including emergency drugs, antibiotics, controlled substances, and products for infusion is provided in sealed containers in compliance with state regulations
- when an emergency dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply.
- if exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening.
On 1/8/26 at 0810 hours, an inspection of Medication Room A, interview, and concurrent facility document review was conducted with RN 2. Review of the E-kit log book showed the IV E-kit was accessed on 1/2/26, and was replaced by pharmacy on 1/6/26.
On 1/8/26 at 0825 hours, an interview was conducted with the Administrator. The Administrator stated the IV E-kit was replaced on 1/6/26, because she personally called the pharmacy to replace it on 1/6/26. The Administrator stated the policy to replace E-kits was 72 hours and verified the E-kit dated 1/6/26, should have been replaced.
3. On 1/8/26 at 0810 hours, an inspection of Medication Room A's IV E-kit, interview, and concurrent facility document review was conducted with RN 2. The E-kit had a yellow lock. RN 2 stated a yellow lock indicated the E-kit had been accessed and needed a replacement. Review of the E-kit log book showed the E-kit was accessed on 1/2/26, but was replaced on 1/6/26. There were no additional entries in the Pharmacy Log inside of the E-kit or in the E-kit log book to show the E-kit was accessed after 1/6/26. RN 2 stated the IV E-kit must have been accessed after it was replaced on 1/6/26, because it had a yellow lock. RN 2 stated she did not know what happened. RN 2 spoke to RN 1 and determined RN 1 accessed the IV E-kit on the previous shift but did not complete the IV E-kit pharmacy log.
On 1/8/26 at 0918 hours, an interview was conducted with RN 1. RN 1 stated he accessed the IV E-kit in Medication Room A to start an IV infusion on a new admission. RN 1 stated he was aware of the policy to fill out the pharmacy log when he accessed the E-kit but forgot.
On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper medication storage was followed in one of three nurse stations (Nurse Station A), one of two medication rooms (Medication Room A), two of two medication carts (Medication Cart A and Treatment Cart A), and one of two medication refrigerators (Medication Refrigerator A) observe. * Multiple medications were left unattended at Nurse Station A, after the pharmacy delivery. * The facility failed to maintain the recommended medication refrigerator temperatures in Medication Room A. * The facility failed to keep Treatment Cart A free of unnecessary items such as batteries, tools, and insulin syringes. * The facility failed to ensure there were no unlabeled loose medications in Medication Cart A. * The facility failed to ensure the storage bin for the OTC medications in Medication Cart A was free from dirt like debris. * The facility failed to ensure the top exterior part of Medication Refrigerator A was free of white powder like debris. * The facility failed to ensure Medication Cart B storing bin containing Coban (self- adherent, cohesive bandages), etc. was free from dirt like debris. These failures had the potential for the non-nursing staff, residents, and visitors to have access to the medications, as well as the potential for medication degradation and contamination. Findings:
1. Review of the facility's P&P titled Storage of Medication revised January 2025 showed medications are stored safely and securely, and only licensed nurses, pharmacy personnel, and those lawfully authorized ae allowed access to medications. The medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier.
On 1/8/25 at 0523 hours, RN 1 was observed sitting at Nurse Station A and a stack of 19 medication bubble packs, a large paper bag with a pharmacy medication list with nine medications stapled to it, and three plastic bags with a pharmacy paperwork attached to each bag were observed on top of the nurse station counter. CNA 2 asked RN 1 for assistance and RN 1 was observed leaving the nursing station and leaving the medications unattended. A housekeeping staff member was observed sweeping the floor, just outside the nurse station, and a resident was observed on his wheelchair in the lobby, just down a short hallway from the nurse station.
On 1/8/26 at 0532 hours, LVN 4 walked into Nurse Station A and grabbed the large paper bag. LVN 4 stated the paper bags were the pharmacy delivery that arrived a little after 0400 hours that morning.
On 1/8/26 at 0605 hours, an interview was conducted with RN 1. RN 1 verified the pharmacy delivery (medications) were left unattended at the nurse station when he left to assist CAN 2. RN 1 stated the medications should have been secured in the medication room until the LVNs were available to secure the medications in the medication carts.
2. Review of the facility's P&P titled Medication Storage in the Facility revised January 2025 showed:
- Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring
- Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.
On 1/8/26 at 0810 hours, an interview and concurrent inspection of Medication Room A was conducted with RN 2. RN 2 was asked to unlock the medication refrigerator Immediate observation of the thermometer inside the refrigerator showed the temperature was 30 degrees. The medications stored in the refrigerator included:
- Humulin R (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit;
- insulin lispro (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit;
- Lantus solostar (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit; and
-Veltassa powder (used to treat hyperkalemia) and the recommended storage temperature was 36 to 46 degrees Fahrenheit.
RN 2 stated the refrigerator temperature should be between 36 and 46-degrees Fahrenheit according to the facility's policy. RN 2 verified a temperature of 30 degrees Fahrenheit was too low for the medication refrigerator.
On 1/8/26 at 1247 hours, a follow up observation of the medication refrigerator inside Medication Room A and a concurrent interview was conducted with RN 2. RN 2 was asked to unlock the medication refrigerator. Immediate observation of the thermometer inside the refrigerator showed the temperature was 30 degrees Fahrenheit. RN 2 verified the above findings.
3. On 1/7/26 at 1219 hours, an inspection of Treatment Cart A and concurrent interview was conducted with LVNs 1 and 2. The following was observed:
- A storage bin in the top drawer, containing different sized batteries, insulin syringes, and miscellaneous tools.
LVN 1 stated he did not know why the items listed above were in stored inside the medication cart. LVN 1 stated the batteries and tools could be stored in the central supply and the insulin syringes were not used when providing wound care treatments to the residents. LVN 2 was also present and stated the above items should be kept in central supply.
On 1/7/26 at 1230 hours, an interview was conducted with RN 2. RN 2 stated Treatment Cart A should only have wound treatment supplies stored inside and any other items the licensed nurses needed could be found in the central supply.
On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON was informed of the above findings.
4. Review of the facility's P&P on Medication Administration dated 8/19/25, showed to prepare medications for one resident at a time and not to pre- pour medications.
On 1/8/26 at 0600 hours, right after the medication administration observation with LVN 5 was completed, five cups of pre-poured unlabeled loose medications (tablets and capsules) were observed in the first drawer of Medication Cart A. LVN 5 verified the following unlabeled loose medications in a transparent medication cup:
- 1st medication cup: one blue capsule, one white tablet and one yellow tablet;
- 2nd medication cup: one yellow tablet;
- 3rd medication cup: one white round tablet;
- 4th medication cup: one blue tablet and one blue capsule; and
- 5th medication cup: one white round tablet.
LVN 5 stated the medications from two of the medication cups were for Resident 52, who wanted to take her medications after she got changed. LVN 5 showed four bubble packs, where she dispensed the medications from for two of the five medication cups for Residents 52 and 67. Reconciled the medications against Resident 52's due medication bubble packs. The unlabeled medications on the 1st medication cup were comparable to bubble pack for Resident 67. The 2nd medication cup was comparable to Resident 52's due medication bubble pack. However, LVN 5 was not able to identify the rest of the medications or the resident's name.
On 1/8/26 at 0615 hours, an interview was conducted with RN 1. RN 1 was informed and verified the above findings. RN 1 was shown the five pre-poured medication cups with unlabeled medications on the first drawer of Medication Cart A. RN 1 was unable to account for the remaining unlabeled medications, stated these should have been labeled.
5. Review of the facility's P&P on Medication Storage in the Facility dated January 2025 showed the medication storage areas are kept clean, well - lit and free of clutter and extreme temperatures and medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.
On 1/7/26 at 0945 hours, an inspection of Medication Cart A was conducted with LVN 6. Multiple brownish dirt-like debris were observed in one of the storage bins, farthest left of the 1st drawer. LVN 6 verified the findings and stated all the charge nurses clean the medication carts from all shifts; this should have been cleaned.
On 1/7/26 at 1006 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified the above findings and stated the medication cart should have been cleaned and sanitized.
6. On 1/7/26 at 1010 hours, an inspection of Medication Refrigerator A was conducted with LVN 7. The top exterior part of Medication Refrigerator A was observed with white powder- like debris and was partially removed when wiped clean with a paper towel. LVN 7 verified the findings and stated all the areas of medication room, including Medication Refrigerator A should have been cleaned by licensed nurses from all the shifts.
On 1/7/26 at 1023 hours, an observation and concurrent interview was conducted with the DON. The DON verified the white powder like debris on the top exterior part of the Medication Refrigerator A and stated the refrigerator should have been cleaned.
7. On 1/7/26 at 1027 hours, an inspection of Medication Cart B was conducted with RN 2. Medication Cart B was observed to have dirt like debris to one of the storage bins storing Coban and other items. RN 2 stated the dirt like debris were rusts and could not be removed. RN 2 attempted to clean the dirt like debris and was able to partially remove it.
On 1/7/26 at 1119 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above findings and stated the storage bin should have been cleaned.
On 1/9/25 at 1508 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents. * The menu spreadsheet was not followed for Resident 62's CCHO (Consistent Carbohydrate Diet/Controlled Carbohydrate) diet. * Resident 68 did not receive a salad listed on the lunch menu. These failures posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings:
Review of the facility's document titled Diet Type Report dated 1/6/26, showed 77 out of 85 residents received food from the kitchen.
Review of the facility's P&P titled Therapeutic Diets dated 6/1/2014, showed therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the dietitian. Therapeutic diets are reflected on the menu extension.
Review of the facility's document titled Winter Menus dated 1/7/26, showed the residents on a CCHO and renal diet are to receive oven crisp fish with tartar sauce, salt free french fries, ketchup, seasonal carrots, apple hill cake 2 x 2 1/2, and milk. Further review of the document showed residents on a CCHO diet were not to receive a wheat roll.
Review of Resident 62's Diet Ticket dated 1/7/26, showed Resident 62 was to receive a renal, CCHO, regular texture diet. The Diet Ticket further showed Resident 62 disliked cold cereal and fish.
During the tray line observation and concurrent interview with the DSS on 1/7/26 at 1225 hours, the dietary staff set up the tray for Resident 62's lunch. The tray had seasoned carrots, chicken, brown rice, apple hill cake 2 x 2 1/2, milk and wheat rolls. The DSS stated the tray was ready to be served to the resident. The DSS then verified the above tray to be served to Resident 62. The DSS was observed checking the winter menus and verified Resident 62 was on CCHO diet. The DSS verified Resident 62 should not have wheat rolls per the winter menus.
Medical record review for Resident 62 was initiated on 1/7/26. Resident 62 was admitted to the facility on [DATE].
Review of Resident 62's H&P examination dated 1/5/25, showed Resident 62 had diagnoses including Type II Diabetes.
On 1/9/26 at 1142 hours, the Administrator and the DON were informed and acknowledged the above findings.
2. Review of the facility's January Menu dated 1/6/26, showed the lunch menu consisted of pork chops with pear sauce, polenta, seasoned broccoli, a green salad with dressing, and a cranberry crunch bar.
On 1/6/26 at 1241 hours, an observation and concurrent interview was conducted with Resident 68. Resident 68 was eating his lunch in his room. Resident 68's lunch tray did not include a green salad. Resident 68 stated he was not sure what was on the lunch menu, but would have liked a green salad. Resident 68's lunch tray ticket did not show the menu items, but did include the resident's dislikes, which did not show salad. CNA 3 came into Resident 68's room and verified there was no green salad on their tray per the menu.

Based on interview and facility document review, the facility failed to implement their QAPI plan and their past Recertification Survey POC for F694. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee. Findings: Review of the facility's 2024 Recertification Survey POC accepted by the department on 10/25/24, included the following for F694:- The DON will in-service the RNs on measuring the external PICC line catheters length on admission. - The DON will review residents with PICC lines to ensure RNs are measuring the external catheter length on admission. - The DON will report any findings related to PICC line care to the QA committee monthly for three months. On 1/9/26 at 1545 hours, a review of the facility's QAPI binder was conducted with the Administrator. The facility's QAPI binder failed to show the above POC interventions were completed. The Administrator verified the above findings. Cross reference F694.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * A stainless-steel blender was stored wet. * Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) was not handled safely as the leftover chicken was not maintained at the proper temperature. In addition, there was no documentation of the leftover chicken cooked on the previous day on the cooling down log. These failures had the potential to cause foodborne illness for the residents who consumed food prepared in the kitchen.Findings: Review of facility's document titled Diet Type Report dated 1/6/26, showed 77 out of 85 residents were receiving food from the kitchen. a. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 1/6/26 at 0754 hours, an observation and concurrent interview was conducted with the DSS. A stainless-steel blender was observed on food preparation area. The blender was observed with the lid closed. The DSS opened the lid of the blender, and the blender was observed to be stored wet. The DSS verified the observation and stated the kitchen staff should have air dried the blender before storing it. b. According to the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) Within two hours from 57 Celsius (C) [135 Fahrenheit (F)] to 21 C (70 F); and (2) Within a total of six hours from 57 C (135 F) to 5 C (41 F) or less. Review of the facility's P&P titled Hazardous Foods Cooling Monitor dated 7/1/2014, showed the dietary department employees will follow food handling rules for hazardous foods. Hazardous foods included.chicken/turkey/Shellfish. Under the section procedure showed hot food should be cooled from 140 F to 70 F within two hours and cooled from 70 F to 41 F or lower in an additional 4 hours. Further review of the P&P showed to record the temperature of food every hour, and action taken to achieve proper temperature cooling on cooling monitor log. On 1/6/26 at 0754 hours, an observation and concurrent interview was conducted with the DSS. A container of cooked chicken dated 1/5/26, was observed in the reach in refrigerator. The DSS was asked to measure the temperature of cooked leftover chicken, the temperature reading showed 43 F. The DSS verified the observation and stated the temperature of the leftover chicken should have been less than 41 F. The DSS was asked to show the cooling monitor log, however, the DSS verified the cooling down process was not documented for the leftover chicken. The DSS could not verify if the cooling down process was followed for the above leftover chicken. The DSS was observed discarding the leftover chicken. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure for an accurate medical record for one of one final sampled resident (Resident 5) reviewed for dialysis. * Resident 5's blood pressure log inaccurately showed his blood pressure was obtained on his left arm, where the resident had an AV shunt (a surgical connection between an artery and a vein). This failure resulted in inaccurate documentation of the resident's blood pressure measurements site.Findings: Medical record review for Resident 5 was initiated on 1/6/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 11/28/25, for no blood pressure checks on the resident's left arm AV shunt. Review of Resident 5's Blood Pressure Log showed the following blood pressure readings were obtained from the resident's left arm:- on 12/17/25 at 0722 hours;- on 12/18/25 at 0639 hours;- on 12/25/25 at 0646 hours;- on 12/25/25 at 2152 hours;- on 12/26/25 at 0655 hours;- on 1/1/26 at 0834 hours; and- on 1/5 at 1928 hours. On 1/7/26 at 1149 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 5 had a left arm AV shunt, and the blood pressures readings should not be checked on the arm with the AV shunt. The DON verified Resident 5's Blood Pressure Log showed the above blood pressure readings were documented as being taken on the left arm. On 1/7/26 at 1415 hours, an interview was conducted with Resident 5. Resident 5 stated the licensed nurses always checked his blood pressure readings on his right arm because his AV shunt was on his left arm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate and complete medical record for two of 13 sampled residents (Residents 12 and 13). * The facility failed to ensure the licensed nurses documented their initials on Residents 12 and 13's TARs (indicating the treatments were provided) as per the facility's P&P. This failure had the potential for the residents' care needs not being met as their medical record information was inaccurate and/or incomplete.Findings: Review of the facility's P&P titled Completion and Correction revised 1/1/2012, showed the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The facility will ensure the medical records are complete and accurate. Entries will be recorded promptly as the event occurs. 1. Medical record review for Resident 12 was initiated 8/29/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 5/20/25, to cleanse Resident 12's sacrum fragile scar tissue with soap and water, pat dry, then apply zinc oxide (skin barrier cream), every shift for skin maintenance. Review of Resident 12's TAR (Treatment Administration Record) for 7/2025 failed to show documentation the licensed nurse performed Resident 12's treatment on 7/7, 7/18, 7/19, and 7/28/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident 12's sacrum and the application of her barrier cream. 2. Medical record review for Resident 13 was initiated on 8/29/25. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed an order dated 7/12/25, to cleanse Resident 13's MASD (sacrococcyx and right left buttocks) with normal saline, pat dry, then apply moisture barrier cream every shift. Review of Resident 13's TAR for 7/2025 failed to show documentation the licensed nurse performed Resident 13's treatment on 7/18/25 and 7/19/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident's 13 MASD (sacrococcyx and right left buttocks) and the application of her barrier cream. On 9/2/25 at 1550 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings and stated after a licensed nurse provided resident treatment, the licensed nurse would then document the treatment provided in the resident's medical record (TAR). The DON stated she would contact the nurses who failed to document Resident 12 and 13's treatments were provided and determine whether the nurses failed to provide the treatments or had provided the residents' treatments, however, forgot to document in the residents' medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the failed to provide the reasonable accommodations to meet the care needs for two of 13 sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's call lights were answered in a timely manner. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.Findings: Review of facility's P&P titled Communication-Call System dated 1/1/2012, showed the facility will provide a call system to enable residents to alert the nursing staff from their rooms. The nursing staff will answer the call bells promptly, in a courteous manner. In answering to request, the nursing staff will return to resident with the item or reply promptly. a. On 8/28/25 at 0925 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 3 was conducted with CNA 1. Resident 3's call light was turned on from hallway and there was an audible beeping sound on the call light panel at the nurses station. There were two facility staff in the hallway who passed by Resident 3's room without answering the call light. Resident 3 started screaming and was heard in the hallway. No facility staff answered the call light to assist Resident 3. On 8/28/25 at 0945 hours, 20 minutes after Resident 3's call light was on, CNA 1 answered Resident 3's call light. In a concurrent interview, CNA 1 stated Resident 3 needed to be changed. CNA 1 stated she needed to answer the call light right away and if she could not answer the call light, she would ask other staff to answer the call light. Medical record review for Resident 3 was initiated on 8/28/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severe cognitive impairment and needed substantial to maximum assistance for ADL care from the staff. b. On 8/28/25 at 1025 hours, an observation and concurrent interview for Resident 2 was conducted with CNA 1. Resident 2's call light was turned on from hallway and there was an audible beeping sound on the call light panel at the nurses station. LVNs 2 and 3 were sitting at the nurses station. RNA 1 passed by Resident 2's room without answering the resident's call light. No facility staff answered the call light to provide assistance to Resident 2. On 8/28/25 at 1045 hours, 20 minutes after Resident 2's call light was on, CNA 1 answered Resident 2's call light. In a concurrent interview, CNA 1 stated Resident 2 wanted the lunch tray removed from her room. On 8/28/25 at 1050 hours, an interview was conducted with LVNs 2 and 3, and RNA 1. LVN 2 verified she heard the beeping sound of the call light for Resident 2. LVN 2 stated they needed to answer the call light right away when it was turned on. LVN 2 verified she did not answer the call light of Resident 2 right away. LVN 3 verified he heard the beeping sound of the call light for Resident 2. LVN 3 verified he did not answer the call light of Resident 2 right away. RNA 1 verified the call light of Resident 2 was turned on when he passed by the room and acknowledged he did not answer the call light of Resident 2 right away. RNA 1 stated the call light of Resident 2 should have been answered right away. On 9/3/25 at 1655 hours, an interview was conducted with the Administrator and DON was conducted. The Administrator and the DON were informed and verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure the infection control practices were observed. * LVN 1 failed to follow the EBP infection control practices while performing the wound care for Resident 1. * LVN 2 failed to follow the infection control practices on wearing PPE in the hallway. These failures posed the risk for transmission of disease-causing microorganisms and infections.Findings: Review of the facility's P&P titled Enhanced Barrier Precaution dated 5/28/24, showed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. EBP are indicated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers). In addition, to facilitate compliance with EBP, gowns and gloves are to be donned before each high contact task, not prior to entering the room. Health care personnel should not routinely wear gowns and gloves in the hallway. Review of the facility's Enhanced Standard Precaution signage showed everyone must perform hand hygiene before entering the room. Anyone participating in any of these six moments must also don gown and gloves for morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, cleaning and disinfecting the environment, and mobility assistance and preparing to leave room. a. On 8/28/25 at 0900 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 1 was conducted with LVN 1. An EBP signage was observed outside of Resident 1's room. There was a small drawer on Resident 1's door which contained gloves, gowns, and a bottle of alcohol-free wipes. LVN 1 was observed providing wound care to Resident 1 in bed without wearing the gown. LVN 1 verified Resident 1 was on EBP for wound. LVN 1 verified he was not wearing a gown while providing wound care to Resident 1. Medical record review for Resident 1 was initiated on 8/28/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 6/17/25, for low air loss mattress for wound management re-opened right buttock pressure injury stage four every shift for wound management. b. On 8/28/25 at 0930 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 2. Resident 2's room was closed and had a sign for COVID-19 isolation. There was a small drawer on Resident 2's door which contained gloves, gowns, and a bottle of alcohol-free wipes. LVN 2 was observed preparing medication from the medication cart in front of Resident 2's room. LVN 2 donned PPE and went to the medication room in the hallway wearing PPE. LVN 2 stated she did not enter Resident 2's room because she needed medication inside the medication room. On 8/28/25 at 1520 hours, an interview was conducted with the IP. The IP was informed of the observation and verified the findings. IP stated LVN 1 should have been wearing a gown while providing wound care to Resident 1 and LVN 2 should not be wearing any PPE when in the hallway. On 8/28/25 at 1630 hours, an interview was conducted with the Administrator. The Administrator was informed and verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation process for one of eight sampled residents (Resident 1).
* The facility failed to suspend CNA 1 from work when Resident 1 reported an allegation of physical abuse against CNA 1 on 6/17/25. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abuser.
Findings:
Review of the facility's P&P titled Reporting Abuse revised 1/8/14, showed upon an allegation of abuse by a facility staff member, the facility staff member will be suspended and removed from the premises during the investigation.
On 6/17/25, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNA 1.
Medical record review for Resident 1 was initiated on 6/26/25. Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 1's H&P examination dated 5/27/25, showed Resident 1 had capacity to make his own medical decisions.
Review of the facility's investigation documents for Resident 1's allegation of abuse showed the interviews and statements of the facility's staff members and residents. However, further review of the documents failed to show CNA 1 was suspended immediately after Resident 1 had voiced concerns about an alleged physical abuse to LVN 4 on 6/17/25 at 0140 hours.
On 6/26/25 at 1055 hours, a telephone interview was conducted with CNA 1. CNA 1 verified she worked with Resident 1 on 6/17/25, during the night shift from 2300 to 0700 hours. CNA 1 reported Resident 1's allegation of abuse to LVN 4 on 6/17/25 at 0140 hours. When asked if she was suspended immediately after the reporting of the alleged abuse, CNA 1 stated that LVN 4 and RN 1 gave her a different assignment to not work directly with Resident 1 that night.
On 6/27/25, at 0900 hours, a telephone interview was conducted with LVN 4. LVN 4 stated that Resident 1 was assessed immediately after reporting of the alleged physical abuse. There was no injury indicated. LVN 4 stated CNA 1 was asked to take another assignment. At around 0215 hours, an officer was called to the facility by Resident 1. RN 1 accompanied the officer, and the officer concluded there were no signs of elder abuse.
On 6/27/25 at 0930 hours, a telephone interview was conducted with RN 1. RN 1 acknowledged he failed to inform the Administrator immediately after the allegation of abuse was reported. RN 1 further stated the alleged staff should also be suspended pending the investigation to ensure the safety of Resident 1 and other residents in the facility.
On 6/27/25 at 1430 hours, an interview was conducted with the Administrator. The Administrator acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections.
* Treatment Nurse 1 failed to perform hand hygiene before providing the wound care treatment to Resident 2.
* Treatment Nurse 2 failed to perform hand hygiene before providing the wound care treatment to Resident 1.
* CNA 1 failed to perform hand hygiene and change her gloves in between tasks and before accessing the clean linen cart.
These failures had the potential for transmission of disease-causing pathogens and infections.
Findings:
Review of the facility's P&P titled Hand Hygiene (undated) showed the facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections and facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers and visitors.
1. On 2/27/25 at 0835 hours, a wound care observation was conducted with Treatment Nurse 1 for Resident 2. Treatment Nurse 1 was observed initiating the wound care treatment to Resident 2's left shin wound site without performing hand hygiene. Treatment Nurse 1 then donned on gloves, cleaned the wound site with normal saline (sterile, clear solution containing sodium chloride and water), removed the soiled gloves, then donned on a new set pair of gloves. Treatment Nurse 1 was not observed performing hand hygiene after removing the soiled gloves and before donning on the clean gloves. Treatment Nurse 1 was then observed continuing the wound care treatment to Resident 2's left shin wound as ordered by the physician.
On 2/27/25 at 0850 hours, an interview was conducted with Treatment Nurse 1. When asked if he performed hand hygiene prior to providing the wound care treatment to Resident 2, Treatment Nurse 1 stated he should have washed his hands before providing the wound care treatment to the resident to prevent the spread of infection.
Medical record review for Resident 2 was initiated on 2/27/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's Order Summary Report dated 2/27/25, showed a physician's order dated 2/26/25, to apply Santyl (topical enzyme medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin) external ointment 250 unit/gm to the left shin topically every day shift for wound care.
2. On 2/27/25 at 1030 hours, a wound observation was conducted with Treatment Nurse 2 and CNA 1 for Resident 1. After verifying the physician's order and gathering the wound care supplies, Treatment Nurse 2 was observed walking towards Resident 1's bed. CNA 1 was observed cleaning Resident 1's buttock area with soap and water. CNA 1 then alertedTreatment Nurse 2 to apply the barrier cream to the resident's buttock area. Treatment Nurse 2 was observed donning on gloves and applying the barrier cream to Resident 1's buttock area using a tongue depressor, without performing hand hygiene. CNA 1 was also observed changing Resident 1's bed linens and attempting to grab linen from the clean linen cart with the soiled gloves used to clean Resident's buttock area. CNA 1 was stopped from removing linen from the clean linen cart and asked if she needed to change her soiled gloves and perform hand hygiene before accessing the clean linen cart. CNA 1 then removed her soiled gloves, performed hand hygiene and donned on set pair of gloves.
Medical record review for Resident 1 was initiated on 2/27/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review Resident 1's Order Summary Report dated 2/27/25,showed a physician's order dated 2/27/25, to apply skin barrier cream to the sacrococcyx extending to left and right buttocks every day shift for skin maintenance.
On 2/27/25 at 1045 hours, an interview was conducted with CNA 1. CNA 1 verified she did not perform hand hygiene and donned clean gloves after providing care to Resident 1 and before attempting to grab supplies from the clean linen cart. CNA 1 stated she should have performed hand hygiene and changed her gloves in between tasks to prevent contamination.
On 2/27/25 at 1050 hours, an interview was conducted with Treatment Nurse 2. When asked if he performed hand hygiene prior to providing wound care treatment to Resident 1, Treatment Nurse 2 stated that he should have washed his hands before providing the wound care treatment to the resident for safety and to prevent the spread of infection.
On 2/27/25 at 1415 hours, an interview was conducted with the IP. The IP stated the facility staff should perform hand hygiene before providing the wound care treatment to the residents. In addition, the gloves should be changed, and hand hygiene should be performed in between the tasks to prevent transmission of diseases and infections.
On 2/27/25 at 1545 hours, an interview was conducted with the DON. The DON acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide oral care every shift for one of four sampled residents (Resident 2). This failure had the potential to negatively impact Resident 2's well-being.
Findings:
Medical record review for Resident 2 was initiated on 1/8/25. Resident 2 was admitted to the facility on [DATE], with diagnoses including dysphagia.
Review of Resident 2's Order Summary Report showed an order dated 10/17/24, for every shift to provide the oral care and use the swab/suction as appropriate.
Review of Resident 2's Intervention/Task for Oral Hygiene forJanuary 2025 showed the oral hygiene was provided to Resident 2 during the day shifts (7 AM -3 PM) and evening shifts (3 PM -11 PM) only on the following dates/times but not every shift every day as ordered:
- On 1/1/25 at 1127 and 1651 hours.
- On 1/2/25 at 1323 and 2219 hours.
- On 1/3/25 at 1427 and 1640 hours.
- On 1/4/25 at 1058 and 2259 hours.
- On 1/5/25 at 1134 and 1816 hours.
- On 1/6/25 at 1013 and 2132 hours.
- On 1/7/25 at 1039 and 1702 hours.
- On 1/8/25 at 1302 and 1749 hours.
On 1/8/25 at 1138 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 stated the oral care should be provided every shift to Resident 2. LVN 1 confirmed Resident 2's mouth was dirty, and the lips were dry with white patches. LVN 1 further stated Resident 2 had not had oral care yet.
On 1/9/25 at 0925 hours, a concurrent interview and medical record review for Resident 2 was conducted with RN 1. RN 1 confirmed the oral care was not provided to Resident 2 every shift. RN 1 stated the oral care was important to prevent the resident's mouth infection and sores.
On 1/9/25 at 1004 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the facility had three shifts: day, evening, and night shifts. The DON confirmed the oral care was not provided every shift to Resident 2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTI for two of two sampled residents (Residents 1 and 2) reviewed for catheter care.
* The facility failed to ensure proper positioning of Residents 1 and 2' s urinary drainage bag to prevent urine from flowing back into the residents' bladder.
* The staff member failed to monitor or assess the color of Resident 2's urinary output.
These failures posed the risk for Residents 1 and 2 to develop CAUTI.
Findings:
Review of the facility's P&P titled Care of Catheter revised 6/10/21,showed the residents with Foley catheters will be cared for utilizing the most current CDC Guidelines to prevent Urinary Tract Infections. Nursing Staff will assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. The catheter tubing, bag or spigot will be anchored to not touch the floor. The catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
1. On 12/4/24 at 1035 hours, an observation was conducted with Resident 1. Resident 1 was observed lying in bed with the bed in a low position. Resident 1's urinary catheter drainage bag was observed on the top of Resident 1 ' s bed without a dignity bag. Resident 1's urinary output was visible from the hallway and from the opened patio door, which lead to facility's patio. There were other residents and visitors observed in the facility's patio.
Medical record review for Resident 1 was initiated on 12/4/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's H&P examination dated 10/5/24, showed Resident 1 had no capacity to make medical decisions.
Review of Resident 1's Order Summary Report showed the following physician'sorders:
- dated 9/19/24, for an indwelling urinary catheter size 16 Fr with 10 cc balloon via gravity.
- dated 10/4/24, for urinary Foley catheter care to be provided every shift and to assess the urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and the amount of urine output.
Review of Resident 1's plan of care showed a care plan problem dated 10/20/24, addressing Resident 3's urinary catheter use. The interventions included to position the urinary catheter bag and tubing below the level of the bladder and away from the entrance door.
On 12/4/24 at 1106 hours, a follow up observation was conducted with Resident 1. Resident 1's urinary catheter bag was observed on top of Resident 1's bed and not covered with a dignity bag. Family Member 1 was observed at the bedside, and she stated she did not touch the urinary catheter bag and no staff had come in to check the resident's urinary catheter bag.
On 12/4/24 at 1130 hours, an observation and concurrent interview was conducted with the DON. The DON verified Resident 1's urinary catheter bag should be covered with a dignity bag and positioned below Resident 1's bladder.
2. On 12/5/24 at 1020 hours, an observation of Resident 2 and concurrent interview was conducted with the DON. Resident 2 was observed lying on his back with the urinary catheter bag on top of Resident 2's bed and not covered with a dignity bag. The urinary catheter bag was visible from the hallway and the patio door, which was facing the facility's outdoor sidewalk near the handicap parking lot. Resident 2's urine color output was also observed to be dark yellow brown in color.
Medical record review for Resident 2 was initiated on 12/4/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's H&P examination dated 5/7/24, showed Resident 2 could make needs known but could not make medical decisions.
Review of Resident 2's Order Summary Report showed the following physician's orders dated 5/8/24:
- for an indwelling urinary catheter size 16 Fr via gravity drainage for obstructive uropathy.
- Foley catheter care to be provided every shift and assess the urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount the of urine output every shift.
Review of Resident 2's plan of care showed a care plan problem dated 2/22/24, addressing Resident 2's indwelling urinary catheter use. The interventions included to position the urinary catheter bag and tubing below the level of the bladder and away from the entrance door.
On 12/5/24 at 1030 hours, an observation and concurrent interview was conducted with Treatment Nurse 2. Treatment Nurse 2 acknowledged Resident 2's urinary bag should be covered with a dignity bag and positioned below Resident 2's bladder. Treatment Nurse 2 further stated Resident 2's urinary output should not be dark yellow brown in color, and instead, the urine should be clear yellow. Treatment Nurse 2 stated Resident 2's urine output should be properly monitored.
On 12/5/24 at 1513 hours, an interview was conducted with the DON. The DON acknowledged and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records for two of sixsampled residents (Residents 1 and 2) were complete and accurately documented.
* The licensed nurses failed to ensure documentation on the TAR for Residents 1 and 2 were complete and accurate. This failure had the potential for the residents' care needs not being met as their medical information was incomplete.
Findings:
1. Medical record review for Resident 1 was initiated on 12/4/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's TAR for November 2024 showed the following:
a. Missing documentation of the assessment of the resident's urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and the amount of urine output every shift as per the physician's order dated 10/4/24, on the following dates:
- 11/3/24, for the night shift;
- 11/4/24, for the evening shift;
- 11/15/24, for the night shift; and
- 11/28/24, for the evening shift.
b. Missing documentation for the Foley catheter care to be provided to the resident every shift as per the physician's order dated 10/4/24, on the following dates:
-11/3/24, for the night shift;
-11/4/24, for the evening shift;
-11/15/24, for the night shift; and
-11/28/24, for the evening shift.
2. Medical record review for Resident 2 was initiated on 12/4/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's TAR for November 2024 showed the following:
a. Missing documentation for the assessment of the resident's urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and the amount of urine output every shift as per the physician's order dated started 5/8/24, on the following dates:
-11/7/24, for the evening shift; and
-11/15/24, for the night shift.
b. Missing documentation for the Foley catheter care to be provided every shift as per the physician's order dated 5/8/24, on the following dates:
-11/7/24, for the evening shift; and
-11/15/24, for the night shift.
c. Missing documentation to monitor/record/report to the MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns every shift as per the physician's order dated 7/23/24, on the following dates:
- 11/7/24, for the evening shift; and
- 11/15/24, for the night shift.
On 12/5/24 at 1030 hours, an interview and concurrent medical record review for Residents 1 and 2 was conducted with Treatment Nurse 2. Treatment Nurse 2 verified all the above missing documentation in Residents 1 and 2's TAR.
On 12/5/24 at 1513 hours, an interview was conducted with the DON. The DON acknowledged and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop and implement a plan of care to reflect the individual care needs for one of two sampled residents (Resident 2).
* The facility failed to ensure a care plan was developed to address Resident 2's Court Investigator's allegation of possible financial abuse from alleged Resident 2's family member. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.
Findings:
Review of the facility's P&P titled Comprehensive Person - Centered Care Planning revised 11/2018 showed in part, the facility should ensure that a comprehensive person-centered care plan is developed for each resident. It is the policy of this facility to provide person - centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
IV. Comprehensive Care Plan. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments.
In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems
ii. Change of condition
iii. In preparation of discharge
iv. To address changes in behavior and care, and
v. Other times as appropriate or necessary.
Review of the Report of Suspected Dependent Adult/Elder Abuse SOC 341 form, completed and signed by the facility's Social Services Director dated 10/10/24, showed the Court Investigator informed the facility that there was an open investigation for possible financial abuse from Resident 2's family member.
Medical record review for Resident 2 was initiated on 10/18/24. Resident 2 was admitted to the facility on [DATE].
Record review of Resident 2's H&P examination dated 6/4/24, showed Resident 2 had no capacity to understand and make decisions.
Record review of Resident 2's MDS Section C - Cognitive Patterns dated 9/4/24, showed the resident's BIMS score of 1 (indicated severe cognitive impairment).
Review of Resident 2' plan of care did not show a care plan addressing Resident 2 was at risk for possible financial abuse from Resident 2's alleged family member.
On 10/18/24 at 1422 hours, a concurrent record review and interview was conducted with the DON. The DON was asked if she could find a care plan for Resident 2 addressing alleged possible financial abuse from the resident's family member. The DON verified she could not find any care plan to address for the risk of financial abuse.
On 10/18/24 at 1546 hours, during the exit conference with the DON in her office and a telephone interview with the Regional Consultant, the Regional Consultant asked the DON if she could not find a care plan addressing the alleged financial abuse. The DON verified again she could find any documentation on the plan of care addressing the possible financial abuse of Resident 2. The DON acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide thorough investigation and reported the results of the investigations for the allegation of possible financial abuse from the resident's family member to the CDPH, L&C Program within five working days of the incident for one of two sampled residents (Resident 2). This posed the risk for potential abuse to remain unidentified and for Resident 2 to go unprotected.
Findings:
Review of the facility's P&P titled Abuse - Reporting & Investigations revised 3/2018 showed in part, the facility promptly reports and thoroughly investigates all allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of an unknown source, and suspicion of crimes.
XII. Providing State Survey Agency and Other Agencies of the Results
A. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to CDPH Licensing and Certification and others that maybe required by state or local laws, within five (5) working days of the reported allegation.
Review of the Report of Suspected Dependent Adult/Elder Abuse SOC 341 form, completed and signed by the facility's Social Services Director dated 10/10/24, showed the Court Investigator informed the facility that there was an open investigation for possible financial abuse from Resident 2's family member.
Medical record review for Resident 2 was initiated on 10/18/24. Resident 2 was admitted to the facility on [DATE].
Record review of Resident 2's H&P examination dated 6/4/24, showed Resident 2 had no capacity to understand and make decisions.
Record review of Resident 2's MDS Section C - Cognitive Patterns dated 9/4/24, showed the resident's BIMS score of 1(indicated severe cognitive impairment).
On 10/18/24 at 1426 hours, a concurrent medical record review and interview was conducted with the DON. The DON was asked if the facility had submitted the results of their investigation to CDPH, L&C Program within five business days of the incident. The DON stated their investigation was still ongoing.
On 10/18/24 at 1546 hours, during the exit conference with the DON in person and Regional Director on the phone, the concern regarding the result of the facility's investigation for possible financial abuse from Resident 2's family member was raised. The Regional Director asked the DON to open the Administrator's office to find the documentation of the results of investigation. The DON had only the SOC 341 which was already submitted via fax by the Administrator dated 10/10/24, to the CDPH, L&C Program. The DON called the Administrator to inquire again if she had the facility's investigation regarding Resident 2's Court Investigator's allegation on possible financial abuse from Resident 2's family member. The Administrator called back and verified their facility's internal investigation was still ongoing, more than five working days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to maintain a homelike environment for one of three sampled residents (Resident 3) and one nonsampled resident (Resident B).
* Residents 3 and B's rooms had peeled paint above the headboards of the residents' beds. This failure had the potential to negatively affect the residents' well-being.
Findings:
1. Review of the facility's P&P titled Resident Rights Personal Property revised 1/2012 showed to ensure the quality of life of all residents by allowing to create a home-like environment.
Medical record review for Resident 3 was initiated on 10/2/24. Resident 3 was admitted to the facility on [DATE].
On 10/2/24 at 1102 hours, an observation of Resident 3's room was conducted and found to have chipped paint on the wall above the resident's headboard.
On 10/2/24 at 1438 hours, an interview and concurrent observation was made with LVN 2. LVN 2 verified Resident 3's wall above the headboard had chipped paint.
2. Medical record review for Resident B was initiated on 10/2/24. Resident B was admitted to the facility on [DATE], and readmitted on [DATE].
On 10/2/24 at 1431 hours, a concurrent observation of Resident B's room and interview was conducted with CNA 2. CNA 2 verified Resident B's wall above the headboard had peeling paint.
On 10/2/24 at 1435 hours, a concurrent observation of Resident B's room and interview with LVN 3. LVN 3 verified Resident B's wall above the headboard had peeling paint.
On 10/2/24 at 1602 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. When asked if peeling paint on the walls of resident's room considered a homelike environment, the DON stated no. The DON stated the process would be to notify the maintenance faculty so it could be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and the facility P&P review, the facility failed to ensure food preferences were honored for one nonsampled resident (Resident 30). Resident 30 disliked Brussels sprouts and preferred nonfat milk but was served Brussels sprouts and low fat milk for lunch. This had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Dietary Profile and Resident Preference Interview revised 4/21/22, showed resident preferences would be reflected in the medical record and tray-card and updated in a timely manner. The Dietary Department would provide residents with meals consistent with their preferences and physician order as indicated on the tray card. If a preferred item was not available, a suitable substitute should be provided.
Medical record review for Resident 30 was initiated on 9/9/24. Resident 30 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 30's H&P examination dated 6/16/24, showed Resident 30 had the capacity to understand and make decisions.
On 9/9/24 at 1302 hours, a lunch observation was conducted in Resident 30's room. Resident 30's meal tray was observed with mashed potatoes with gravy, ground meat, and Brussels sprouts. An open carton of reduced fat milk was also observed on Resident 30's tray. However, review of Resident 30's meal ticket showed Resident 30 disliked Brussels sprouts and preferred nonfat milk. When asked, Resident 30 stated she did not like Brussels sprouts.
On 9/9/24 at 1305 hours, an interview and concurrent observation was conducted with MDS Coordinator 2. MDS Coordinator 2 verified the above findings and stated Resident 30 should have had an alternative vegetable on her tray. MDS Coordinator 2 was observed asking Resident 30 about her choice for alternative vegetable and left to place the order. MDS Coordinator 2 was then observed entering Resident 30's room with a carton of nonfat milk.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated the resident's food preferences and dislikes should be honored. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 63 was initiated on 9/9/24. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 63's POLST dated 10/8/22, under Section D, showed Resident 63 did not have an advance directive.
Review of Resident 63's Advance Healthcare Directive (AHCD) Acknowledgement Form dated 7/5/21, showed on 8/14/21, an advance directive was executed.
Review of Resident 63's Progress Notes showed an entry dated 8/14/21 at 0913 hours, documenting an advance directive was executed for Resident 63, and the Ombudsman and a witness at bedside. The note showed a copy of the advance directtive was placed in the resident's chart.
On 9/11/14 at 1215 hours, an interview and concurrent medical record review for Resident 63 was conducted with the SSD. The SSD stated the POLST form including Section D was completed by the nursing staff. The SSD stated if the resident formulated an advance directive, or an advance directive was obtained after the resident's admission, the Social Services would update the AHCD Acknowledgement Form. When asked, the SSD stated she did not inform the nursing staff of the update, and she did not update the POLST. The SSD verified the above findings and stated the POLST was inaccurate and should have been updated.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated as soon as the facility was aware and had obtained a copy of the resident's advance directive, the facility should update the POLST immediately to accurately reflect the resident's advance directive. The DON was informed and acknowledged the above findings.
Based on interview and medical record review, the facility failed to ensure the medical records for two of 19 final sampled residents (Residents 63 and 64) were accurate and complete.
* The facilty failed to ensure Resident 64's POLST form was complete.
* The facility failed to ensure Resident 63's POLST form was updated to reflect Resident 63 had an advance directive and a designated Health Care Agent.
These failures had the potential for the residents' care needs not being met as their medical information was incomplete.
Findings:
1. Medical record review for Resident 64 was initiated on 9/9/24. Resident 64 was readmitted to the facility on [DATE].
Review of Resident 64's POLST dated 7/9/24, under Section D, showed no information checked whether Resident 64 had an advance directive or health care agent.
Review of Resident 64's Advance Healthcare Directive (AHCD) Acknowledgement form dated 7/9/24, showed Resident 64 did not have an AHCD.
On 9/11/24 at 1214 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD acknowledged Resident 64's POLST was incomplete and should have been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the CDC's Infection Control Guidance: SARS-CoV-2 dated 6/24/24, the health care providers who enter the room of a patient with suspected or confirmed COVID-19 should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
Medical record review for Resident 75 was initiated on 9/9/24. Resident 75 was admitted to the facility on [DATE].
Review of Resident 75's Order Summary Report dated 9/10/24, showed a physician's order dated 9/1/24, for Standard, Droplet and Contact precautions for COVID-19 positive.
Review of Resident 75's Change in Condition Evaluation dated 9/1/24, showed Resident 75 was noted to have labored breathing and hoarseness. Upon testing Resident 75 for COVID-19, Resident 75 was COVID-19 positive.
On 9/10/24 at 1435 hours, RN 2 was observed entering Resident 75's room without wearing an N95 mask. RN 2 stated Resident 75's COVID-19 isolation was completed the day prior.
On 9/10/24 at 1448 hours, a follow-up interview was conducted with RN 2. RN 2 acknowledged he did not don an N95 while entering Resident 75's room and stated he knew he was required to wear an N95 mask.
On 9/11/24 at 1038 hours, an interview was conducted with IP 1. IP 1 stated Resident 75 was on COVID-19 isolation for 10 days and 9/10/24 was the 10th day. IP 1 stated the required PPE for COVID-19 isolation was to wear the N95 mask, face shield, goggles, gown, and gloves. The IP was informed and acknowledged the above findings.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infections.
* The facility failed to maintain an accurate infection control surveillance program for the months of January 2024 through August 2024. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications (medications used to treat infections). The facility failed to ensure the residents who exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log. The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection met the McGeer's criteria for true infection.
* The facility failed to ensure the infection control practices were implemented in the facility's laundry room.
* The facility failed to ensure RN 2 wore the appropriate PPE when entering a COVID-19 isolation room for Resident 75.
These failures have the potential risk for not identifying, managing, containing, and controlling the transmission of communicable disease within the facility.
Findings:
1. Review of the facility's P&P titled Infection Control- Policies & Procedures revised 1/1/12, showed the Quality Assessment and Assurance Committee, through the Infection Control Committee, oversees the implementation of infection control policies and procedures, and helps department heads ensure that they are implemented and followed. The objective of the facility's infection control policies and procedures is to prevent, detect, investigate, and control infections in the facility.
Review of the facility's P&P titled Infections Caused by Delivery of Healthcare Services-Identification revised 1/1/12, showed when an infection is identified the infection control coordinator confirms that the infection meets the criteria for an infection and works to identify if the infection developed in the facility.
Review of the facility's P&P titled Infection Control Surveillance revised 3/1/14, showed the licensed nurse would initiate the gathering of the surveillance data for each resident and document on Section A of the appropriate Surveillance Data Collection Form. The Infection Preventionist would review the Surveillance Data Collection Form initiated by the licensed nurse and determine if the infection was HAI or CAI. The IP would document accordingly on Section B of the appropriate Surveillance Data Collection Form.
1. Review of the facility's monthly Infection Control Surveillance Logs from January 2024 through August 2024 showed the following resident infection surveillance data for HAIs, CAIs, and Criteria Not Met.
- January 2024: a total of 35 cases, including 15 HAIs and 18 CAIs,
- February 2024: a total of 27 cases, including 14 HAIs and 10 CAIs,
- March 2024: a total of 41 cases, including 15 HAIs, 21 CAIs, and 1 Criteria Not Met,
- April 2024: a total of 30 cases, including 7 HAIs, 20 CAIs, and 3 Criteria Not Met,
- May 2024: a total of 24 cases, including 7 HAIs, 13 CAIs, and 3 Criteria Not Met,
- June 2024: a total of 32 cases, including 10 HAIs, 20 CAIs, and 1 Criteria Not Met,
- July 2024: a total of 25 cases, including 8 HAIs, 16 CAIs, and Criteria Not Met,
- August 2024: a total of 27 causes, including 14 HAIs, 11 CAIs and 2 Criteria Not Meet.
Further review of the facility's monthly Infection Control Surveillance Logs from January through August 2024 showed all residents determined to have either an HAI, CAI, or Criteria Not Met were also prescribed antimicrobial medications. There was no documented evidence the residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications were included in the monthly surveillance logs.
On 9/11/24 at 1420 hours, a concurrent interview, medical record review, and facility document review was conducted with IP 1. IP 1 stated she was responsible for conducting the surveillance of the resident infections in the facility. When asked about the facility's infection surveillance program, IP 1 stated a Surveillance Data Collection Form was completed for the residents admitted to the facility currently on antibiotics and for the residents at the facility with signs and symptoms of an infection and was prescribed antibiotics. IP 1 stated the Surveillance Data Collection Form was a two-part form, with Section A specific to the McGeer's criteria. IP 1 further stated once Section A of the form was completed, the IP would complete Section B, which determined whether the infection was a hospital-acquired infection (HAI, nosocomial infection), or a community-associated infection (CAI), and whether the infection met the McGeer's criteria for a true infection. IP 1 stated the information on the Surveillance Data Collection Form would then be documented into the monthly Infection Control Surveillance Log for tracking of infections. IP 1 was asked if the residents who exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection surveillance logs. IP 1 stated only the residents with infections and were prescribed antimicrobial medications were on the facility's monthly infection surveillance logs.
The Surveillance Data Collection Form for Residents 16, 47, 48, 77, 87, and 603 were reviewed with IP 1. The residents' Surveillance Data Collection Form showed the following documentation:
* For Resident 48, the report was completed on 7/23/24, and showed the following:
- The antibiotic treatment prescribed for Resident 48 was vancomycin (antibiotic) 10 ml four times a day for 10 days for c-diff (clostridium difficile, a bacteria which causes diarrhea and inflammation of the colon), started on 7/23/24, and the type of isolation documented was enhanced precautions
- Section B of the form was not completed by the IP to indicate whether the infection was an HAI, CAI, or DNMC (did not meet criteria).
* For Resident 47, the report was completed on 7/16/24, and showed the following:
- the antibiotic treatment prescribed for Resident 47 was Macrobid oral capsule 100 mg for urinary tract infection started on 7/7/24.
- Section B of the form was not completed by the IP to indicate whether the infection was an HAI, CAI, or DNMC.
* For Resident 16, the reports were completed on 5/29 and 6/27/24.
The 5/29/24 report showed the following:
- The antibiotic treatment prescribed for Resident 16 was meropenem intravenous 500 mg every eight hours for seven days for urinary tract infection, started on 5/26/24
- Section B of the form was not completed by the IP to indicate whether the infection was an HAI, CAI, or DNMC.
The 6/27/24 report showed the following:
- The antibiotic treatment prescribed for Resident 16 was Bactrim oral tablet 800-160 mg two times a day for 30 days for urinary tract infection started on 6/24/24.
- Section A, the McGeer's criteria tool was not filled out; however, it was determined to be an CAI.
* For Resident 603, the report was completed on 6/27/24, and showed the following:
- The antibiotic treatment prescribed for Resident 603 was Levaquin oral tablet 500 mg daily for pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making breathing difficult and painful) until 6/25/24.
- Under Section A, the McGeer's criteria tool was incomplete, indicating Resident 603 only met two out of three required criteria; however, it was determined to be a CAI.
* For Resident 77, the report was completed on 6/25/24, and showed the following:
- The antibiotic treatment prescribed for Resident 77 was azithromycin oral tablet 250 mg daily for five days for possible lung infiltration until 6/24/24.
- Under Section A, the McGeer's criteria tool was incomplete, indicating Resident 77 only met two out of three required criteria; however, it was determined to be a CAI.
* For Resident 87, the report was completed on 6/21/24, and showed the following:
- The antibiotic treatment prescribed for Resident 87 was meropenem intravenous 500 mg every eight hours for seven days for urinary tract infection, started on 6/14/24.
- Under Section A, the McGeer's criteria tool was incomplete, indicating Resident 87 only met one out of two required criteria; however, it was determined to be a HAI.
IP 1 verified the Surveillance Data Collection Form for Residents 16, 47, 48, 77, 87, and 603 were incomplete. IP 1 also verified the infections for Residents 77, 87, and 603 did not meet the McGeer's criteria for a true infection. IP 1 stated the Surveillance Data Collection Form completed for each resident should be complete and accurate and if results were pending, the IP should follow-up to ensure the form was completed.
On 9/11/24 at 1445 hours, an interview and concurrent record review for Resident 48 was conducted with IP 1. IP 1 was asked about the isolation for a resident being treated for c.diff. IP 1 stated if the resident was being treated for c.diff, then the resident should be on contact isolations. IP 1 verified Resident 48 was placed only on enhanced precaution. IP 1 was asked if Resident 48 was placed on contact precautions in July 2024. IP 1 reviewed Resident 48's medial record and stated there was no physician's order to place Resident 48 on contact isolation for c.diff infection in July 2024.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated the purpose of the facility's Infection Control Surveillance Log was for tracking and surveillance purposes. The DON stated the log should also include the residents with signs and symptoms of infection and were not prescribed antibiotics. The DON was informed and acknowledged the above findings.
Cross reference to F881.
2. On 9/10/24 at 0920 hours, an inspection of the laundry area and concurrent interview with Laundry Services Personnel 1 was conducted. The following was observed:
- two eyeglasses and an employee phone were on top of the clean table area where the clean clothes or linens were folded.
Laundry Services Personnel 1 verified the above finding and stated the items should not be on the table used to fold the clean laundry. Laundry Service Personnel 1 was observed removing the employee belongings from the table.
On 9/11/24 at 1544 hours, an interview was conducted with IP 1. IP 1 stated the clean laundry should be folded on the clean laundry table. IP 1 further stated the clean laundry table should be cleaned routinely and should not have any personal items on it.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection) for one of 19 final sampled residents (Resident 87) and three nonsampled residents (Residents 59, 77, and 603). This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.
Findings:
According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile (a type of bacteria that can cause diarrhea and inflammation of the colon), increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms.
Review the facility's P&P titled Antibiotic Stewardship revised 5/20/21, showed the facility will promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents. The IP (Infection Preventionist) will collect and analyze infection surveillance data, coordinate data collection, and monitor adherence to infection control policies and procedures. Further review of the facility's P&P showed the facility had chosen to use Revisited McGeer''s Criteria (2012) for surveillance. Antibiotic time-outs (ATO, a review process for all antibiotics prescribed in the facility, which prompts clinicians to reassess the ongoing need for an antibiotic after culture results are available) would be utilized when appropriate. The IP is responsible for tracking the following antibiotic stewardship processes:
- Surveillance and multi drug resistant organism (MDRO) tracking
- The antibiotic ordered, dose, route and ordering physician as well as the cost of the drug
- Whether or not the Resident's condition met McGeer's Criteria when the antibiotic was ordered
- If cultures were ordered
- Any changes in antibiotic orders during therapy
- Outcomes of antibiotic therapy
On 9/11/24 at 1420 hours, a concurrent interview and facility document review was conducted with IP 1. IP 1 stated she was responsible for conducting surveillance of residents with infections in the facility. IP 1 stated a Surveillance Data Collection Form was completed for each resident with signs and symptoms of an infection and were prescribed antibiotics at the facility, and also completed for the residents admitted to the facility on antibiotics. IP 1 stated Section A of the Surveillance Data Collection Form was used to determine if the residents' signs and symptoms of infection met the McGeer's criteria as a true infection. IP 1 stated the Infection Preventionist was responsible for completing Section B of the form to indicated whether the infection was an HAI, CAI, or DNMC (did not meet criteria). IP 1 further stated if the residents' signs and symptoms did not meet the McGeer's criteria and antibiotics were prescribed, then the physician would be notified to determine if the antibiotic should be discontinued or continued. IP 1 stated once the physician was informed, the IP nurse would document in the Antibiotic Time Out form.
Review of the facility's Monthly Antibiotic Stewardship Reports for June 2024 showed the following documentation:
- 9.3% HAI, census of 96 residents,
- 1 case of residents prescribed antibiotic who did not meet McGeer's criteria for infection.
Review of the facility's Monthly Antibiotic Stewardship Reports for July 2024 showed the following documentation:
- 9.2% HAI cases, census 98 residents,
- 1 case of residents prescribed antibiotic who did not meet McGeer's criteria for infection.
Review of the residents' Surveillance Data Collection Form for the months of June and July 2024 was conducted with IP 1. After reviewing the resident's Surveillance Data Collection Forms, the IP verified Residents 77 and 87 (June 2024) and Resident 603 (July 2024) did not meet Mc Geer's criteria for a true infection, were prescribed antibiotics, and were not indicated as DNMC in Section B of the Residents' Surveillance Data Collection Forms. Furthermore, Resident 87's Surveillance Data Collection Form was completed on 6/21/24. Resident 87 had been started on antibiotics on 6/14/24, and Resident 87's Surveillance Data Collection Form showed a urine culture was not obtained.
IP 1 also verified Resident 59 (July 2024) did not meet McGeer's criteria for a true infection and the resident was prescribed antibiotics. IP 1 was asked to show the documentation that the physicians had been notified when the infection criteria were not met for the above residents. IP 1 reviewed the medical records for the above residents and stated she was unable to provide the documentation.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated the purpose of the facility's Infection Control Surveillance Form was for tracking and surveillance purposes and the monthly Surveillance Logs should be complete and accurate to reflect the numbers of HAIs, CAIs, and infections that did not meet criteria in the facility. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 69 was initiated on 9/9/24. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE].
On 9/9/24 at 0845 and 1010 hours, Resident 69 was observed lying on a low air loss mattress bed and the pump had a red light blinking. Resident 69 had alternating pump of low air loss mattress malfunctioned and the alarm was muted.
On 9/9/24 at 1240 hours, MDS Coordinator 1 was summoned to Resident 69's room. Resident 69's alternating pump for the low air loss mattress was malfunctioned and the alarm was muted. MDS Coordinator 1 was tried to unmute the alarm and the alarm kept beeping. MDS coordinator verified the finding.
On 9/12/24 at 1110 hours, an interview was conducted with LVN 2. LVN 2 stated he checked all the low air loss mattress every morning. LVN 2 stated he was not aware of any low air loss mattress pump malfunction or any muted alarms.
Based on observation and interview, the facility failed to ensure essential kitchen equipment was maintained in proper working condition when:
* The ice machine located in the kitchen was not clean and the manufacturer guidelines were not followed.
* The walk-in freezer floor was not in a cleanable condition.
* The facility failed to ensure the low air loss matress for Resident 69 was functioning properly.
These failures had the potential for essential equipment to not function in the way it was intended.
Findings:
According to the USDA Food Code 2022 Section 4-601. 11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-Contact surfaces, and utensils shall be clean to the sight and touch.
Review of the ice machine manufacturer guidelines (undated) located on the interior cover of the ice machine showed in part, Scale Removal and Sanitizing Instructions: .7. Mix a cleaning solution of one ounce ice machine scale remover [Scotsman Clear 1 ice machine scale remover] to 12 ounces of water. 8. Locate curtain, push in on edge of curtain by pivot pin to release it. Pull curtain out of machine .10. Locate ice thickness sensor. Squeeze mounting legs together to release sensor. 11. Wash the sensor and the adjustment screw with ice machine scale remover solution, rinse with clean water. Also wash the water distributor and curtain with the ice machine cleaner solution. 12. Locate water level sensor. Squeeze catches together and pull up to remove sensor. 13. Separate probes from housing and wash all surfaces with ice machine scale remover solution. Rinse and return probes to holder. 14. Create a solution of sanitizer by mixing one gallon or four-liter solution of locally approved sanitizer and clean, warm water. Use an EPA approved food equipment sanitizer at the solution mix recommended by the sanitizer manufacturer .15. Thoroughly wash all surfaces of the ice thickness sensor, water level sensor, curtain and water distributor with the sanitizer solution. 16. Wash all interior surfaces of the freezing compartment, including evaporator cover and right-side panel liner with the sanitizing solution. 17. Return water level sensor, ice thickness sensor, water distributor and curtain to their normal positions. Be sure water level sensor and ice thickness sensor are completely dry. 18. Push and release the Clean button. The yellow Clean light will blink, and the display will show C. The machine will go through a harvest cycle, drain the reservoir and begin to refill it .20. Pour the sanitizing solution into the reservoir until it is full. The unit will circulate the sanitizer, then drain and flush it. This will take 35 minutes .
On 9/9/24 at 0829 hours, an observation of the ice machine located in the kitchen and concurrent interview was conducted with the Maintenance Assistant (MA) using the DSS as a translator. The MA stated he cleaned the ice machine monthly. Upon removal of the ice machine harvester curtain (a plastic panel that directed ice from the ice harvester to ice storage bin) a rubber strip attached to the harvester curtain was observed not intact. The rubber strip had a white residue that was flaking off. The MA stated the white residue was dried glue that was used to attach the rubber strip to the harvester curtain. The MA confirmed the rubber strip should be replaced. The ice machine chute (section of the ice machine that directs the ice from the ice harvester to the ice storage bin) was observed with a grayish, white residue. The DSS and MA agreed the ice machine chute was not clean and the ice machine would be taken out of service.
The MA was asked to describe the process he used to clean the ice machine. The MA stated he mixed one ounce of [Scotsman Clear 1 ice machine scale remover] with 32 ounces of water then ran the cleaning solution through the machine on the clean cycle. The MA stated he removed the internal components of the ice machine and sprayed the internal components with hot water. The MA stated he also sprayed the ice storage bin and ice chute with hot water. The MA was asked if he had read the ice machine manufacturer's instructions located on the inside cover of the ice machine. The MA stated he had not read the ice machine manufacturer's instructions because they were in English. The MA stated he used the kitchen sanitizing solution to clean the ice storage bin. The MA stated he added water to the kitchen sanitizing solution once it was dispensed from the sanitizing solution dispensing nozzle. The MA stated after rinsing the ice storage bin with the diluted kitchen sanitizing solution, he rinsed the ice storage bin with hot water.
1. According to the USDA Food Code 2022 Annex 3 Section 4-201.11 Equipment and Utensils showed, Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents.
On 9/09/24 at 0758 hours, an observation of the walk-in freezer was conducted with the DSS. The floor of the walk-in freezer had black anti-slip tape on the small ramp leading to the freezer floor. The black anti-slip tape was not intact which exposed the metal floor underneath. The metal floor underneath the black anti-slip tape had a hard thick brown residue which resembled rust. The walk-in freezer floor beyond the small ramp was composed of linoleum. The linoleum was cracked with a brown residue and not intact. The DSS confirmed the observation and stated the maintenance was aware of the problem.
On 9/09/24 at 0930 hours, an observation of the walk-in freezer floor and concurrent interview was conducted with the Maintenance Director. The Maintenance Director stated he was not aware of the freezer floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for six of six residents (Residents 45, 47, 63, 64, 78, and 601) who were reviewed for grab bar use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.
Findings:
According to the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:
- Zone 1: within the rail;
- Zone 2: under the rail, between the rail supports or next to a single rail support;
- Zone 3: between the rail and the mattress;
- Zone 4: under the rail, at the ends of the rail;
- Zone 5: between split bed rails;
- Zone 6: between the end of the rail and the side edge of the head or foot board; and
- Zone 7: between the head or foot board and the mattress end.
Review of the facility's P&P titled Bed Rails revised 11/16/22, showed the facility's maintenance team is responsible for installing the bed rails. The entrapment zone review will focus on the following: any gaps that exist between the mattress, bed frame or bed rail that is wide enough to entrap the resident's head, body, arm or legs. The maintenance department will routinely inspect the beds and bed rails for preventive maintenance, safety standards and assess for need for repair. Annual bed measurement inspections to review and document entrapment areas in accordance with the FDA's Potential Zones.
1. Medical record review for Resident 64 was initiated on 9/9/24. Resident 64 was readmitted to the facility on [DATE].
Review of Resident 64's H&P Examination dated 7/9/24, showed Resident 64 had the capacity to understand and make decisions.
Review of Resident 64's Order Summary Report failed to show a physician's order for the use of bilateral bed grab bars.
Review of Resident 64's Bed Rail assessment dated [DATE] and 7/9/24, showed there were no siderail or assist bars indicated at this time for Resident 64.
However, on 9/9/24 at 1054 hours and 9/11/24 at 0831 hours, Resident 64's bed was observed to have bilateral grab bars installed on the bed.
On 9/11/24 at 0913 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 64 used the bilateral bed grab bars for repositioning and turning. LVN 1 was informed of and verified the above findings.
On 9/11/24 at 0947 hours, an interview and concurrent facility document review for Resident 64 was conducted with the Maintenance Director. The Maintenance Director stated he was responsible for the entrapment assessment of the facility's beds with side rails. The Maintenance Director stated he checked the entrapment zones on the bed once a year and would use the Bed System Measurement Device Test Results Worksheet for the beds with side rails. The Maintenance Director stated he did not measure or document the entrapment zones for the use of grab bars and would only check the gap between the mattress space and the grab bar.
On 9/12/24 at 1710 hours, the DON and Administrator were informed and acknowledged the above findings.
Cross reference to F700, example #1.
2. On 9/12/24 at 0902 hours, Resident 45 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 45 was initiated on 9/12/24. Resident 45 was admitted to the facility on [DATE].
Review of Resident 45's Bed Rail assessment dated [DATE], showed the side rails/assist bar were indicated and served as an enabler to promote independence. Resident 45 had expressed a desire to have side rails/assist bar.
However, further review of the medical record for Resident 45 failed to show a documentation for the entrapment assessment prior to Resident 45's use of bilateral grab bars.
Cross reference to F700, example #2.
3. On 9/12/24 at 0921 hours, Resident 47 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 47 was initiated on 9/12/24. Resident 47 was admitted to the facility on [DATE].
Review of Resident 47's Bed Rail assessment dated [DATE], showed Resident 47 did not express a desire to have side rails/assist bar for safety and/or comfort and side rails/assist bar are not indicated at this time.
Further medical record review for Resident 47 failed to show a documentation for the entrapment assessment prior to Resident 47's use of the bilateral grab bars.
Cross reference to F700, example #3.
4. On 9/12/24 at 0945 hours, Resident 63 was observed in bed with a grab bar on the left side of the bed elevated.
Medical record review for Resident 63 was initiated on 9/12/24. Resident 63 was admitted on [DATE].
Review of Resident 63's Bed Rail assessment dated [DATE], showed the side rails/assist bar were indicated and served as an enabler to promote independence. Resident 63 had expressed a desire to have side rails/assist bar.
However, further review of the medical record for Resident 63 failed to show documentation for the entrapment assessment completed for the use of grab bar on the left side of the bed.
5. On 9/12/24 at 1002 hours, Resident 78 was observed in bed with a grab bar on the left side of the bed elevated.
Medical record review for Resident 78 was initiated on 9/12/24. Resident 78 was readmitted to the facility on [DATE].
Review of Resident 78's Bed Rail assessment dated [DATE], showed Resident 78's left side rail placement was indicated and served as an enabler to promote independence. Resident 78 had expressed a desire to have side rails/assist bar.
Further medical record review for Resident 78 failed to show a documentation of the entrapment assessment prior to Resident 78's use of the grab bar on the left side of the bed.
Cross reference to F700, example #4.
6. On 9/12/24 at 1016 hours, Resident 601 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 601 was initiated on 9/12/24. Resident 601 was readmitted to the facility on [DATE].
Review of Resident 601's Bed Rail assessment dated [DATE], showed Resident 601 did not express a desire to have side rails/assist bar for safety and/or comfort and the side rails/assist bar were not indicated at this time.
Further medical record review for Resident 601 failed to show a documentation of the entrapment assessment prior to Resident 601's use of the bilateral grab bars.
On 9/11/24, an interview was conducted with the Maintenance Director. The Maintenance Director verified there was no documentation of measurements for the grab bars.
The DON acknowledged the above findings.
Cross reference to F700, example #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of four sampled residents (Resident 76) reviewed for the use of indwelling urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). The facility failed to ensure Resident 76's urinary catheter collection bag was inside the privacy bag. This failure had the potential to negatively impact Resident 76's emotional well-being.
Findings:
On 9/9/24 at 0849 hours, during the initial tour of the facility, Resident 76 was observed lying in bed with an indwelling urinary catheter draining yellow urine into a urine collection bag. The urine collection bag was observed hanging on the right side of Resident 76's bed, not inside the privacy bag.
On 9/9/24 at 0853 hours, an interview and concurrent observation was conducted with CNA 2. CNA 2 verified the above finding. CNA 2 stated the urine collection bag should be inside the privacy bag for the resident's privacy. CNA 2 was then observed donning gloves and placing the urine collection bag inside the privacy bag.
Medical record review for Resident 76 was initiated on 9/9/24. Resident 76 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 76's H&P examination dated 11/28/23, showed Resident 76 was able to make some of his needs known, but he was not able to make his own decisions.
Review of Resident 76's Order Summary for September 2024 showed a physician's order dated 7/18/24, for the placement of a 16 Fr indwelling/suprapubic catheter (a tube used to drain urine from the bladder through a small incision in the lower abdomen) with balloon via gravity drainage for benign prostatic hyperplasia (a noncancerous condition that occurs when the prostate gland enlarges).
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated for all the residents with the indwelling urinary catheters, she expected all the catheter collection bags to be inside the privacy bag to provide the residents with dignity. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was within reach for three of 19 final sampled residents (Residents 16, 38, and 76) and two nonsampled residents (Residents 39 and 61). This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care and services to the residents.
Findings:
Review of the facility's P&P titled Communication-Call System revised 1/1/12 showed the facility will provide a call system to enable the residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the resident's reach in the resident's room.
1. Medical record review for Resident 16 was initiated on 9/9/24. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE].
On 9/9/24 at 0800 hours, Resident 16 was observed with the call light clipped on edge of the head of the bed. When asked if she could reach the call light to ask for staff assistance, Resident 16 stated she could not reach it.
2. Medical record review for Resident 38 was initiated on 9/9/24. Resident 38 was admitted to the facility on [DATE], and readmitted on [DATE].
On 9/9/24 at 0820 hours, Resident 38 was observed with the call light placed underneath the pillow. When asked if he could reach call light to ask for staff assistance, Resident 38 state he could not reach it.
On 9/9/24 at 0925 hours, an observation and concurrent interview was conducted with LVN 7 for Residents 16 and 38. Resident 16 was observed with the call light clipped on the head of the bed and out of Resident 16's reach. Resident 38 was observed with the call light underrneath the pillow. LVN 7 verified the findings.
4. On 9/10/24 at 0845 hours, Resident 39 was observed awake and in bed. Resident 39's call light button was observed on the top of the bedside drawer. The call light button was not within Resident 39's reach. When Resident 39 asked about his call light button, he was made aware the call light button was on the top of the bedside drawer and he was not able to reach it.
On 9/10/24 at 0847 hours, MDS Coordinator 3 was summoned inside Resident 39's room. MDS Coordinator 3 verified the call light button for Resident 39 was placed on top of the bedside drawer. MDS Coordinator 3 stated the call light button should have been placed near the resident so he could call the staff when he needed assistance.
5. On 9/9/24 at 0808 hours and 9/10/24 at 0853 hours, Resident 61 was observed awake and in bed. Resident 61's call light cord was clipped to the wire cord on the wall at the head of the bed with the call light button hanging. The call light button was not within Resident 61's reach .
On 9/10/24 at 1331 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 verified the call light button was not within Resident 61's reach.
On 9/12/24 at 1417 hours, an interview for Resident 39 and 61 was conducted with the DON. The DON was informed and acknowledged the above findings.
3. On 9/9/24 at 0849 hours, during the initial tour of the facility, Resident 76 was observed lying in bed. Resident 76's call light was observed on top of the bedside drawer, to the left side of Resident 76's bed.
Medical record review for Resident 76 was initiated on 9/9/24. Resident 76 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 76's H&P examination dated 11/28/23, showed Resident 76 was able to make some of his needs known, but he was not able to make his own decisions.
Review of Resident 79's MDS dated [DATE], showed Resident 76 required dependent assistance for bed mobility, which included rolling from left to right, sit to lying, and lying to sitting on the side of the bed.
On 9/9/24 at 0853 hours, an interview and concurrent observation was conducted with CNA 2. CNA 2 verified Resident 76's call light was on top of the bedside drawer. CNA 2 stated the call light should be within the resident's reach. CNA 2 was observed placing Resident 76's call light within the resident's reach.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated she expected the call lights to be placed within the residents' reach. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 351 was initiated on 9/9/24. Resident 351 was admitted to the facility on [DATE].
Review of Resident 351's MDS dated [DATE], showed Resident 351 had severe cognitive impairment.
Review of Resident 351's POLST form prepared on 8/24/24, under Section D, failed to show if Resident 351 had or did not have an advance directive.
Further medical record review for Resident 351 failed to show documented evidence the formulation of an advance directive was offered to Resident 351's representative.
On 9/11/24 at 1215 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the above finding and stated there should have been documented evidence the advance directive information was offered and if the resident representative accepted or denied the formulation of an advance directive.
On 9/12/24 at 1417 hours, an interview and concurrent medical record review for Resident 351 was conducted with the DON. The DON was informed and verified the above findings.
3. Medical record review for Resident 45 was initiated on 9/9/24. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 45's H&P examination dated 6/13/24, showed Resident 45 had the capacity to understand and make decisions.
Review of Resident 45's Quarterly MDS dated [DATE], showed Resident 45 was cognitively intact.
Review of Resident 45's Physician Orders for Life Sustaining Treatment (POLST) dated 2/14/22, showed under Section D, Resident 45 had no advance directive.
However, review of Resident 45's Advance Directive Acknowledgment form, (undated), showed Resident 45 had no advance directive and would like more information.
Review of the Social Services progress notes from 12/21 to 7/24, failed to show documented evidence when Resident 45 was offered information on how to formulate an advance directive.
On 9/11/24 at 1224 hours, an interview and concurrent medical record review was conducted the SSD. The SSD verified the Advance Directive Acknowledgment form was undated and stated it should have been dated to verify when the information on how to formulate an advance directive was offered to Resident 45.
On 9/11/24 at 1240 hours, a follow-up interview and concurrent medical record review was conducted with the SSD. The SSD verified there was no documentation to show when Resident 45 was offered information on how to formulate an advance directive.
4. Medical record review for Resident 601 was initiated on 9/9/24. Resident 601 was readmitted to the facility on [DATE].
Review of Resident 601's Advance Healthcare Directive (AHCD) Acknowledgement Form dated 1/31/22, showed Resident 601 had an AHCD in place and a copy was requested by the facility.
Review of Resident 601's medical record failed to show a copy of the AHCD was maintained in the resident's medical record.
On 9/11/24 at 1214 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated she was responsible for completing the Advance Healthcare Directive Acknowledgement Forms and if the resident had an AHCD in place, she would request for a copy to keep in their medical record.
On 9/11/24 at 1601 hours, a follow-up interview was conducted with the SSD. The SSD verified Resident 601 did not have a AHCD maintained in her medical record and there was no follow up to obtain a copy of Resident 601's AHCD.
Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the advance directives (legal document of a person's wishes regarding medical care when the person is no longer able to make medical decisions), and obtain and/or maintain copies of the advance directives in the medical records for five of 19 final sampled residents (Residents 17, 45, 76, 351, and 601). These failures had the potential for the residents' decisions regarding their healthcare and treatment not being honored.
Findings:
Review of the facility's P&P titled Advance Directive revised 7/25/24, showed upon admission, the admissions staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. During the Social Service Assessment process, the Director of Social Services or designee will also ask the resident if they have a written advance directive. If the resident has an advance directive, the facility shall request a copy of the document from the resident or resident's representative. If the resident does not have an advance directive and additional information was requested, the SSD or designee may provide the resident with a copy of the advance directive form for their review.
1. Medical record review for Resident 17 was initiated on 9/9/24. Resident 17 was admitted to the facility on [DATE].
Review of Resident 17's Social Services assessment dated [DATE], under the Advance Directive section, showed Resident 17 had an advance directive and a copy from the resident/resident representative was requested.
Review of Resident 17's medical record failed to show a copy of Resident 17's advance directive.
Review of Resident 17's Progress Notes failed to show documentation the facility had followed up to obtain a copy of Resident 17's advance directive.
On 9/11/24 at 1215 hours, an interview was conducted with the SSD. The SSD stated upon admission the resident/resident representatives were asked if the resident had an advance health care directive in place. If the resident did, the facility would request for a copy to keep in the resident's medical records.
On 9/11/24 at 1600 hours, a follow-up interview and concurrent record review for Resident 17 was conducted with the SSD. The SSD verified the above findings. The SSD reviewed the Social Service Notes and stated there was no documentation to show the facility had followed up to obtain Resident 17's advance directive. The SSD further stated the facility did not have a system and should establish a system to notify the facility of the residents who required a follow-up to obtain their advance directive.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated upon admission, if the resident had an advance directive, the facility would request a copy and the Social Services department would be responsible to follow-up to obtain the copy. The DON further stated the Social Services department should continue to follow up and document their attempts until they were able to obtain the residents' advance directive. When asked about the importance of obtaining the residents' advance directive, the DON stated the advance directive was the wishes of the residents and the facility should ensure the residents' wishes were honored. The DON was informed of and acknowledged the above findings.
2. Medical record review for Resident 76 was initiated on 9/9/24. Resident 76 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 76's H&P examination dated 11/28/23, showed Resident 76 was able to make some of his needs known, but he was not able to make his own decisions.
Review of Resident 76's Social Services Assessments dated 12/6/23 and 7/24/24, under the section for Advance Directive, showed none of the options was selected.
Review of Resident 76's medical record failed to show documentation Resident 76 or his representative was offered literature on how to formulate an advance directive.
On 9/11/24 at 1215 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated upon admission, the residents/resident representatives were asked if the resident had an advance directive in place. If the resident did not have an advance directive and had no capacity to make decisions but wished to formulate an advance directive, the facility would still provide information about advance directions and how to formulate one. The SSD further stated each resident should have an Advance Health Care Directive (AHCD) Acknowledgement form in their medical record to indicate the resident received information regarding advance directives. The SSD verified the above findings. The SSD reviewed Resident 76's medical record and verified Resident 76 did not have an AHCD Acknowledgement form in his medical record.
On 9/11/24 1559 hours, a follow-up interview and concurrent medical record review for Resident 76 was conducted with the SSD. The SSD stated there was no documentation in the resident's medical record to show the facility had followed up regarding whether Resident 76 had an advance directive or wanted additional information to be provided.
On 9/12/24 at 1421 hours, and interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record upon discharge for one of two closed records reviewed (Resident 99). This failure posed the risk for not identifying discrepancies or differences in Resident 99's pre-discharge and post-discharge medication orders, which had the potential to negatively affect Resident 99's well-being.
Findings:
Review of the facility's P&P titled Discharge and Transfer of Residents revised 2/2018 showed the following:
- The discharge summary/post discharge plan of care will contain a summary of the resident's status, including a description of the resident's: Drug therapy, licensed nurse's discussion with the resident/resident representative regarding his/her pre-SNF placement medications, and reconciliation to post discharge medication regimen.
- The discharge summary/post discharge plan will include documentation from the IDT regarding transfers or discharges, and the following information: Medications, including all prescription and over-the-counter medications to be taken by the resident with information on dosage, frequency of administration, and recognition of common significant side-effects.
Closed medical record review for Resident 99 was initiated on 9/10/24. Resident 99 was admitted to the facility on [DATE], and discharged home on 6/14/24.
Review of Resident 99's Order Summary Report dated 9/11/24, showed the physician's orders for medications that Resident 99 was receiving in the facility. The physician's orders included medications such as apixaban (blood thinner), atorvastatin (medication to lower cholesterol), furosemide (medication to decrease fluid retention), insulin, and several medications to lower blood pressure.
Review of Resident 99's medical record failed to show documented evidence a medication reconciliation had been completed upon Resident 99's discharge on [DATE].
On 9/11/24 at 1143 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator 2. The MDS Coordinator 2 was informed and verified the above findings. The MDS Coordinator 2 verified the discharge nurse would complete and document the medication reconciliation.

Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when:
* A food preparation sink did not have a backflow prevention.
* A rack used to dry plate covers was not clean.
* Resident 64's room was observed with perishable food items brought from the outside.
These failures posed the risk for cross contamination which could lead to food poisoning in the 83 residents who consumed food from the kitchen.
Findings:
Review of the facility matrix showed 83 of 93 residents consumed food from the kitchen.
1. According to the USDA Food Code 2022 Section 5-402.11 Backflow Prevention, (A) .a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
On 9/9/24 at 1140 hours, an observation of the plumbing of a food preparation sink located adjacent to the DSS's office and concurrent interview was conducted with the Maintenance Assistant. The drain pipe of the food preparation sink did not have backflow prevention. The Maintenance Assistant verified the finding and stated the drain previously had backflow prevention but it had been removed.
2. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
On 9/9/24 at 0910 hours, an observation of a rack used to dry plate covers and concurrent interview was conducted with the DSS. The drying rack had a greasy residue and food debris. The DSS verified the finding and asked the kitchen staff to clean the drying rack.
3. Review of the facility's P&P titled Food Brought in by Visitors revised 6/2018 showed perishable food requiring refridgeration will be discarded after two hours at bedside.
On 9/9/24 at 1054 hours, an observation and concurrent interview was conducted with Resident 64. Resident 64's bedside table, nightstand, and cart to the left side of his bed were observed filled with food items, including opened cans of soda, bagged bread, and a block of cheese. Resident 64 stated the cheese on his bedside table needed to be in the refrigerator.
On 9/11/24 at 0911 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 64's family provided Resident 64 with food from the outside. LVN 1 stated for food items in the room, the items should be sealed and kept in the refrigerator if they needed to keep it in the refrigerator. LVN 1 was informed and acknowledged the above findings. LVN 1 stated the cheese should be refrigerated.
On 9/11/24 at 0925 hours, a follow-up observation was conducted for Resident 64. The block of cheese was observed on Resident 64's bedside table.
On 9/11/24 at 0944 hours, an interview was conducted with MDS Coordinator 2. MDS Coordinator 2 was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for two of two residents reviewed for IV access (Residents 89 and 600).
* The facility failed to ensure the PICC line external catheter measurements were performed and documented in the medical record upon admission for Resident 600.
* The facility failed to ensure the IV antibiotic medication was properly labeled for Resident 89.
These failures had the potential to delay the identification of catheter related complications for the residents.
Findings:
Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed in part, the length of the external catheter is obtained upon admission, during dressing changes, if signs or symptoms of complications are present. Documentation in the medical record includes but is not limited to date and time, site assessment, length of external catheter .
1. Medical record review for Resident 600 was initiated on 9/9/24. Resident 600 was admitted to the facility on [DATE].
Review of Resident 600's Order Summary Report dated 9/11/24, showed the following physician's orders:
- dated 9/11/24, for TPN at 150 ml/hr for 12 hours via PICC line.
- dated 8/21/24, to measure the arm circumference and external lumen catheter weekly every day shift, every seven days.
Further review of Resident 600's medical record failed to show documented evidence the measurement of the external catheter length for Resident 600's PICC line was obtained upon admission.
On 9/12/24 at 1018 hours, an interview and concurrent record review was conducted with RN 2. RN 2 verified he was responsible for the IV maintenance in the facility. RN 2 was informed and verified Resident 600's medical record did not show the PICC line external catheter measurement was obtained upon admission.
2. Review of the facility's P&P titled Administration of an Intermittent Infusion dated 3/23 showed the RN should label the IV container and administration set with date, time and nurses initials when administering IV medications to the residents with an IV medication physician's order.
During the initial tour of the facility on 9/9/24 at 0809 hours, Resident 89 was observed in bed awake, receiving IV antibiotic medication at a rate of 150 ml/hr via a rotary dial regulator. However, Resident 89's IV medication bag was unlabeled and undated.
On 9/9/24 at 0907 hours, an observation and concurrent interview for Resident 89 was conducted with RN 2. RN 2 was summoned to Resident 89's bedside and asked about the IV antibiotic medication for the resident. RN 2 verified Resident 89 was receiving an IV antibiotic medication. RN 2 verified the IV antibiotic medication bag was undated and unlabeled. RN 2 stated he forgot to place the label on the IV medication bag.
Medical record review for Resident 89 was initiated on 9/10/24. Resident 89 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 89's Order Summary Report dated 9/11/24, showed a physician's order dated 8/8/24, to administer cefoxitin sodium (antibiotic medication) intravenously 2 gm three times a day for discitis of the lumbosacral region (infection of the spine).
On 9/12/24 at 1417 hours, an interview and concurrent medical record review for Resident 89 was conducted with the DON. The DON was informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 69 was initiated on 9/9/24. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE].
On 9/9/24 at 0845 hours, Resident 69 was observed lying in bed. Resident 69's CPAP (continuous positive airway pressure- machine used to provide air to gently keep the airway open during sleep) inner mask was observed touching the bedside table and the tubing was undated.
On 9/9/24 at 1240 hours, MDS Coordinator 1 was summoned to the room. Resident 69's CPAP inner mask was observed touching the bedside table and the tubing was undated. MDS Coordinator 1 verified the finding.
On 9/9/24 at 1400 hours, an interview was conducted with the Director of Central Supply. The Director of Central Supply stated the CPAP tubing and mask were replaced every Wednesday and the CPAP tubing should be dated. The Director of Central Supply stated the CPAP mask should be placed inside a plastic bag.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 58, and 351) and three nonsampled residents (Resident 69, 75, and 352) were provided with the appropriate respiratory care when:
* The facility failed to ensure Resident 58's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P and stored in a set up bag when not in use.
* The facility failed to ensure Resident 351's nebulizer mask and tubing were stored in a set up bag when not in use. In addition, the facility failed to formulate a plan of care for the use of the nebulizer therapy.
* The facility failed to ensure Resident 352's oxygen tubing was not touching the floor.
* The facility failed to ensure Resident 75's nebulizer mask and tubing were stored in a set up bag when not in use
* The facility failed to ensure Resident 69's CPAP mask was stored in a set up bag when not in use.
These failures had the potential to affect the respiratory health and well-being of the residents in the facility.
Findings:
Review of the facility's P&P titled Oxygen Therapy revised November 2017 showed the facility to ensure a safe storage and administration of oxygen to the residents with a physician's order. It is the facility's protocol to administer oxygen under safe and sanitary conditions to meet the residents need. In addition, the oxygen tubing, mask, and cannulas will be changed every seven days and as needed, the supplies will be dated each time they are changed.
1. During the initial tour of the facility on 9/9/24 at 0906 hours, Resident 58 was observed receiving oxygen therapy at 2 liters per minute via nasal cannula attached to an oxygen machine. A portable oxygen tank at the back of Resident 58's wheelchair with an oxygen nasal cannula tubing attached was observed undated, unlabeled, and not placed inside a set up bag.
On 9/10/24 at 1355 hours, Resident 58 was not in his room. However, the oxygen machine was turned on and the oxygen tubing nasal cannula was observed on top of Resident 58's bed .
Medical record review for Resident 58 was initiated on 9/10/24. Resident 58 was admitted to the facility on [DATE].
Review of Resident 58's Order Summary Report dated 9/11/24, showed a physician's order dated 1/13/24, to administer oxygen at 2 liters per minute via nasal cannula to keep the oxygen saturation level above 92% every shift.
On 9/10/24 at 1356 hours, an observation and concurrent interview for Resident 58 was conducted with LVN 1. LVN 1 verified Resident 58's use of oxygen therapy. LVN 1 verified Resident 58's nasal cannula tubing was unlabeled, undated, and not placed inside a set up bag when not in use.
2. On 9/9/24 at 1010 hours and 9/10/24 at 0810 hours, Resident 351 was observed in bed receiving oxygen therapy at 2 liters per minute via nasal cannula attached to an oxygen machine. Resident 351's nebulizer machine was observed on top of the bedside drawer and with the nebulizer mask placed on top of the machine.
On 9/10/24 at 1351 hours, an observation and concurrent interview with LVN 1. LVN 1 verified Resident 351's use of the nebulizer machine as needed for shortness of breath. LVN 1 stated after the administration of the breathing treatment via the nebulizer machine, the mask and tubing were placed in a set up bag at the bedside of the resident. LVN 1 verified the findings and stated the nebulizer mask and tubing should have been placed inside a set up bag.
Medical record review for Resident 351 was initiated on 9/10/24. Resident 351 was admitted to the facility on [DATE].
Review of Resident 351's Order Summary Report dated 9/11/24, showed a physician's order dated 9/5/24, to administer ipratropium-albuterol (bronchodilator -opening the airways in the lungs medication) inhalation solution 0.5-2.5 (3) mg/3 ml orally every four hours as needed for shortness of breath/wheezing for 30 days.
Review of Resident 351's plan of care failed to show documented evidence a care plan problem was developed to address Resident 351's use of the breathing treatment medication via nebulizer machine.
On 9/11/24 at 1459 hours, an interview and concurrent medical record review for Resident 351 was conducted with LVN 1. LVN 1 stated the charge nurses and the RNs were responsible in formulating a plan of care on each resident condition. LVN 1 verified Resident 351's use of nebulizer machine for breathing treatment. LVN 1 verified there was no plan of care for the use of the breathing treatment for shortness of breath/coughing.
3. On 9/10/24 at 1322 hours, an observation and concurrent interview for Resident 352 was conducted with RN 2 at the bedside. Resident 352's oxygen tubing was observed on the floor. RN 2 verified Resident 352's use of oxygen therapy. RN 2 was observed removing the nasal cannula tubing and replaced it with a new oxygen tubing.
Medical record review for Resident 352 was initiated on 9/11/24. Resident 352 was admitted to the facility on [DATE].
Review of Resident 352's Order Summary Report dated 9/11/24, showed a physician's order dated 9/7/24, to administer oxygen at 2 liters per minute via nasal cannula to keep the oxygen saturation level above 95% every shift for shortness of breath.
On 9/12/24 at 1417 hours, an interview and concurrent medical record review for Residents 58, 351, and 352 was conducted with the DON. The DON stated she expected the residents' oxygen tubing, nebulizer masks and tubing to be labeled and placed inside a set up bag when not in use. The DON was informed and verified the above findings.
4. On 9/9/24 at 1617 hours, and 9/10/24 at 1430 hours, Resident 75 was observed lying in bed. Resident 75's nebulizer mask and tubing were observed undated and placed on top of the nebulizer machine on her bedside table.
Medical record review for Resident 75 was initiated on 9/9/24. Resident 75 was admitted to the facility on [DATE].
Review of Resident 75's Order Summary Report dated 9/10/24, failed to show the physician's orders for medications which required the use of a nebulizer.
On 9/10/24 at 1439 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident 75's nebulizer mask and tubing should have been labeled and stored inside a plastic bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of one resident reviewed for pain management (Resident 600). The facility failed to ensure Resident 600 was monitored for side effects related to the use of the narcotic pain medication. Additionally, the facility failed to consistently provide non-pharmacological interventions for pain prior to the administration of a narcotic pain medication to Resident 600. These failures had the potential for not effectively managing the resident's pain.
Findings:
Review of the facility's P&P titled Pain Management revised 11/2016 showed the facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible. The nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Residents receiving medications for pain management will be monitored for side effects of the medication ordered.
1. Medical record review for Resident 600 was initiated on 9/9/24. Resident 600 was admitted to the facility on [DATE].
Review of Resident 600's H&P examination dated 8/22/24, showed Resident 600 had the capacity to understand and make decisions.
Review of Resident 600's Order Summary Report dated 9/11/24, showed the following physician's orders:
- dated 8/21/24, for Norco (a narcotic medication) 5-325 mg one tablet by mouth every four hours as needed for moderate pain.
- dated 8/21/24, for Norco 5-325 mg two tablets by mouth every four hours as needed for severe pain.
Further review of Resident 600's physician's orders failed to show an active order for non-pharmacological interventions nor a physician's order to monitor for the side effects of the Norco medication.
Review of Resident 600's MAR for September 2024 showed Resident 600 had received the Norco medication on 9/2, 9/6, 9/7, and 9/10/24. The MAR showed non-pharmacological interventions were being implemented only until 9/3/24.
On 9/12/24 at 1018 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 600 was receiving Norco medication for pain management. RN 2 stated non-pharmacological interventions should be given as long as the resident was receiving the narcotic medication. RN 2 verified the non-pharmacological interventions were stopped on 9/3/24, and stated when the facility did a reassessment of the pain management after 14 days, the non-pharmacological interventions were not reinstated. RN 2 verified there was no side effect monitoring ordered by the physician or completed for the Norco medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to complete the assessments, attempt the least restrictive alternative measures, obtain the physician's orders and informed consents, and initiate care plans for the use of side rails for five of six sampled residents reviewed for side rail use (Residents 45, 47, 64, 78, and 601). This failure had the potential to put the residents at risk for serious injuries.
Findings:
Review of the facility's P&P titled Bed Rails revised 5/2024 showed the facility will use bed rails as mobility enablers. Prior to the use of a bed rail, staff will attempt the use of appropriate alternatives. If the alternatives were not adequate to meet the resident's needs, the resident will be evaluated for the use of bed rails. Prior to the installation of bed rails, alternatives will be attempted. An evaluation of the tried alternatives and how they failed to meet the Resident's needs will be documented in the medical record. Prior to the installation of bed rails, the ordering physician will obtain informed consent from the resident or their representative. The licensed nurse will initiate a care plan around the use of bed rails.
1. On 9/9/24 at 1054 hours, and 9/11/24 at 0831 hours, Resident 64's bed was observed to have bilateral grab bars.
Medical record review for Resident 64 was initiated on 9/9/24. Resident 64 was readmitted to the facility on [DATE].
Review of Resident 64's H&P examination dated 7/9/24, showed Resident 64 had the capacity to understand and make decisions.
Review of Resident 64's Order Summary Report failed to show a physician's order for the use of bilateral bed grab bars.
Review of Resident 64's Comprehensive Care Plan failed to show a care plan problem was developed addressing the use of bilateral bed grab bars.
Review of Resident 64's Bed Rail assessment dated [DATE] and 7/9/24, showed there were no side rail or assist bars indicated at this time for Resident 64.
Further medical record review for Resident 64 failed to show documented evidence the least alternative measures were attempted; physician's order was obtained; informed consent was obtained; and assessment was completed prior to the use of the bilateral bed grab bars.
On 9/11/24 at 0913 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 64 used the bilateral bed grab bars for repositioning and turning. LVN 1 stated prior to using the grab bars, an assessment would be completed, and the rehabilitative staff would make a recommendation for the need of grab bars. LVN 1 stated for the use of grab bars, they needed a physician's order, informed consent, and care plan. LVN 1 was informed of and verified the above findings.
On 9/11/24 at 0934 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 stated Resident 64 needed partial assistance for his mobility. MDS Coordinator 2 was informed and verified the above findings.
On 9/12/24 at 1710 hours, the DON and Administrator were informed and acknowledged the above findings.
Cross reference to F700, example #1.
2. On 9/12/24 at 0902 hours, Resident 45 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 45 was initiated 9/12/24. Resident 45 was admitted to the facility on [DATE].
Review of Resident 45's H&P examination dated 6/13/24, showed Resident 45 had the capacity to understand and make decisions.
Review of Resident 45's Order Summary Report dated 9/12/24, showed a physician's order dated 6/14/24, for bilateral grab bars for bed mobility and repositioning.
Review of Resident 45's Bed Rail assessment dated [DATE], showed the side rails/assist bar were indicated and served as an enabler to promote independence. Resident 45 had expressed a desire to have side rails/assist bar.
Review of Resident 45's Care Plan revised 8/13/24, showed a care plan problem adressing the requested grab bars. The interventions included the bilateral grab bars for bed mobility assistance.
Further medical record review for Resident 45 failed to show an informed consent was obtained from the resident and/or representative prior to the use of grab bars.
On 9/12/24 at 0910 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 45 used the grab bars to hold on to during the diaper changes.
On 9/12/24 at 1349 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified there was no informed consent for the use of bilateral grab bars.
Cross reference to F700, example #2.
3. On 9/12/24 at 0921 hours, Resident 47 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 47 was initiated on 9/12/24. Resident 47 was admitted to the facility on [DATE].
Review of Resident 47's H&P examination dated 6/13/24, showed Resident 47 had the capacity to understand and make decisions.
Review of Resident 47's Order Summary Report dated 9/12/24, showed a physician's order dated 7/16/24, for bilateral grab bars to aid in bed mobility and repositioning.
Review of Resident 47's Bed Rail assessment dated [DATE], showed Resident 47 did not express a desire to have side rails/assist bar for safety and/or comfort and the side rails/assist bar were not indicated.
Review of Resident 47's care plan failed to show a care plan problem or intervention was developed for Resident 47's use of bilateral grab bars.
Further medical record review for Resident 47 failed to show an informed consent was obtained from the resident and/or representative prior to the use of bilateral grab bars.
On 9/12/24 at 1349 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified there was no informed consent for the use of bilateral grab bars.
On 9/12/24 at 1410 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified Resident 47's bed rail assessment did not match with the physician's order.
Cross reference to F700, example #3.
4. On 9/12/24 at 1002 hours, Resident 78 was observed in bed with grab bar on the left side of the bed elevated.
Medical record review for Resident 78 was initiated on 9/12/24. Resident 78 was readmitted to the facility on [DATE].
Review of Resident 78's H&P examination dated 1/22/24, showed Resident 78 had the capacity to understand and make medical decisions.
Review of Resident 78's Order Summary Report dated 9/12/24, showed a physician's order dated 4/17/24, for grab bar on the left side of bed to aid with bed mobility and repositioning.
Review of Resident 78's Bed Rail assessment dated [DATE], showed Resident 78's left side rail placement was indicated and served as an enabler to promote independence. Resident 78 had expressed a desire to have side rails/assist bar.
Review of Resident 78's Care Plan initiated on 4/17/24, showed an intervention for the use of left grab bar to maximize independence with turning and repositioning in bed.
Further medical record review for Resident 78 failed show an informed consent was obtained from the resident and/or representative prior to the use of left grab bar.
On 9/12/24 at 1002 hours, an interview was conducted with CNA 3. CNA 3 stated the grab bar at the left side of the bed of Resident 78 was used for repositioning.
On 9/12/24 at 1349 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified there was no informed consent for the use of left grab bar.
Cross reference to F700, example #5.
5. On 9/12/24 at 1016 hours, Resident 601 was observed in bed with bilateral grab bars elevated.
Medical record review for Resident 601 was initiated on 9/12/24. Resident 601 was readmitted to the facility on [DATE].
Review of Resident 601's H&P examination dated 1/24/24, showed Resident 601 had the capacity to understand and make decisions.
Review of Resident 601's Order Summary Report dated 9/12/24, showed a physician's order dated 7/12/24, for bilateral grab bars to aid in bed mobility and repositioning.
Review of Resident 601's Bed Rail assessment dated [DATE], showed Resident 601 did not express a desire to have side rails/assist bar for safety and/or comfort and side rails/assist bar were not indicated
Review of Resident 601's care plan failed to show a care plan problem or intervention was developed for Residen 601's use of the bilateral grab bars.
Further medical record review for Resident 601 failed to show an informed consent was obtained from the resident and/or representative prior to the use of bilateral grab bars.
On 9/12/24 at 1349 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified there was no informed consent for the use of bilateral grab bars.
On 9/12/24 at 1452 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the above findings.
Cross reference to F700, example #6.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of the residents when:
* The facility failed to ensure proper accounting and safeguarding of the controlled medications when the incoming and outgoing licensed nurses were not consistently signing the controlled count each shift for Medication Carts 1 and 3. This failure had the potential for drug diversion.
Findings:
Review of the facility's P&P titled Medication Storage in the Facility dated 8/2014 showed at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medications accountability record.
Review of the facility's Narcotic Book Guide titled Using the Brigg's Narcotic Record Book dated 2/2021 showed the oncoming licensed nurse will perform a narcotic inventory count at the change of shifts with the off-going licensed nurse according to the facility's policy and procedure. The two licensed nurses will:
-Verify and count each medication as listed according to the Index of the Narcotic Record Book
-Refer to the individual Narcotic Record page for the remaining amount for each listed resident and medication.
-Verify that the remaining amount recorded on the individual narcotic record page is consistent with the actual amount in the medication card or medication bottle.
-The on-coming Licensed Nurse and off-going Licensed Nurse will both sign the Controlled Drugs-Count Record located in the back of the Narcotic Record Book.
a. On 9/10/14 at 1420 hours, a medication cart inspection of Medication Cart 3 was conducted with LVN 8. During the medication cart inspection, the binder for controlled drugs count record for Medication Cart 3 was reviewed. During the review of the Controlled Drugs-Count Record log, the following dates were observed with missing signatures from the outgoing and incoming licensed nurses: 8/21, 8/22, 9/1, and 9/7/24. LVN 8 verified the above findings.
b. On 9/10/14 at 1430 hours, a medication cart inspection of Medication Cart 1 was conducted with LVN 1. During the medication cart inspection, the binder for controlled drugs count record for Medication Cart 1 was reviewed. During the review of the Controlled Drugs-Count Record log, the following dates were observed with missing signatures from the outgoing and incoming licensed nurses: 8/6, 8/18, 8/22, 8/24, 8/31, and 9/1/24. LVN 1 verified the above findings.
On 9/10/24 at 1453 hours, an interview and concurrent facility document review was conducted with the DON. The DON was informed and verified the above findings. The DON stated there should be signatures from both licensed nurses in the narcotic count book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one for five residents (Resident 17) reviewed for unnecessary medications was free from unnecessary psychotropic drugs. The facility failed to ensure Resident 17's orthostatic blood pressure was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for Resident 17 to have adverse complications from the medications.
Findings:
Review of the facility's P&P titled Behavior/Psychoactive Drug Management revised 1/25/24, showed when a resident is admitted with an antipsychotic medication(s), or a resident is prescribed an antipsychotic medication(s), the resident's orthostatic blood pressure is monitored weekly. Depending on the specific classification of psychoactive medication the resident should be observed and/or monitored for side effects and adverse consequences. All complications and side effects should be reported to the healthcare practitioner.
Review of the facility's P&P titled Orthostatic Hypotension revised 1/1/12, showed orthostatic vital signs will be taken and recorded when ordered by the physician, and when a sudden drop in blood pressure is suspected as the cause of resident falls, vertigo, feelings of dizziness, and similar occurrences. The procedure for taking orthostatic blood pressure is as follows:
a. In a lying down position use the appropriate size of BP cuff on the resident's arm and take his/her BP and heart rate. Record the numbers.
b. Have the resident stand up, taking precautions to ensure he/she does not fall.
c. Immediately take the resident's blood pressure and heart rate. Record the numbers.
d. Ask whether the resident is experiencing divineness. Record the response.
If the resident has a drop in systolic blood pressure greater than 10 mmHg and an increase in heart rate of 10 beats per minute when standing, check his/her medications for possible side effects. Notify the physician for possible medication adjustment.
Medical record review for Resident 17 was initiated on 9/9/24. Resident 17 was admitted to the facility on [DATE].
Review of Resident 17's Order Summary Report dated 9/12/24, showed the following physician's orders dated 8/28/24:
- to administer risperidone (antipsychotic medication) 0.25 mg one tablet by mouth in the morning for psychosis (a mental condition that causes people to lose touch with reality, making it hard to distinguish what's real and what's not) manifested by paranoid feelings causing fear;
- to administer risperidone 0.5 mg one tablet by mouth at bedtime for psychosis manifested by paranoid feelings causing fear;
- to monitor the orthostatic blood pressure in the lying position, every Wednesday during the day shift;
- to monitor the orthostatic blood pressure in the sitting position, every Wednesday during the day shift; and
- to monitor the orthostatic blood pressure in the standing position, every Wednesday during the day shift.
Review of Resident 17's MAR for September 2024 showed Resident 17 was administered risperidone 0.25 mg daily from 9/1/24 through 9/12/24 at 0900 hours, and risperidone 0.5 mg daily at bedtime from 9/1/24 through 9/12/24 at 2100 hours. Further review of the MAR for September 2024 showed orthostatic blood pressures (lying, sitting, and standing) were scheduled to be monitored every Wednesday. However, the blood pressure readings were documented as follows:
- On 9/4/24: the blood pressure readings were recorded as NA for the lying and sitting positions, and 121/60 mmHg for the standing position.
- On 9/11/24: the blood pressure readings were recorded as 121/67 mmHg for the lying position, 119/74 mmHg for the sitting position, and NA for the standing position.
On 9/12/24 at 0929 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 4. LVN 4 reviewed the medical record for Resident 17 and verified the above findings. LVN 4 stated there was no documentation in Resident 17's medical record to show why the nurses documented NA for the blood pressure readings for the above dates. LVN 4 further stated the blood pressure readings should not be documented as NA, and the blood pressure should have been obtained and compared as per the physician's order to monitor the blood pressure for orthostatic hypotension.
On 9/12/24 at 1421 hours, an interview was conducted with the DON. The DON stated the residents on antipsychotic medications should be monitored for potential side effects such as orthostatic hypotension. The DON stated monitoring for orthostatic hypotension was done by measuring the resident's blood pressure in different positions, and the blood pressures were then compared to determine if there was a drastic drop in the blood pressure, which could indicate orthostatic hypotension. When asked, the DON stated the staff should not document NA and the blood pressure reading should be obtained in the indicated positions and compared. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage in three of three medication storage rooms inspection when:
* The facility failed to ensure the discharged resident's syringes with needles were discarded and removed from Medication room [ROOM NUMBER].
* Four bottles of lactulose (medication to treat constipation) solution was stored next to 30 lidocaine patches in Medication room [ROOM NUMBER].
* The temperatures for three of three medication room refrigerators used to store medications in Medication rooms [ROOM NUMBER] were out of range.
These failures had the potential for the residents to receive ineffective medication dosages and negatively impact their well-being.
Findings:
Review of the facility's P&P titled Medication Storage in the Facility dated 8/2014 showed the following:
- Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medications, and recorded from the pharmacy if an order exists.
- Orally administered medications are kept separate from externally used medications.
- Medications requiring refrigeration or temperature between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.
1. On 9/9/24 at 1024 hours, during the inspection of Medication room [ROOM NUMBER] with IP 1 and RN 2 the following was observed:
-59 3 ml-syringes with 25-gauge needles in an open plastic bag labeled for Resident 603 were found on the medication room shelf.
-Four bottles of lactulose solution for Resident 88 was stored next to 30 patches of lidocaine 4 % for Resident 73 on the medication room shelf.
IP 1 and RN 2 verified the above findings. IP 1 verified Resident 603 was discharged from the facility on 7/5/24. IP 1 and RN 2 stated the syringes with needles should have been discarded in the pharmaceutical waste bin when Resident 603 was discharged . In addition, IP 1 and RN 2 stated the oral solution medication should not be stored next to the lidocaine patches.
2.a. On 9/9/24 at 1055 hours, an observation of the medication refrigerator temperature in Medication room [ROOM NUMBER] was conducted with IP 1 and RN 2. When IP 1 opened the medication refrigerator to check the temperature inside, IP 1 stated the medication refrigerator temperature was 64 degrees Fahrenheit. The following medications were observed in the refrigerator:
- TPN dextrose clinsol clinlipid IV parental
- 1 bottle of Vancomycin (antibiotic) 50 mg
- 18 capsules of dronabinol (an orally active cannabinoid) 5 mg capsules
- 3 Lantus insulin pen 100 u/ml
- 2 vials of Aplisol 5TU (purified protein derivation) 0.1 ml
- 2 vials of MVI (multivitamin supplement) 30 ml to be added to TPN
- 2 vials of Novulin R 100 units per vial
- 24 packets of Velstassa (for hypercholemia) oral suspension 8.4 grams
- 2 Insulin e-kits 2 - humlin N and humlin R humlog, 3 ml each, quantity=8 total, expiration date of 11/24
According to Lexicomp (pharmaceutical resource online), Aplisol, Lantus, and Velstassa are to be stored at 36-46 degrees Fahrenheit; and dronabinol is to be stored at 46 - 59 degrees Fahrenheit.
Review of the Medication Fridge and Room Temp Log inside Medication room [ROOM NUMBER] showed the medication refrigerator temperature range was 36 - 46 degrees Fahrenheit. The log also showed the temperature on 9/9/24, for the 7-3 (0700 hours to 1500 hours) shift was 38.1 degrees Fahrenheit. IP 1 stated she checked the medication refrigerator temperature at 0730 hours on 9/9/24. When asked, IP 1 did not know when the medication refrigerator was last opened. IP 1 stated the medication refrigerator temperature was too high and not within the range. RN 2 verified the findings.
b. On 9/9/24 at 1059 hours, an observation of the medication refrigerator temperature in Medication room [ROOM NUMBER] was conducted with IP 1, LVN 9, and RN 2. When IP 1 opened the medication refrigerator to check the temperature inside, IP 1 stated the medication refrigerator temperature was 55 degrees Fahrenheit. The following medications were observed in the refrigerator:
- 1 bottle of Vancomycin 50 mg, 80 ml in the bottle
- 2 injectable Ozempic (antidiabetic) 0.25 - 00.5 mg
- 2 injectable Ozempic 2 mg
- 1 injectable Ozempic 2 mg
- 1 injextable Ozempic 0.25-.0.5 mg
- 2 injectable pens of Wegovy (for weight loss) 0.25 mg
- 2 injectable Trulicity (antidiabetic) 1.5 mg
- 3 injectable pens of lispro (antidiabetic) 100 mg
- 1 injectable pen of Lantus 100 unit
- 1 injextable pen of Humilin R insulin 500 units
- 1 injectable pen of Lantus 100 units
According to Lexicomp, Ozempic, Wegovy, Trulicity, lispro, Lantus, and Vancomycin are to be stored at 36 to 46 degrees Fahrenheit.
Review of the Medication Fridge and Room Temp Log inside Medication room [ROOM NUMBER] showed the medication refrigerator temperature range was 36 - 46 degrees Fahrenheit. The log also showed the temperature on 9/9/24 for the 7-3 shift was 38 degrees Fahrenheit. LVN 9 stated she checked the medication refrigerator temperature at 0730 hours on 9/9/24, and the temperature was within the range. When asked, LVN 9 did not know when the medication refrigerator was last opened. Infection Preventionist 1 stated the medication refrigerator temperature was too high and not within the range. RN 2 verified the medication refrigerator temperature was too high and not within the range.
c. On 9/9/24 at 1115 hours, an observation of the medication refrigerator temperature in Medication room [ROOM NUMBER] was conducted with IP 1 and LVN 8. When IP 1 opened the medication refrigerator to check the temperature inside, IP 1 stated the medication refrigerator temperature was 50 degrees Fahrenheit. The following medications were observed in the refrigerator:
- 3 boxes of acetylcysteine (to relieve chest congestion) 20% vials (quantity 90 ml total per box)
- 2 injectable pens of Lantus insulin 50 units
- 6 injectable pens of basaglar insulin 100 unit
- 1 vial of Lantus insulin 100 mg
- 1 vial of lorazpam (antianxitey) 20 mg per 10 ml
- 1 injectable pen of bydureon BCISE (antidiabetic) 2 mg
According to Lexicomp, acetylcysteine is to be store at 68 to 77 degrees Fahrenheit and Lantus is to be stored at 36 to 46 degrees Fahrenheit.
Reviw of the Medication Fridge and Room Temp Log inside Medication room [ROOM NUMBER] showed the medication temperature range was 36 - 46 degrees Fahrenheit. The log also showed the temperature on 9/9/24 for the 7-3 shift was 40 degrees Fahrenheit. IP 1 verified the medication refrigerator temperature was too high. LVN 8 stated she checked the medication refrigerator temperature around 0745 - 0750 hours on 9/9/24, and the temperature was within the range. When asked, LVN 8 did not know when the medication refrigerator was last opened.
On 9/9/24 at 1130 hours, an interview was conducted with the Administrator. The Administrator was informed of the above findings and stated all of the medication refrigerators out of the temperature range would be replaced.
On 9/10/24 at 1036 hours, an interview was conducted with the Pharmacist. The Pharmacist stated the nurses and Pharmacy Consultants made rounds in the facility monthly and checked the medication refrigerator temperatures. The Pharmacist further stated the medication refrigerator temperature during these monthly checks were not logged.
Review of the Skilled Nursing Pharmacy Summary of Nurse Consultant Services dated 8/7/24, was conducted with the DON. Under the Services Provided section, showed the following:
- Med Pass done with AM Nurse;
- Med Cart and Med Room audited, Med Refrigerator; and
- E-kits (emergency kits) and required logs checked.
The DON verified the medication refrigerator temperature was checked by the Pharmacy Nurse Consultant but not logged.

Based on observation, interview and facility P&P review, the facility failed to ensure the facility employees and visitors who brought food from the outside to the facility were educated on safe food handling practices. This failure posed the risk for residents who consumed food brought from the outside to be exposed to unsafe food handling which could lead to food borne illness.
Findings:
Review of the facility P&P titled Food Brought by Visitors revised June 2018, showed in part, B. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold food holding, and handling of leftovers.
On 9/10/24 at 853 hours, an interview was conducted with RN 2. RN 2 was asked how the facility ensured safe food handling practices were followed when the visitors brought food to the facility from the outside. RN 2 stated he was not sure how the facility ensured safe food handling practices were followed. RN 2 was asked if he had received education on safe food handling practices. RN 2 stated he could not recall if he received education on safe food handling practices. When asked if RN 2 was aware of what safe food handling practices included, RN 2 stated he was not sure. RN 2 was asked if the visitors received any information regarding safe food handling. RN 2 verified the facility did not provide the visitors with information on safe food handling practices.
On 9/10/24 at 900 hours, an interview was conducted with the DSD. The DSD stated she had worked at the facility for two months and verified she had not educated the facility staff on safe food handling practices, but she would check the education records for any training given in the past.
On 9/10/24 at 910 hours, an interview and concurrent facility P&P review was conducted with the DON. The policy titled Food Brought by Visitors revised June 2018 was reviewed with the DON. The DON was asked how the facility ensured safe food handling practices were followed when the visitors brought food to the facility from the outside. The DON stated the food must be clean and in a sealed container. The DON was not able to state how the facility ensured safe food handling practices were followed when the visitors brought food to the facility from the outside.
On 9/10/24 at 1126 hours, an interview was conducted with the DSD. The DSD verified the facility had not given the facility employees training regarding safe food handling practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the written notification of room changes were provided to the resident and RP for two of two sampled residents (Residents 7 and 8). This failure had the potential for violating the residents' rights.
Findings:
Review of the facility's P&P titled Room or Roommate Change revised 3/2018 showed prior to changing a room or roommate assignment, the resident, the resident's representative (if available), and the resident's new roommate will be provided timely advance notice of such a change.
A. The notice of a change in room or roommate assignment must be given in writing, and will include the reason(s) for such change.
B. The Facility will use SS – 12 – Form A – Notification of Room Change or SS-12 – Form B Notification of Roommate Change to notify the resident, or the resident's representative of the room or roommate change.
On 8/1/24 at 1120 hours, an interview was conducted with the SSD. The SSD was asked regarding the facility's process for room transfers and the requirements in room changes. The SSD stated the residents could transfer their rooms either due to incompatibility, per family request, or need for isolation. The SSD further stated the facility must notify the resident, RP, or family member and the resident already in the room of the new resident would be moving to. After the movement, the residents needed to be checked if everything was okay. The SSD stated there should be the Room Change transfer form completed during the room transfer.
On 8/1/24 at 1202 hours, the SSD provided a list of room transfers for review. Review of the room transfer list showed Residents 7 and 8 had their room changes on 7/25/24.
a. Medical record review for Resident 7 was initiated on 8/2/24. Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's H&P Examination dated 7/11/24, showed Resident 7 was nonverbal, confused and did not have mental capacity to make decisions.
Further review of Resident 7's medical record failed to show documentation the RP was notified of the room change prior to moving rooms.
b. Medical record review for Resident 8 was initiated on 8/2/24. Resident 8 was admitted to the facility on [DATE].
Review of Resident 8's H&P examination dated 7/18/24, showed Resident 8 had mental capacity to make decisions.
Review of Resident 8's medical record failed to show documentation Resident 8 was notified of the room change prior to moving rooms.
On 8/1/24 at 1332 hours, a follow-up interview was conducted with the SSD. The SSD stated the Admissions Director would talk to the residents, RPs or family regarding room changes. The SSD was asked if the facility provided the written notification to the residents, RP or family regarding room changes. The SSD stated according to the Admissions Director, there was no room change form provided to document room changes. The SSD further stated the room change notifications were done verbally.
On 8/1/24 at 1505 hours, an interview was conducted with Resident 8. Resident 8 was asked what date he moved to his current room. Resident 8 stated he did not recall the exact date but was transferred about a week ago. Resident 8 was asked if someone talked to him about being transferred to his current room. Resident 8 statedsomeone verbally informed him of the room change, but he was not provided a written notice or documentation.
On 8/1/24 at 1516 hours, an interview was conducted with the Admissions Director. The Admissions Director was asked about the facility process for room changes. The Admissions Director stated they informed the residents and/or family of the room change verbally. The Admissions Director was asked if the written notice was provided regarding room changes. The Admissions Director stated they only provided a verbal notification. The Admissions Director confirmed Residents 7 and 8 did not have documented room changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records for two of four sampled residents (Resident 1 and Resident 3) were accurate.
* Resident 1's Elopement evaluation was inaccurate
* Resident 3's Fall risk evaluation was inaccurate
These failures had the potential for the incidents to be reoccurred.
Findings:
1. Review of the facility's P & P titled Wandering & Elopement revised 7/2017 showed the resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated upon admission, readmission, quarterly, and upon change in condition.
Medical record review for Resident 1 was initiated on 7/2/2024. Resident 1 was readmitted to the facility on [DATE] with several diagnoses including abrasion of other part of head, Atrial fibrillation, toxic effect of unspecified alcohol, nicotine dependence, alcohol abuse with intoxication and dehydration.
On 7/3/24 at 0950 hours, an interview with LVN 1 was conducted. Asked about Resident 1, LVN 1 stated he did not know exactly what time Resident 1 left the facility, but it was around noon time, the resident ate breakfast but not lunch. He always walked around, he was able to walk out to his car in the parking lot because his car always parked in the parking lot. He usually walked in and out of the building all the time. LVN 1 also stated Resident 1 had a history of elopement before and he left the facility many times before without telling anyone.
On 7/3/24 at 1500 hours, an interview and concurrent medical record review with the DON was conducted. The DON verified Resident 1's Elopement evaluations below:
- 7/9/23: score of 6 – at risk of elopement.
- 12/12/23: score of 1 – at risk of elopement
- 1/22/23: score of 2 – at risk of elopement
- 4/28/24: score of 1 – at risk of elopement
- 6/17/24: score of 0 – no risk of elopement
Review of Resident's 1 Elopement evaluations dated 7/9/23, 12/12/23, 1/22/23, 4/28/23 showed resident had a history of elopement, while the Resident 1's Elopement evaluation on 6/17/24 indicated no history of elopement. Asked about the Elopement evaluation on 6/17/24 upon admission and the answer No to history of Elopement, the DON verified it was incorrect. The DON stated the resident did have an elopement in the past when he was at the facility. The DON also stated the nurse should have checked the medical record before answer the question.
2. Review of the facility's P & P titled Fall Management Program - Policy No. FA – 01 revised on 3/13/2021 showed a licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed.
Medical record review for Resident 3 was initiated on 7/2/2024. Resident 3 was admitted to the facility on [DATE], and Resident 3 had an unwitnessed fall on 5/28/24.
Review of Resident 3's medical history dated 6/25/24 by Dr. [NAME], [NAME] showed resident has had several diagnoses including Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Diabetes Mellitus (DM), Atrial Fibrillation, Pain, Dementia, other abnormalities of gait and mobility. It also stated: Resident has also fall risk as she had major fall in May 2024 resulting in facial bruising and arm laceration.
On 7/3/24 at 1500 hours, an interview and concurrent medical record review with the DON was conducted. The DON verified Resident 3's Fall assessments showed below:
- On 1/4/24 : Fall risk score of 19
- On 3/21/24 : Fall risk score of 9
- On 5/26/24 : Fall risk score of 10
- On 6/21/24 : Fall risk score of 4.
Asked about why the fall risk evaluation dated 6/21/24 has a score of 4, DON states that the nurse answered the item 8 in History and disposing condition incorrectly, it should be 3-4 (disposing diseases), and item 2 in medications it should be 3-4 these medications. The DON also stated the nurse supposed to answer all questions with accurate information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility's P & P, the facility failed to ensure the comprehensive care plan for one of four sampled residents (Resident 3) was revised to reflect the current resident assessments.
These failures placed the residents at risk for the specific care issues not being addressed for medical and physical needs.
Findings:
Review of the facility's P & P titled Change of Condition Notification- Policy No. NP – 23 revised 4/1/2015 showed the licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. The licensed nurse will also document and update the care plan to reflect the resident's current status.
Review of the facility's P & P titled Fall Management Program - Policy No. FA – 01 revised on 3/13/2021 showed following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan as necessary.
Medical record review for Resident 3 was initiated on 7/2/2024. Resident 3 was readmitted to the facility on [DATE] with several diagnoses including dementia, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus (DM), abnormal of gait and mobility, Chronic congestive heart failure.
Review of Resident 3's Minimum Data Set (MDS) -section C dated on 3/21/24 showed Resident 3 has a BIMS score of 8 which indicated moderate cognitive impairment.
Review of Resident 3's Change of condition (COC) showed Resident 3 had an unwitnessed fall on 5/26/24 with discoloration to right side of head and complaint of pain.
Review of Resident 3's Interdisciplinary Team (IDT) meeting dated 5/28/24 showed the IDT recommended to continue with neuro-checks per protocol, pain management as needed, to position resident's bedside table on the opposite side to minimize tripping hazards and adding every two hours toileting schedule.
Review of Resident 3's care plan revised on 5/28/24 showed a focus problem of fall incident on 5/26/24, and there was no revision of the goal and the interventions which were recommended from the IDT meeting.
On 7/2/24 at 1423 hours, an observation and concurrent interview with Resident 3 was conducted in her room. Resident 3 was observed sitting on the wheelchair. Resident stated she could not speak English. CNA 1 helped translate to English. Resident 3 was alert and oriented x two to three. Asked about the fall, Resident 3 stated she had a fall recently, but did not remember exactly what date. She also stated she tried to go to the restroom, but she fell. She went back to bed by herself, and it was around 2 or 3 AM.
On 7/2/24 at 1137 hours, an interview and concurrent medical record review with the DON was conducted. The DON stated when resident has an unwitnessed fall, the nurses need to initiate 72 hours neuro-check, a care plan, do a pain assessment, fall risk assessment, post fall assessment, notify dr. and family and do an IDT meeting. The DON verified there was a care plan with a focus problem of fall incident revised on 5/28/24, but the goal and interventions were not updated for the fall. The DON also states the nurses supposed to update the care plan for the fall, but they did not do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the visual privacy was provided for one of two non-sampled Residents (Resident 6) during care. This failure posed the risk of negatively affecting the resident's dignity.
Findings:
Review of the facility's P&P title Resident Rights revised 1/1/12, showed the employees are to treat all residents with kindness, respect and dignity and honor the exercise of resident's rights. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: Privacy and confidentiality.
Medical record review was initiated on 6/11/24. Resident 6 was initially admitted to the facility on [DATE] and readmitted [DATE].
Review of Resident 6's MDS dated [DATE], showed Resident 6 had a BIMS Summary Score of 15, indicating cognitively intact.
On 6/11/24 at 1108 hours, an observation was conducted along the hallway a few feet away from Resident 6's room. Resident 6's door was observed halfway open, and there wasno curtain pulled for privacy. CNA 6 was observed pulling Resident 6's diaper up. Resident 6 was standing, and his left buttock was exposed.
On 6/11/24 at 1124 hours, an interview was conducted with Infection Preventionist. The Infection Preventionist acknowledged and verified CNA 6 should have pulled the curtain to provide privacy for Resident 6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained.
* The staff failed to perform hand hygiene during care for one of seven sampled residents (Resident 6) and one of two nonsampled residents (Resident 9).
* The facility failed to label the basin found on top of a common dresser table found in room [ROOM NUMBER].
These failures had the potential to result in the spread of infection to the residents.
Findings:
Review of the facility's P&P titled Hand Hygiene Policy revised 9/1/20, showed the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol based hand rub including foam or gel. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers and visitors. Facility staff, healthcare personnel, residents, visitors and volunteers must perform hand hygiene to prevent transmission of healthcare associated infections. The following situations require appropriate hand hygiene: before and after food preparation, before and after assisting a resident with dining if direct contact with food is anticipated or occurs, after contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage, and soiled dressing.
Review of facility's P&P titled Infection Control revised 1/1/12 showed the facility's infection control P&Ps are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. The facility's infection control policies and procedures apply equally to all Facility Staff, consultants, contractors, residents, visitors, volunteer workers and the general public alike regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. Infection control objectives are to prevent, detect, investigate, and control infections in the Facility. Maintain a safe, sanitary, and comfortable environment from personnel, residents, visitors, and the general public. establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard Precautions.
1.a. On 6/11/24 at 0752 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was assisting Resident 9 with her breakfast meal tray. CNA 4 did not performhand hygiene when she left Resident 9's room. CNA 4 proceeded to get a clean towel from a mobile clean towel shelf, then entered Resident 9's room without performing hand hygiene. CNA 4 stated she did not need to perform hand hygiene because she did not touch Resident 9. CNA 4 was asked if she touched the breakfast food tray of Resident 9 and if she assisted her in preparing her meals. CNA 4 stated she did.
b. On 6/11/24 at 1108 hours, CNA 6 was observed assisting Resident 6 in pulling up his diaper. After assisting Resident 6, CNA 6 did not perform hand hygiene. CNA 6 proceeded to walk to the soiled linen bin without performing hand hygiene and moved the mobile soiled linen bin along the hallway near laundry.
On 6/11/24 at 1120 hours, an interview was conducted with Infection Preventionist. The Infection Preventionist acknowledged CNA 4 should have performed hand hygiene after assisting Resident 9 with her breakfast meal tray, before leaving the room and getting a clean towel from the mobile clean towel shelf. The Infection Preventionist also stated CNA 6 should have performed hand hygiene after assisting Resident 6.
2. On 6/11/24 at 0801 hours, an observation was conducted in room [ROOM NUMBER]. An unlabeled basin was observed placed on top of a common table dresser. The unlabeled basin contained an opened box of tissue and kidney basin.
On 6/11/24 at 1108 hours, follow up observation was conducted in room [ROOM NUMBER]. The unlabeled basin containing an opened tissue box, towel and kidney basin was still observed placed on top of the common dresser table.
On 6/11/24 at 1120 hours, an interview was conducted with Infection Preventionist. The Infection Preventionist acknowledged and verified the basin contained an open tissue box, kidney basin and towel should have been labeled to avoid transmission of infection.

Based on observation and interview, the facility failed to ensure the garbage was properly stored in three of six garbage dumpsters. The failure had the potential to attract pest/rodents that carried disease.
Findings:
According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.
On 2/1/24 at 1256 hours, an observation of the facility's garbage dumpsters was conducted. Two dumpsters were observed with the lids open and garbage inside. One dumpster was observed with the lid propped open by garbage, preventing the lid from fully closing.
On 2/1/24 at 1400 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the findings. The Maintenance director stated the trash dumpster lids needed to be closed as a pest control measure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 1 and 3) were provided the treatment and care in accordance with the professional standards of practice, comprehensive person-centered care plan, and resident choices.
1. The facility failed to ensure the medication administration was arranged when Resident 3 was out on pass. Resident 3's order for out on pass did not specify the length of time the resident could be out on pass as per the facility's P&P, nor was a care plan developed to address the out on pass process and how the resident's care needs would be met during the out on pass.
2. The facility failed to ensure Resident 1 received five scheduled evening medications, including Resident 1's insulin and antiseizure medication.
These failures had the potential to cause harm to Residents 1 and 3.
Findings:
Review of the facility's P&P titled Medication - Administration revised January 2012 showed whenever a medication is held for any reason, the licensed nurses will initial the medication the hour it was held and will document in the MAR noting the time and reason the medication was held.
Review of the facility's P&P titled Out On Pass revised January 2016 showed the physician should specify on the out on pass order the length of time the resident may be on the out on pass. Additionally, the licensed nurses should document the time the resident left the facility and the expected time of return.
1. Medical record review for Resident 3 was initiated on 12/20/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's History and Physical examination dated 9/5/23, showed a diagnosis of DM II.
Review of Resident 3's BIMS assessment dated [DATE], showed Resident 3 had no cognitive impairment.
Review of Resident 3's MAR for December 2023 showed the following medications to be scheduled at 1700 hours and 2100 hours were not administered on 12/15/23:
* Medications scheduled at 1700 hours:
1.
Insulin Lispro 100 Units/ml. Inject as per sliding scale. If blood sugar is 100-150 mg/dl, give 0 units; 151-200 mg/dl, give 2 units; 201-250 mg/dl, give 4 units; 251-300 mg/dl, give 6 units; 301-350 mg/dl, give 8 units; 351-400 mg/dl, give 10 units. Administer within 15 minutes before or immediately after a meal on breakfast and dinner. Administer subcutaneously in the evening for diabetes mellitus. Rotate sites. If blood sugar is less than 60 mg/dl, give orange juice if conscious or Glucagon IM 1 mg if unconscious.
2.
Gabapentin oral capsule 300 mg (gabapentin) one capsule by mouth two times a day for neuropathy.
3.
Loratadine tablet 10 mg by mouth in the evening for allergies.
4.
Magnesium tablet 400 mg one tablet by mouth two times a day for supplement.
5.
MiraLax Powder 17 grams/scoop (polyethylene glycol 3350) one scoop by mouth two times a day for bowel management. Dilute in 6-8 oz of water and hold for loose stools.
6.
Senna Plus Tablet 8.6-50 mg (sennosides-docusate sodium) two tablets by mouth, two times a day for bowel management. Hold for loose stools.
7.
Fish Oil Capsule 1000 mg (omega-3 fatty acids) one capsule by mouth two times a day for supplement.
* Medications scheduled at 2100 hours:
1.
Lantus Solution 100 Units/ml (insulin glargine) 45 units subcutaneously at bedtime for diabetes mellitus.
2.
Famotidine Tablet 20 mg one tablet by mouth at bedtime for ulcer prophylaxis.
3.
Genteal Nighttime Ointment 3.5 instill one application in both eyes at bedtime for dry eyes syndrome.
4.
Artificial Tears Solution 1.4% (polyvinyl alcohol) instill one drop in both eyes two times a day for dry eyes syndrome.
Review of Resident 3's Order Summary Report showed an order dated 5/4/20, OK TO GO OUT ON PASS HERSELF AS NEEDED IF NOT SICK. The order did not specify the length of time Resident 3 may be out on pass.
Review of Resident 3's Progress Notes, dated 12/15/23, showed no documentation stating the reason why Resident 3's medications were not given. Additionally, the note did not state Resident 3's out on pass details, including her expected return time.
Review of Resident 3's Care Plans failed to show a care plan was developed to address Resident 3's out on pass process and how the resident's care needs including the medication administration would be met during the out on pass.
On 12/20/23 at 1415 hours, an interview was conducted with Resident 3. Resident 3 stated she did not receive her scheduled evening medications on 12/15/23, after returning from an out on pass. Resident 3 stated she returned to the facility around 2100 hours, and was not seen by the nurse until 0200 hours.
On 1/11/24 at 1117 hours, a follow-up interview was conducted with Resident 3. When asked about her out on pass schedule, Resident 3 stated she would leave the facility 3-4 times a week for 4-6 hours each day. Resident 3 stated she verbally informed the nurse that she was going out on pass. When asked if she took her medication while she was gone, Resident 3 stated no, she took all her medications at the facility. When Resident 3 returned to the facility, the nurse would see her within 30 minutes to administer her evening medications. Resident 3 stated on 12/15/23, the nurse did not administer her evening medications when she returned to the facility.
On 12/20/23 at 1544 hours, an interview and concurrent medical record review was conducted with LVN 1. When asked about the process for a resident being out on pass, LVN 1 stated the nurse would check on the resident when they returned to the facility and would administer any missed scheduled medications. LVN 1 stated she worked on 12/15/23, and was Resident 3's assigned nurse for the 1500-2300 shift. LVN 1 further stated Resident 3 was out on pass and returned to the facility towards the end of her shift. Upon review of Resident 3's December 2023 MAR, LVN 1 verified Resident 3's above medications were not documented or given. When asked for the reason, LVN 1 stated she gave report to RN 1 on 12/15/23 at 2045 hours, who agreed to give Resident 3's scheduled medications when the resident returned to the facility.
On 12/20/23 at 1622 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated she worked on 12/15/23 from 0900 to 2330 hours. Upon review of Resident 3's December 2023 MAR, RN 1 stated she was not sure why the resident did not receive her medications. RN 1 stated she did not receive report that Resident 3 was out on pass and was not told to administer Resident 3's medications when she returned.
On 12/20/23 at 1654 hours, an interview was conducted with LVN 2. LVN 2 stated she worked on 12/15/23 from 1500 - 0700 hours. When asked about Resident 3, LVN 2 stated she opened the facility's front door for Resident 3 when she returned from being out on pass and verified Resident 3 returned to facility at 2230 hours.
On 12/21/23 at 1100 hours, an interview and concurrent medical record review was conducted with the DON. When asked about the process when a resident was out on pass, the DON stated the primary nurse or supervisor should administer scheduled medications before a resident leaves for out on pass. When a resident returned to the facility, the nurse should see the resident within 1 hour from arrival. If scheduled medications were on hold while a resident was out on pass, the nurse should document that reason on the MAR. Upon review of Resident 3's December 2023 MAR, the DON verified the medications listed above were not documented.
On 1/18/24 at 1000 hours, an interview and concurrent medical record review was conducted with LVN 6. When asked about the out on pass process, LVN 6 stated the nurse should document in the chart the details of the resident's out on pass, including the time the resident left the facility and the expected return time. When asked about Resident 3, LVN 6 stated the resident did not take the medications with her while out on pass and received the evening medications in the facility when she returned. Upon review of Resident 3's Progress Note dated 12/15/23, LVN 6 verified there was no documentation in the medical record regarding Resident 3's out on pass details. Additionally, LVN 6 verified there was no documentation stating the reason why Resident 3's medications were not given. LVN 6 further stated the nurse should have documented on the MAR the reason why Resident 3's medications were not administered or held.
On 1/18/24 at 1700 hours, a follow-up interview and concurrent medical record review was conducted with the DON. Upon review of Resident 3's out on pass order, the DON acknowledged the order did not state the timeframe Resident 3 was allowed to be out on pass. Upon review of Resident 3's care plan, the DON verified there was no care plan addressing the resident's out on pass. The DON stated Resident 3's care plan should have reflected their plan for medications since Resident 3's out on pass order had no time frame specified.
2. Medical record review for Resident 1 was initiated on 12/20/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 1's History and Physical examination dated 12/22/22, showed a diagnosis of DM II.
Review of Resident 1's MAR for December 2023 showed the following medications to be scheduled at 2100 hours were not documented on 12/15/23:
1.
Insulin Glargine Subcutaneous Solution 100 Unit/ml (insulin glargine) 10 unit subcutaneously at bedtime for diabetes mellitus rotate sites.
2.
Primidone Oral Tablet 50 mg (primidone) one tablet by mouth at bedtime for seizure disorder.
3.
Atorvastatin Calcium Oral Tablet 20 mg (atorvastatin calcium) one tablet by mouth at bedtime for hyperlipidemia.
4.
Donepezil HCL Oral Tablet 5 mg (donepezil hydrochloride) one tablet by mouth at bedtime for dementia.
5.
Lactulose Oral Solution 10 grams/15 ml (lactulose) 30 ml by mouth four times a day for abnormal ammonia.
On 12/21/23 at 1100 hours, an interview and concurrent medical record review was conducted with the DON. Upon review of Resident 1's December 2023 MAR, the DON verified the medications listed above were not documented. The DON verified there was no documentation in the medical record stating the reason why the medications were held. The DON further stated the medications placed on hold should be reflected in the documentation.
On 1/18/24 at 1715 hours, the Administrator and DON were informed and acknowledge the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility staff failed to immediately reported an allegation of abuse to the administrator, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement within two hours after the allegation was made for one of nine sampled residents (Resident 7). This failure had the potential to delay the investigation of the alleged abuse and for staff to not take prompt and appropriate corrective actions to prevent the abuse.
Findings:
Review of the facility's P&P titled Abuse Reporting and Investigation revised 3/2018 showed allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the administrator or designated representative immediately. Under the section notification outside agencies of allegation of abuse with no serious bodily injury showed the administrator or designated representative will notify within two hours, by telephone, CDPH, the ombudsman and law enforcement.
On 12/26/23, CDPH, L&C Program received an SOC 341 from the facility regarding CNA 1 reported witnessing Resident Representative 1 slapping Resident 7's cheek during dinner time about 2 months ago.
Review of Resident 7's medical record was initiated on 1/16/24. Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's MDS dated [DATE], showed Resident 7 had a memory problem.
Review of Resident 7's Progress Notes dated 12/27/23 at 1445 hours, showed on 12/26/23, Resident Representative 1 slapped Resident 7 during dinner time about two months ago.
On 1/17/24 at 1540 hours, a telephone interview was conducted with CNA 1. CNA 1 stated about few months ago around dinner time, Resident Representative 1 was trying to fix Resident 7's dinner tray, Resident 7 pushed Resident Representative 1 with his leg, then Resident Representative 1 got angry and slapped Resident 7 left cheek with her hand. CNA 1 further stated then, Resident 7's left cheek turned red and he cried. When asked CNA 1 why he did not report the case immediately after the incident, CNA 1 stated he was a good friend with Resident Representative 1 who took a good care of Resident 7, so he did not report the incident. CNA 1 stated he made a mistake for not reporting the case immediately after the incident. CNA 1 stated he should have reported the case immediately after the incident.
On 1/18/24 at 1154 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, facility document review, employee file review, and facility P&P review, the facility failed to ensure one of five registry CNAs (CNA 16) was provided training on abuse before providing the necessary care and services to the residents at the facility. This failure had the potential to put the vulnerable residents at risk for abuse.
Findings:
Review of the facility's P&P titled Abuse Prevention, Screening & Training Program revised 7/2018 showed the facility conducts mandatory staff training programs during orientation, annually and as needed on the following:
i. Prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property or mistreatment;
ii. Identifying what constitutes abuse, neglect, exploitation misappropriation of resident property, or mistreatment;
iii. Recognizing signs of abuse, neglect, exploitation, misappropriation of resident property and mistreatment;
iv. Reporting abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source, to whom and when to report and to report without fear of reprisal; and
v. Understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond.
Review of the facility's Terms of Use and Master Service Agreement with the Staffing Agency dated 12/1/22, showed the Client (facility) shall provide any required orientations such as review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA, and EMR/Charting where applicable and Client shall provide HCP all necessary equipment and software needed to perform Client's required duties. It is the sole responsibility of the Client to monitor and enforce all policies and procedures with HCP. Marketplace (staffing agency) will assume no liability for any equipment, software, policies, or enforcement measures provided to HCP.
Review of the facility's SOC 341 forms dated 9/15 and 9/16/23, showed the abuse allegations reported against CNA 16 for the following:
- Residents 1's missing ID and credit card reported on 9/15/23,
- Resident 2's missing gift cards, debit cards, cash, California ID, SS Card, and wedding ring reported on 9/3/23,
- Resident 3's stolen ID and debit cards reported on 9/6/23,
- Resident 4's missing ID, SS Card, debit/credit cards, and 84.00 cash reported on 9/11/23, and
- Resident 5's missing ID, debit card and cash reported on 9/16/23.
Review of CNA 16's personnel file failed to show the documentation of CNA 16's abuse training.
On 9/27/23 at 1100 hours, an interview and concurrent facility document review was conducted with the DSD. When asked regarding the abuse training of CNA 16, the DSD verified the facility did not have a copy of CNA 16's abuse training and did not provide an abuse training to CNA 16.
On 10/24/23 at 1453 hours, an interview and concurrent document review was conducted with the Administrator. When asked regarding CNA 16's abuse training, the Administrator provided the documentation of CNA 16's abuse training from the Staffing Agency completed on 10/4/23. The Administrator verified and acknowledged CNA 16's California Department of Justice – DMFEA Mandated Reporter training was completed on 10/4/23, after CNA 16 had started working with the residents at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensurethe abuse allegation was reported to CDPH L&C Program for one of 22 sampled residents (Resident 5). Resident 5 reported a missing ID, debit card, and cash, and reported the debit card had fraudulent charges. This failure had the potential for the abuse allegation going unreported and uninvestigated.
Findings:
Review of the facility's P&P titled Abuse Reporting and Investigation revised 3/2018 showed under section Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury, the Administrator or designated representative will notify within two (2) hours, by telephone, to the CDPH, Ombudsman, and Law Enforcement; and the Administrator or designated representative will send a written SOC 341 report to the Ombudsman, Law Enforcement and CDPH, Licensing and Certification within two (2) hours.
Medical record review for Resident 5 was initiated on 9/21/23. Resident 5 was admitted to the facility on [DATE].
Review of the facility's SOC 341 dated 9/16/23, showed an abuse allegation against CNA 16 for Resident 5's reported missing ID, cash, debit card with fraudulent charges. The SOC 341 showed the facility reported the abuse allegation to the local ombudsman and law enforcement via telephone, but not to CDPH, L&C Program. owever,
On 9/22/23 at 1600 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD verified the facility's SOC 341 for Resident 5's abuse allegation was not reported to CDPH, L&C Program.
On 9/22/23 at 1609 hours, an interview was conducted with the Administrator. The Administrator was made aware and verified Resident 5's abuse allegation was not reported to CDPH.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate the abuse allegations for five of 22 sampled residents (Residents 1, 2, 3, 4, and 5). These failures posed the risk of Residents 1, 2, 3, 4, and 5 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.
Findings:
Review of the facility's P&P titled Abuse Reporting and Investigations revised 3/2018 showed when the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled by technology, exploitation or injuries of an unknown source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately; and the administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime and who may have information relevant to the allegation or suspected crime are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc.
Review of the facility's P&P titled Theft and Loss revised 7/2017showed the Administrator or designee investigates all reports of stolen items and documents the investigation on the Theft and Loss Report. The investigation may consist of the following: an interview with any individuals who may have knowledge of the missing items, including the facility staff on all shifts and interviews of the resident roommate, family members, and visitors.
1. Review of the facility's SOC 341 dated 9/15/23, showed Resident 1's family member reported a missing ID and credit cards and had received fraudulent charges.
Medical record review for Resident 1 was initiated on 9/21/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Theft and Loss Report initiated by the SSD on 9/15/23, showed an investigation was conducted for Resident 1's missing credit card.
2. Review of the facility's SOC 341 dated 9/15/23, showed Resident 2 reported missing the gift cards, debit cards, cash, California ID, SS card, and wedding ring on 9/3/23.
Medical record review for Resident 2 was initiated on 9/21/23. Resident 2 was admitted to the facility on [DATE], and discharged on 9/7/23.
Review of Resident 2's Theft and Loss Report initiated by the DON on 9/3/23, showed an investigation was conducted for Resident 2's missing California ID, SS card, eight gift cards, wedding ring, and $22.00 cash.
3. Review of the facility's SOC 341 dated 9/15/23, showed Resident 3 and Resident 3's family member reported the stolen ID and debit cards on 9/6/23, and Resident 3's family member noted fraudulent charges on 9/85/23.
Medical record review for Resident 3 was initiated on 9/21/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's Theft and Loss Report initiated by the SSA on 9/6/23, showed an investigation was conducted for Resident 3's missing ID, debit cards and credit cards.
4. Review of the facility's SOC 341 dated 9/15/23, showed Resident 4 reported a missing ID, SS card, debit/credit cards, and $84.00 cash on 9/11/23.
Medical record review for Resident 4 was initiated on 9/21/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 4's Theft and Loss Report initiated by the SSA on 9/11/23, showed an investigation was conducted for Resident 4's missing debit cards, SS card, and $84.00 cash.
5. Review of the facility's SOC 341 dated 9/16/23, showed Resident 5 reported a missing ID, debit card and cash. Resident 5 received a call for fraudulent charges on 9/16/23.
Medical record review for Resident 5 was initiated on 9/21/23. Resident 5 was admitted to the facility on [DATE].
Review of Resident 5's Theft and Loss Report initiated by the SSA on 9/16/23, showed an investigation was conducted for Resident 5's missing ID, debit card, and $50.00 cash.
Review of the facility's file folder for the investigations failed show documented evidence the staff and/or residents were interviewed regarding the abovetheft and loss reports or the abuse allegations.
On 10/24/23 at 1141 hours, an interview and concurrent facility document review was conducted with the SSD. When asked if the facility had conducted thestaff and/or resident interviews regarding the theft and loss and abuse allegations, the SSD stated the facility had conducted the interviews but was not able to provide documented evidence of the staff or resident interviews.
On 10/24/23 at 1453 hours, an interview was conducted with the Administrator. The Administrator verified and acknowledged the facility did not have documented evidence of the staff and/or resident interviews regarding the theft and loss or the abuse allegations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of 22 sampled residents (Residents 12, 17, 18, 19, and 20) were provided necessary care and services to meet their ADL care needs. The facility failed to provide showers to Residents 12, 17, 18, 19, and 20 as scheduled. This failure had the potential to negatively affect the resident's well-being and delay the detection of the new or worsening skin condition.
Findings:
Review of the facility's P&P titled Showering and Bathing revised 1/2012 showed a tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors, residents are given tub or shower baths unless contraindicated, and observe the skin is performed during bath. Under the section Procedure showed not limited to the following:
- assist the resident into the shower chair,
- transport the resident to the bath area,
- assist the resident into the tub or shower and assist as needed,
- take resident back to his/her room,
- assist the resident with dressing as needed, and
- report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to charge nurse.
Review of the facility's P&P titled ADL Documentation revised 7/2014 showed the facility will ensure documentation of the care provided to the residents for completion of ADL task, and the CNA will document the care provided on the facility's method of documentation, manually or
electronic.
Review of the facility's Shower Binder for all Nurses Station (undated) showed the schedule of resident shower days and skin inspection forms. However, further review of the facility's Shower Binder for all Nurses Station failed to show skin inspection forms for the residents scheduled to shower on 9/30/23.
Review of the facility's Shower Schedule sheet (undated) showed Residents 12, 17, 18, 19, and 20 werescheduled to shower on Wednesdays and Saturdays during the PM shifts. Further review of the Shower Schedule sheet showed the body checks had to be filled out and signed by the charge nurse.
Review of thefacility's ADL-Bathing documentation, under the section for the resident's bathing type, showed to indicate shower, tub bath, bed/towel bath, resident not available, resident refused or not applicable.
1. Medical record review for Resident 12 was initiated on 10/11/23. Resident was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 12's ADL-Bathing documentation from 9/29/23 to 10/1/23, showed Resident 12 was scheduled for bathing on Wednesdays and Saturdays during the PM shifts. Further review of Resident 12's ADL-Bathing documentation for 9/30/23 at 2259 hours, showed Resident 12's bathing type was documented as not applicable.
2. Medical record review for Resident 17 was initiated on 10/13/23. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 17's ADL-Bathing documentation from 9/27/23 to 9/30/23, showed Resident 17 was scheduled for bathing on Wednesdays and Saturdays during the PM shifts. Further review of Resident 17's ADL-Bathing documentation for 9/30/23 at 2259 hours, showed Resident 17's bathing type was documented as not applicable.
3. Medical record review for Resident 18 was initiated on 10/13/23. Resident 18 was admitted to the facility on [DATE].
Review of Resident 18's ADL-Bathing documentation from 9/25/23 to 9/30/23, showed Resident 18 was scheduled for bathing on Wednesdays and Saturdays during the PM shifts. Further review of Resident 18's ADL-Bathing documentation for 9/30/23 at 2259 hours, showed Resident 18's bathing type was documented as not applicable.
4. Medical record review for Resident 19 was initiated on 10/13/23. Resident 19 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 19's ADL-Bathing documentation from 9/25/23 to 9/30/23, showed Resident 19 was scheduled for bathing on Wednesdays and Saturdays during the PM shifts. Further review of Resident 19's ADL-Bathing documentation for 9/30/23 at 2259 hours, showed Resident 19's bathing type was documented as not applicable.
5. Medical record review for Resident 20 was initiated on 10/13/23. Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 20's ADL-Bathing documentation from 9/25/23 to 9/30/23, showed Resident 20 was scheduled for bathing on Wednesdays and Saturdays during the PM shifts. Further review of Resident 20's ADL-Bathing documentation for 9/30/23 at 2259 hours, showed Resident 20's bathing type was documented as not applicable.
On 10/13/23 at 1314 hours, an interview and concurrent facility record review of the shower binder was conducted with the MRD. The MRD reviewed the shower binder and verified there were no Skin Inspection sheets for 9/30/23.
On 10/20/23 at 1424 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD verified the above findings. When asked if Residents 12, 17, 18, 19, and 20 had the showers as scheduled on 9/30/23, the DSD stated if the showers were provided, it should have been documented in the resident's shower type.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical records for eight of 22 sampled residents (Residents 1, 7, 9, 12, 13, 14, 16, and 17) were complete. The care related to bowel/bladder elimination was not documented for these residents, creating the potential for resident's care needs not being met as their medical information were incomplete.
Findings:
Review of the facility's P&P titled ADL Documentation revised 7/2014 showed the facility will ensure documentation of the care provided to the residents for completion of ADL task, and the CNA will document the care provided on the facility's method of documentation, manually or
electronic.
1. Medical record review for Resident 1 was initiated on 9/21/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 1's bladder and bowel elimination.
2. Medical record review for Resident 7 was initiated on 9/21/23. Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 7's bladder and bowel elimination.
3. Medical record review for Resident 9 was initiated on 9/29/23. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 9's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 9's bladder and bowel elimination.
4. Medical record review for Resident 12 was initiated on 10/11/23. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 12's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 12's bladder and bowel elimination.
5. Medical record review for Resident 13 was initiated on 10/11/23. Resident 13 was admitted to the facility on [DATE].
Review of Resident 13's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 13's bladder and bowel elimination.
6. Medical record review for Resident 14 was initiated on 10/11/23. Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 14's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 14's bladder and bowel elimination.
7. Medical record review for Resident 16 was initiated on 10/12/23. Resident 16 was admitted to the facility on [DATE].
Review of Resident 16's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 16's bladder and bowel elimination.
8. Medical record review for Resident 17 was initiated on 10/13/23. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 17's ADL Task Documentation for the night shift on 9/30/23, failed to show documentation for Resident 17's bladder and bowel elimination.
Review of the facility's Nursing Assignment for the night shift on 9/30/23, showed:
- CNA 17 was assigned to Residents 7 and 9,
- CNA 18 was assigned to Residents 12 and 17,
- CNA 19 was assigned to Residents 13 and 1, and
- CNA 20 was assigned to Residents 14 and 16.
On 10/20/23 at 1424 hours, an interview was conducted with the DSD. When asked if the diaper changes were provided at the night shift on 9/30/23, the DSD stated ADL assistance were provided to Residents 1, 7, 9, 12, 13, 14, 16, and 17; however, it was not documented. The DSD further stated CNAs 17, 18, 19, and 20 were contracted staff and they should have used a Registry CNA Charting sheet for documentation if the EHR login wasnot available on 9/30/23.
On 10/20/23 at 1520 hours, a follow-up interview was conducted with the DSD. The DSD verified CNAs17, 18, 19, and 20 did not submit any documentation for their assigned residents in the Registry CNA Charting sheet for the night shift on 9/30/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal property of four of 22 sampled residents (Residents 1, 2, 6, and 7) were protected from theft or loss.
* The facility failed to ensure Residents 1, 6, and 7's personal items were labeled with the residents' names and includedin the residents' inventory lists.
* The facility failed to show documented evidence of personal property was released to Resident 2 upon discharge.
These failures had the potential for the residents' property to get lost or stolen.
Findings:
Review of the facility's P&P titled Personal Property revised 7/2017 showed during the admission process, the admissions staff will inform the resident/resident representative of the need to mark the resident's belongings with the resident's name and to notify nursing when additional items are brought to the facility so that they can be added to the resident's inventory list. Theadmissions staff will also inform theresident/resident representative that items removed from the facility need to be removed from the inventory list; and upon discharge home, the resident/resident representative will review the Resident Inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them.
Review of the facility's P&P titled Theft and Loss revised 7/2017, under the section for Measures to Secure Personal Property, showed at the time of admission and discharge, the facility staff will complete a Resident Inventory, and the admission staff will explain to the resident/responsible party that all personal property is to be clearly marked with the resident's name and listed on the inventory.
1. Medical record review for Resident 1 was initiated on 9/21/23. Resident 1 was admitted to the facility on [DATE].
On 9/22/23 at 0942 hours, an observation was conducted in Resident 1's room. Resident 1 was observed with one pair of black gloves, three eyeglasses with case, one electric razor with charger, and one small pink plastic container at bedside.
On 9/22/23 at 1029 hours, an observation and concurrent interview with CNA 1 was conducted in Resident 1's room. CNA 1 verified Resident 1 had a pair of dentures inside the pink plastic container. CNA 1 verified the above-mentioned personal items at Resident 1's bedside were not labeled with the resident's name.
Review of Resident 1's Resident Inventory form dated 9/6/23, showed one pair of eyeglasses. The form did not include Resident 1's two other pairs of eyeglasses with case, one pair of gloves, one electric razor with charger, and container of dentures.
Review of Resident 1's Personal Effect Inventory dated 9/7/23, showed one pair of eyeglasses. The form did not include Resident 1's two other pairs of eyeglasses with case, one pair of gloves, one electric razor with charger and container of dentures.
On 10/19/23 at 1501 hours, an interview and concurrent medical record review of Resident 1's inventory forms were conducted with the SSD. The SSD acknowledged Resident 1's two pairs of eyeglasses with case, one pair of gloves, one electric razor with charger, and container of dentures should have been included in Resident 1's inventory list.
2. Medical record review for Resident 6 was initiated on 9/21/23. Resident 6 was admitted to the facility on [DATE].
On 9/21/23 at 1500 hours, an observation and concurrent interview with Resident 6 was conducted in Resident 6's room. A laptop with earphones, two electric razors with charger, one pair of prescription eyeglasses, one pair of sunglasses, and one electric toothbrush were observed at bedside. Resident 6 verified having the above-mentioned belongings upon admission.
On 9/22/23 at 1122 hours, an observation and concurrent interview with CNA 1 was conducted in Resident 6's room. CNA 1 verified the above-mentioned personal items at Resident 6's bedside were not labeled with the resident's name.
Review of Resident 6's Resident Inventory form dated 7/24/23, failed to show the laptop with earphones, two electric razors with charger, one pair of prescription eyeglasses, one pair of sunglasses, and one electric toothbrush were listed on the form.
Review of Resident 6's Personal Effect Inventory form dated 8/8/23, failed to show the laptop with earphones, two electric razors with charger, one pair of prescription eyeglasses, one pair of sunglasses, and one electric toothbrush were listed on the form.
On 10/19/23 at 1501 hours, an interview and concurrent medical record review of Resident 6's inventory forms were conducted with the SSD. The SSD acknowledged Resident 6's laptop with earphones, two electric razors with charger, one pair of prescription eyeglasses, one pair of sunglasses, and one electric toothbrush should have been included in Resident 1's inventory list.
3. Medical record review for Resident 7 was initiated on 9/21/23. Resident 7 was admitted to the facility on [DATE].
On 9/22/23 at 0935 hours, an observation was conducted in Resident 7's room. Resident 7 was observed to have a cell phone and eyeglasses on top of the bedside table.
On 9/22/23 at 1010 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified the cellphone and eyeglasses on Resident 7's bedside table and theseitems were not labeled with the resident's name.
Review of Resident 7's Resident Inventory form dated 2/7/23, did not show Resident 7's eyeglasses and cellphone on the list of personal property.
On10/19/23 at 1501 hours, an interview and concurrent medical record review of Resident 7's inventory form was conducted with the SSD. The SSD acknowledged Resident 7's eyeglasses and cellphone should have been included in Resident 7's inventory list.
4. Medical record review for Resident 2 was initiated on 9/21/23. Resident 2 was admitted to the facility on [DATE], and discharged on 9/7/23.
Review of Resident 2's Personal Effect Inventory form dated 9/8/23, showed Resident 2 had one cell phone, one charger, one pair of slippers, one pant, and one blouse. Further review of the form failed to show documented evidence the items were released to Resident 2 upon discharge.
On 10/19/23 at 1501 hours, an interview and concurrent medical record review of Resident 2's inventory form was conducted with the SSD. The SSD acknowledged Resident 2's inventory form should have been signed if Resident 2 took the items upon discharged .

b. According to Lexicomp, an online medical resource, Novalog and Humulin may be stored under refrigeration between 36°F to 46°F until the expiration date or at room temperature <86°F for 28 days.
On 11/12/21 at 0818 hours, an inspection of Medication Room A was conducted with LVN 7. The Refrigerator Temperature Log for November 2021 showed the temperatures must be kept between 36-46 degrees F. The refrigerator contained the refrigerated medications including insulin (medication to control blood sugar) and refrigerated medication emergency kit, including Ativan (medication for anxiety) and insulin (Humalog, Novalog, and Humulin).
Review of the temperature logs for October and November 2021 showed the temperatures were below the parameters (36-46 degrees F) as follows:
-10/1/21 for the 1500-2300 hours shift, a temperature of 25 degrees F.
-10/2/21 for the 1500-2300 hours shift, a temperature of 28 degrees F.
-10/3/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/4/21 for the 1500-2300 hours shift, a temperature of 25 degrees F.
-10/5/21 for the 1500-2300 hours shift, a temperature of 27 degrees F.
-10/6/21 for the 1500-2300 hours shift, a temperature of 25 degrees F.
-10/7/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/8/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/9/21 for the 1500-2300 hours shift, a temperature of 25 degrees F.
-10/10/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/11/21 for the 1500-2300 hours shift, a temperature of 28 degrees F.
-10/12/21 for the 1500-2300 hours shift, a temperature of 30 degrees F.
-10/13/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/14/21 for the 1500-2300 hours shift, a temperature of 28 degrees F.
-10/15/21 for the 1500-2300 hours shift, a temperature of 27 degrees F.
-10/16/21 for the 1500-2300 hours shift, a temperature of 26 degrees F.
-10/22/21 for the 1500-2300 hours shift, a temperature of 22 degrees F.
-10/24/21, and 10/27-10/30/21, no temperatures were documented.
- From 10/1/21 though 10/30/31, the 2300-0700 hours shifts; and 10/31/21 for the 1500-1100 hours shift, no temperatures weredocumented.
-11/4/21 for the 1500-2300 hours shift, a temperature of 33 degrees F.
-11/5/21 for the 2300-0700 hours shift, a temperature of 33 degrees F.
-11/5/21 for the 1500-2300 hours shift, a temperature of 34 degrees F.
-11/6/21 for the 2300-0700 hours and 1500-2300 shifts, a temperature of 34 degrees F.
LVN 7 stated the temperature range for the refrigerated medications was to maintain the medication efficacy and verified the out-of-range temperatures should have been followed-up and reported to the maintenance. The LVN also verified there were gaps in the temperature log.
On 11/12/21 0939 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he had not received a request to fix the medication refrigerators. In addition, the Maintenance Supervisor stated he had never performed maintenance on the medication refrigerators.
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications and biologicals were stored and disposed of properly.
* The skin/wound solution bottles and medication drawer for Treatment Cart B had stains and sticky residues. This posed the risk for unsafe storage of medication that could result to cross-contamination of the solutions.
* The facility failed to ensure the refrigerator temperatures were checked and maintained within the acceptable range daily for two of three medication rooms (Medication Rooms A and B) Medication Room B's refrigerator temperature log had multiple missing entries. Medication Room A's refrigerator temperature log showed the temperatures below the acceptable range without the follow-up actions to correct the out-of-range temperatures. These had the potential to affect the potency of the medications requiring storage at room temperature or refrigeration.
Findings:
1. According to the facility's P&P titled Storage of Medications dated 8/1/10, under the section Procedures showed outdated, contaminated, or deteriorated medications and those in the containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.
On 11/10/21 at 1454 hours, an inspection was conducted on Treatment Cart B with LVN 5. The following skin/wound solution bottles were observed to have stains outside of the bottles:
- one povidone iodine prep solution bottle with dried brown stains on the cap and all over the side of the bottle.
- one Hibiclens (Chlorhexidine Gluconate solution 4.0 percent w/v) bottle with dried pink stains outside of the bottle.
In addition, the bottom of the treatment cart drawer had sticky materials and medication residues.
On 11/10/21 at 1511 hours, an interview was conducted with LVN 5. LVN 5 verified the solution bottles and the bottom of the treatment cart drawer had stains and sticky residues. LVN 5 acknowledged the treatment nurses were responsible to keep the medication carts clean at all times.
On 11/10/21 at 1604 hours, an interview was conducted with the DON. The DON verified the above findings.
2. Review of the facility's P&P titled Storage of Medications dated 8/2010 showed the medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.
a. Review of Medication Room B's Refrigerator Temperature Log showed multiple missing entries as follows:
- 10/2/21, 3-11 and 11-7 shifts
- 10/3/21, 11-7 shift
- 10/4/21, 3-11 and 11-7 shifts
- 10/5/21, 3-11 and 11-7 shifts
- 10/6/21, 11-7 shift
- 10/7/21, 11-7 shift
- 10/8/21, 3-11 shift
- 10/9/21, 3-11 shift
- 10/11/21, 11-7 shift
- 10/12/21, 11-7 shift
- 10/13/21, 11-7 shift
- 10/14/21, 3-11 and 11-7 shifts
- 10/15/21, 3-11 shift
- 10/17/21, 11-7 shift
- 10/18/21, 11-7 shift
- 10/21/21, 3-11 shift
- 10/26/21, 3-11 shift
- 10/27/21, 3-11 shift
- 10/28/21, 3-11 shift
- 10/29/21, 11-7 shift
- 10/30/21, 11-7 shift
- 11/9/21, 3-11 shift
- 11/10/21, 11-7 shift
On 11/10/21 at 1514 hours, an inspection of Medication Room B and concurrent interview was conducted with LVN 9. When asked who was responsible for checking the medication room's refrigerator, LVN 9 stated the 3-11 and 11-7 shift nurses were responsible of checking the temperature and completing the Refrigerator Temperature Log daily. LVN 9 verified the missing entries for the months of October and November 2021. When asked about the purpose of checking the refrigerator temperature log, LVN 9 stated it was to ensure the refrigerator's temperature was within the acceptable range to maintain the medications potency.
On 11/10/21 at 1604 hours, an interview was conducted with the DON. The DON acknowledged the multiple missing entries on the Refrigerator Temperature Log. The DON stated the importance of checking the medication rooms refrigerator and completing the Refrigerator Temperature log was to ensure the refrigerator temperature was maintained within the parameters.

Based on observation, interview, facility P&P, and facility document review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by:
* Multiple food items observed in the kitchen were unlabeled, undated, and had expired.
* A section of the kitchen wall was damaged.
These failures had the potential to cause food borne illnesses in the 82 medically vulnerable residents who consumed food prepared in the kitchen.
Findings:
Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/8/21, showed 82 of 88 residents residing in the facility received food prepared in the kitchen.
1. Review of the facility's P&P titled Food Storage dated 7/25/19, showed all items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated.
During the initial tour of the kitchen with the DSS on 11/8/21 at 0745 hours, the following items were found:
* In the refrigerator,
- a thawed chicken with the use-by date of 11/3/21.
- three small plastic containers of a white substance, unlabeled and undated. The DSS identified the contents as sour cream.
- two small plastic containers of an orange fluid, unlabeled and undated.(salad dressing).
- one small plastic container with light colored fluid, unlabeled and undated (salad dressing).
- a bowl of sliced lemons, uncovered, unlabeled, and undated.
- 11 ham sandwiches without the preparation or use-by dates.
- eight peanut butter and jelly sandwiches without the preparation or use-by dates.
- a plastic bin of oranges with the use-by date of 11/1/21.
- a plastic bin of apples with the use-by date of 11/1/21.
- a plastic bin of potatoes and green peppers with the use-by date of 11/1/21.
- an unlabeled and undated plastic bag of moldy, rotten grapes.
* In the dry storage area,
- banana extract dated 2/18/21 - 8/18/21.
- mango sauce dated 9/27/21 - 10/27/21.
- strawberry sauce dated 8/29/21 - 9/26/21.
- chocolate sauce dated 9/22/21 - 10/26/21.
- craisins dated 4/1/21 - 7/13/21.
- shredded coconut dated 3/12/21 - 9/12/21.
- lemon Jell-o mix, unlabeled and undated.
- biscuit gravy, unlabeled and undated.
- bacon bits dated 4/27/21 - 10/27/21, with the instructions on the bag to refrigerate after opening.
The DSS verified the above findings and stated the food items should be covered and labeled with the name of the food item, preparation date, and use-by date. The DSS stated the expired food items should have been thrown out
2. According to the USDA Food Code 2017 Section 4-601.11 Surface Characteristics, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable for areas where food establishment operations are conducted.
According to the USDA Food Code 2017 Section 4-101.19, non food-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material.
During a concurrent observation and interview on 11/9/21 at 0908 hours, with the DSS in the kitchen. The wall next to the dish washing counter was observed to have large areas of silver coating peeling off. Additionally, the area of wall around a pipe entry point, just below the dish washing counter, was observed to have the sections of wall missing.
The DSS verified the findings and stated it needed to be fixed.
On 11/9/21 at 1445 hours, a concurrent observation and interview was conducted with the Maintenance Director. The Maintenance Director stated the damage to the wall was caused by food, water, and improper cleaning. The Maintenance Director stated there should be a side panel made of a material like stainless steel adding to the dish washing counter, so the food and water did not get on the wall. The Maintenance Director stated it needed to be repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the accurate and complete medical records for six of 18 final sampled residents (Residents 4, 8, 11, 22, 25, and 51a).
* Resident 22's supplemental oxygen use was not documented in the resident's MAR.
* Resident 4's colostomy bag change scheduled for every three days was not documented in the medical record.
* Resident 51a's urinary drainage bag weekly changes were not documented in the medical record.
* Residents 25's urinary drainage bag weekly changes were not documented in the medical record. In addition, Resident 25's pain medication dose was handwritten over without clarification.
* Residents 8 and 11's monitoring for the low air loss mattress setting in the TAR had missing multiple entries.
These failures had the potential for the residents' care needs not being met as their medical information was inconsistent in the medical record.
Findings:
1. Medical record review for Resident 22 was initiated on 11/8/21. Resident 22 was admitted to the facility on [DATE].
Review of the Resident 22's Physician Orders dated November 2021 showed the following orders dated 9/21/21:
- Oxygen at 2 lpm continuously for shortness of breath/desaturation.
- Monitor oxygen saturation level (oxygen level in the blood) every shift and may titrate oxygen from 3-4 lpm if oxygen saturation is below 92%.
Review of the MAR dated October 2021 showed Resident 22's oxygen desaturation levels on 10/6 and 10/12/21, 7-3 shifts were at 70% and 60%, respectively. Further review of the MAR failed to show documented evidence of the oxygen titration when Resident 22's oxygen saturation level below 92%.
On 11/9/21 at 0831 hours, Resident 22 was observed in bed receiving supplemental oxygen at 3.5 lpm via nasal cannula.
On 11/12/21 at 0759 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 stated Resident 22 had a physician's order for continuous oxygen at 2 lpm and should only be increased when his oxygen saturation level was less than 92%. LVN 7 verified there was no documentation in Resident 22's medical record to show when he started receiving oxygen at 3.5 lpm.
2. Medical record review for Resident 4 was initiated on 11/8/21. Resident 4 was admitted to the facility on [DATE].
Review of Resident 4's Physician Order list for November 2021 showed an order dated 2/8/18, to change the resident's colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall) every three days and as needed.
Review of Resident 4's TAR for November 2021 failed to show documentation the resident's colostomy bag was changed as ordered.
On 11/10/21 at 1358 hours, an interview and concurrent medical record review were conducted with LVN 5. LVN 5 stated Resident 4's colostomy bag had been changed regularly. LVN 5 acknowledged there was no documentation in the medical record to show Resident 4's colostomy bag changes.
3. Medical record review for Resident 51a was initiated on 11/8/21. Resident 51a was admitted to the facility on [DATE].
Review of Resident 51a's TAR dated October 2021 showed an order dated 9/19/21, to change the urinary catheter bag weekly. The TAR showed Resident 51a's urinary catheter bag was changed on 10/3/21. There was no documentation to show Resident 51a's urinary catheter bag was changed weekly as ordered.
On 11/10 21 at 1404 hours, an interview and concurrent record review were conducted with LVN 3. LVN 3 stated he was responsible for changing Resident 51a's urinary drainage bag weekly. LVN 3 reviewed Resident 51a's TAR for October 2021 and verified there was no documentation in the medical record to showed Resident 51a's urinary catheter bag was changed weekly.
4.a. Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE].
Review of Resident 25's Physician Orders dated November 2021, showed an order dated 10/23/21, to change the resident's urinary catheter drainage bag weekly.
Review of the TAR dated October 2021 did not show the physician's order to change the urinary catheter bag weekly. There was no documentation to Resident 25's urinary catheter bag was changed weekly as ordered. The The TAR date November 2021 showed encircled nurse's initials. There was no documentation in the TAR Resident 25 refused care.
On 11/10/21 at 1349 hours, an interview and concurrent medical record review were conducted with LVN 5. LVN 5 verified the TAR for October did not include the physician's order to change the urinary drainage bag. LVN 5 and stated their initials were circled for each day which meant it had not been done for the month of November. LVN 5 acknowledged there was no documentation in Resident 25's medical record to show the urinary drainage bag was changed weekly as ordered by the physician. Cross reference to F690.
b. Review of Resident 25's hand written Physician Orders dated 10/2/21 at 1700 hours, showed an order for Norco 5/325 mg every four hours for moderate to severe pain.
Review of Resident 25's Physician Orders lists for October and November 2021, showed an order for Norco 3-325 mg tablet every four hours as needed for moderate to severe pain. The order list showed it was signed by the physician on 11/1/21.
Review of Resident 15's Medication Administration Record for November 2021, showed a typed/printed order for Norco with a hand written 5 over another number/letter to show Norco 5-325 mg.
On 11/10/21 at 1009 hours, an interview and concurrent medical record review were conducted with LVN 6. LVN 6 reviewed Resident 25's MAR and verified a 5 was handwritten in. LVN 6 stated the order should not have been modified in the MAR without clarifying the order with the physician. 5. Review of Resident 11's medical record was initiated on 11/8/21. Resident 11 was admitted to the facility on [DATE].
Review of the Physician's order dated 11/2021, showed an order dated 8/14/21, for staff to monitor the low air loss mattress setting every shift. The order further showed to adjust the low airless mattress based on weight and comfort.
Review of the TAR dated November 2021, showed multiple missing entries for the low air loss mattress settings.
On 11/12/21 at 0931 hours, a concurrent interview and medical records review was conducted with LVN 3. When asked to describe the importance of checking the low air loss mattress every shift, LVN 3 stated it was intended to prevent the wound from getting worse. LVN 3 further stated the low air loss mattress setting had to be check to ensure it was appropriate for the Resident 11. LVN 3 verified the missing entries on the following dates and shifts in Resident 11's TAR:
- 11/1/21, for the 3-11 shift
- 11/2/21, for the 3-11 shift
- 11/3/21, for the 11-7, 7-3 and 3-11 shifts
- 11/4/21, for the 3-11 shift
- 11/5/21, for the 3-11 shift
- 11/6/21, for the 3-11 shift
- 11/7/21, for the 3-11 shift
- 11/8/21, for the 3-11 shift
- 11/9/21, for the 3-11 shift
- 11/10/21, for the 3-11 shift
LVN 3 stated the staff should have documented the assessment for the low air loss mattress settings in Resident 11's medical record. Cross reference to F686.
6. Review of Resident's 8 medical record was initiated on 11/9/21. Resident 8 was admitted to the facility on [DATE].
Review of the Physician Orders for November 2021 showed an order dated 8/12/21 to monitor Resident 8's low air loss mattress setting every shift and may adjust based on weight.
On 11/10/21 at 0847 hours, a wound care observation was conducted with LVN 3, Resident 8 was observed lying on a low air loss mattress in bed.
On 11/10/21 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated the low air loss mattress setting depend on the residents weight. When asked who was responsible on checking and documenting the low air loss mattress setting in the medical record, LVN 3 stated the treatment nurse was responsible for the 7 to 3 and 3 to 11 shifts while the RN supervisor was responsible for the 11-7 shift. LVN 3 verified Resident 8's TAR for November 2021 had multiple missing entries on the following dates:
- 11/1/21, for the 11-7 and 3-11 shifts
- 11/2/21, for the 11-7 and 3-11 shifts
- 11/3/21, for the 11-7, 7-3 and 3-11 shifts
- 11/4/21, for the 11-7 shift
- 11/5/21, for the 11-7, 7-3 and 3-11 shifts
- 11/6/21, for the 11-7 and 3-11 shifts
- 11/7/21, for the 11-7 and 3-11 shifts
- 11/8/21, for the 11-7 and 3-11 shifts
- 11/9/21, for the 11-7 and 3-11 shifts
- 11/10/21, for the 11-7 and 3-11 shifts
When asked about the multiple missing entries, LVN 3 did not respond.
On 11/12/21 at 1533 hours, an interview was conducted with the DON. The DON verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 35), one nonsampled resident (Resident 26), and one staff member were offered or received the influenza or pneumococcal vaccine (an injection given to protect from severe pneumococcal disease) as per the facility's P&P. This failure put the residents and staff at risk for poor health outcomes.
Findings:
Review of the facility's P&P titled Influenza Prevention & Control revised 9/10/20, showed the following:
* Vaccinating Residents Against Influenza:
- The resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization - with such refusal being noted in the resident's medical record.
* Vaccinating Facility Staff Against Influenza:
- Employees are offered the influenza vaccine upon hire or during the annual flu season.
- The vaccination will be documented in the employee's health record.
- The employee may refuse the vaccine. The refusal will be documented in the employee's health record.
Review of the facility's P&P titled Pneumococcal Disease Prevention revised 2/18/21, showed the pneumococcal vaccine is recommended for the residents of nursing homes or long-term care facilities.
1. Medical record review for Resident 35 was initiated on 11/8/21. Resident 35 was admitted to the facility on [DATE].
Review of Resident 35's medical record failed to show Resident 35 was offered the influenza and pneumonia vaccine.
2. Medical record review for Resident 26 was initiated on 11/8/21. Resident 26 was admitted to the facility on [DATE].
Review of Resident 26's medical record showed Resident 26 had consented to the pneumococcal vaccine on 1/21/21; however, the vaccination was never administered to the resident.
3. Review of LVN 3's vaccination records failed to show the facility offered LVN 3 the influenza vaccine.
On 11/15/21 at 0920 hours, a medical record review and concurrent interview was conducted with MDS Nurse 2. MDS Nurse 2 verified the above findings and stated the resident or resident representative should be offered the vaccines within 72 hours of admission. MDS Nurse 2 stated when the consent was obtained for a vaccine, the vaccine should be administered. When asked why documentation of the administration or declination of the vaccine was important, MDS Nurse 2 stated it was important to show the facility had offered the vaccines since the residents could be fragile. MDS Nurse 2 further stated pneumonia or a simple flu could be deadly for the residents. MDS Nurse 2 verified LVN 3 was not offered the influenza vaccine and stated they should have been. When asked why offering the influenza vaccine to the staff was important, MDS Nurse 2 stated so they would not have an outbreak of the flu in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six nonsampled residents (Resident 52) was provided care in a manner that promoted dignity and respect. This failure posed the risk to negatively impact the resident's self-esteem.
Findings:
Review of the facility's P&P titled Restorative Dining Program dated 1/1/12, showed the staff members should sit while assisting or feeding residents.
Medical record review for Resident 52 was initiated on 11/8/21. Resident 52 was readmitted to the facility on [DATE].
Review of Resident 52's MDS dated [DATE], showed Resident 52 required extensive assistance and physical assistance of one person for eating.
On 11/8/21 at 1230 hours, a dining observation and concurrent interview with CNA 1 was conducted. CNA 1 was observed standing over Resident 52 while feeding the resident with a spoon. CNA 1 verified he was standing while assisting Resident 52 with lunch. CNA 1 stated they should not have been standing while feeding Resident 52. When asked why feeding the resident while being seated was important, CNA 1 stated being seated while feeding the resident was important for eye contact and to see if the resident choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to accommodate the needs for one of nonsampled residents (Resident 365). The facility failed to ensure Resident 365 was provided the appropriate type of call light and kept in within her reach. This failure placed the resident at risk for her needs to not be met.
Findings:
Medical record review for Resident 365 was initiated on 11/15/21. Resident 365 was admitted to the facility on [DATE].
Review of the plan of care showed a care plan problem dated 12/28/20, addressing Resident 365's risk for falls. Interventions included to remind the resident to use a call light and the use of a padded call light (used for residents who may have difficulty using standard call lights).
On 11/8/21 at 1024 hours, during an initial tour of the facility, Resident 365 was heard yelling for help. Resident 365 was observed sitting in a wheelchair next to her bed. Resident 365's call light was observed tucked under the blankets on her wheelchair, out of her sight and reach. Resident 365 was observed to have uncontrolled body movements of her arms and legs. Resident 365 attempted to reach her call light by curling her shaky finger around the cord to the call light. Resident 365 stated, I can't reach my call light can somebody help me.
On 11/8/21 at 1033 hours, the DSD entered the room and pulled the call light out from under the blankets on Resident 365's wheelchair. The call light was observed to be the standard type of call light which was a handgrip with a button call light, rather than the padded call light. The DSD acknowledged Resident 365 was unable to use and should have been provided a padded call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to complete the admission, entry, and quarterly MDS assessments timely for three of 18 final sampled residents (Residents 25, 27, and 51a) and seven of 13 nonsampled residents (Residents 7, 37, 52, 700, 701, 702, and 703). This failure had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, strengths and needs.
Findings:
Review of the facility's P&P titled RAI OBRA Required Assessment Summary revised 10/13 showed the following:
* For Assessment Type - admission: the MDS completion date is to be no later than the 14th calendar day from the resident's admission date.
* For Assessment Type - Entry Tracking Record: the MDS completion date is to be no later than 7 calendar days from the entry date.
* For Assessment Type - Quarterly: the MDS completion date is to be no later than 14 calendar days.
On 11/10/21 at 1123 hours, review of the facility's MDS submissions and concurrent interview was conducted with MDS Nurse 1. Review of the MDS submissions showed the following:
* Resident 37's entry record was dated 10/13/21; however, the assessment was not submitted until 11/4/21.
* Resident 7's entry record was dated 10/13/21; however, the assessment was not submitted until 10/26/21.
* Resident 700's entry record was dated 10/7/21; however, the assessment was not submitted until 10/26/21.
* Resident 700's entry record was dated 9/9/21; however, the assessment was not submitted until 9/25/21.
* Resident 52's entry record was dated 9/11/21; however, the entry assessment was not submitted until 10/1/21.
* Resident 25's entry record was dated 10/2/21; however, the entry assessment was not submitted until 10/22/21.
* Resident 25's entry record was dated 9/7/21; however, the entry assessment was not submitted until 9/23/21.
* Resident 701's entry record was dated 10/12/21; however, the entry assessment was not submitted until 10/27/21.
* Resident 27's quarterly assessment was dated 3/15/21; however, the assessment was not submitted until 4/27/21. Another quarterly assessment for Resident 27 was dated 6/15/21; however, the assessment was not submitted until 7/16/21.
* Resident 51a's entry assessment dated [DATE]; however, the assessment was not submitted until 7/29/21.
* Resident 702's entry record was dated 9/27/21; however, the assessment was not submitted until 10/18/21.
* Resident 703's entry record was dated 9/17/21; however, the assessment was not submitted until 10/4/21.
When asked how long the facility had to complete and submit the MDS assessments, MDS Nurse 1 stated for the initial and quarterly assessments, they had 14 days to sign and complete, and for the entry assessments, they had seven days to sign and complete. When asked if the above MDS assessments were submitted on time, MDS Nurse 1 stated no, they were late. When asked why timely submission of the assessments was important, MDS Nurse 1 stated it was important to determine the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure accurate coding of the MDS for two of 18 final sampled residents (Residents 8 and 27).
* For Resident 27, the MDS was coded inaccurately for RNA services.
* The facility failed to ensure Resident 8's indwelling urinary catheter use was coded accurately.
These failures posed the risk of the residents not receiving appropriate care interventions due to incorrect health assessments.
Findings:
1. Medical record review for Resident 27 was initiated on 11/8/21. Resident 27 was admitted to the facility on [DATE].
Review of the Physician's Telephone Order showed an order dated 5/29/21, for RNA services to provide AROM (assisted range of motion) exercise to the right upper extremity five times per week.
Review of the Restorative Nursing flowsheet dated 9/21, showed Resident 27 received AROM exercise on 9/1, 9/2, 9/3, 9/6, 9/7, 9/8, 9/9, and 9/10/21.
Review of Resident 27's MDS dated [DATE], showed under the O - Restorative Nursing Program section, zero was documented for number of days that the resident received AROM exercise.
On 11/09/21 at 1115 hours, an interview and concurrent medical record review was conducted with MDS Nurse 2. MDS nurse 2 verified the MDS was incorrectly coded as zero days and should have been coded as five since the resident received AROM exercise five times in a week.
2. Medical record review for Resident 8 was initiated on 11/9/21. Resident 8 was admitted to the facility on [DATE].
Review of the Physician Orders showed an order dated 8/12/21, for an indwelling urinary catheter to gravity drainage bag related to urinary retention.
Review of the MDS dated [DATE], showed under Section H for Appliances did not show Resident 8 having an indwelling urinary catheter.
On 11/12/21 at 0903 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1 regarding Resident 8's MDS assessment. MDS Nurse 1 stated Resident 8 was admitted with an indwelling urinary catheter for diagnoses including urinary retention. MDS Nurse 1 verified Resident 8's use of indwelling urinary catheter was not coded correctly, and the MDS assessment was not accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. Medical record review for Resident 365 was initiated on 11/15/21. Resident 365 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 365 had severe cognitive impairment and needed assistance from the staff for her ADL care.
Review of the plan of care showed a care plan problem dated 12/28/20, addressing Resident 365's potential for injury related to uncontrolled movements, impaired verbal communication, fatigue related to extremity weakness spasticity, and urinary retention. The interventions include the following:
- To assess resident as necessary every shift, quarterly and annually.
- To report any abnormalities to the MD, resident, and responsible party.
- To ensure the intervention applied as ordered.
- To administer the medications as ordered.
- To perform lab tests as ordered.
- To provide necessary assistance.
- To monitor sings and symptoms of urinary retention.
- To assist with meal time at all times.
- To offer fluids at least 6-8 glasses of water if not contraindication.
- To report to MD for worsening of symptoms.
However, the interventions listed did not address how to prevent injuries due to Resident 365's uncontrolled movement.
On 11/8/21 at 1033 hours, a concurrent observation and interview was conducted with the DSD. The DSD verified the bruising on Resident 365's right arm was from Resident 365's arm hitting the wheelchair. When asked what interventions were in place to prevent Resident 365 from developing bruises from hitting her arms on the wheelchair, the DSD stated there was none.
On 11/15/21 at 1056 hours, an interview and concurrent medical record review was conducted with MDS Nurse 2. MDS Nurse 2 verified Resident 365's plan of care did not provide specific interventions to prevent Resident 365 from developing bruises from hitting the arm of the wheelchair. Cross reference to F689.
Based on interview, and medical record review, the facility failed to develop a care plan problem for one of 18 final sampled residents (Resident 8) and one nonsampled residents (Resident 365).
* Resident 8 was assessed to have moisture-associated skin damage (MASD) problem; however, a care plan problem was not developed to address the MASD. This failure placed Resident 8 at risk of not having her care needs met.
* Resident 365 was observed to have bruising to her right arm; however, a care plan problem was not developed and implemented to show the interventions to address the uncontrolled body movements. This failure caused Resident 365 to sustain bruising to her right arm due to her arms repeatedly hitting the sides of the wheelchair.
Findings:
1. Review of Resident 8's medical record was initiated on 11/9/21. Resident 8 was admitted to the facility on [DATE].
Review of the Wound Assessment and Plan showed Resident 8 had a MASD.
Review of the Physician Orders list showed an order dated 9/16/21, for perineum MASD, to cleanse with soap and warm water, pat dry, apply dermafungal cream daily and as needed.
Review of the medical record did not show a care plan problem addressing Resident 8's MASD was developed.
On 11/10/21 at 0834 hours, an interview and concurrent medical record review was conducted with LVN 3 and MDS Nurse 2. LVN 3 and MDS Nurse 2 reviewed Resident 8's plan of care and was unable to find a care plan problem addressing Resident 8's MASD. LVN 3 stated it was important to develop a care plan to monitor the problem, set a goal, and evaluate if the goal was achieved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were developed and revised for two of 18 sampled residents (Residents 4 and 25) to reflect changes in the residents' care needs.
* The facility failed to revise Resident 4's plan of care to include a reasonable and realistic goal for the resident's chronic pressure injury.
* The facility failed to discontinue Resident 25's care plan problem regarding isolation status.
These failures placed the residents at risk of their care needs not being met.
Findings:
1. Medical record review for Resident 4 was initiated on 11/8/21. Resident 4 was readmitted to the facility on [DATE].
Review of Resident 4's History and Physical Examination dated 6/3/21, showed the resident had a chronic Stage 4 pressure injury.
Review of Resident 4's plan of care showed a care plan problem dated 12/17/20, addressing the resident's Stage 4 pressure injury. One of the care plan's goals was for the pressure injury to heal within 30 days.
Review of Resident 4's Weekly Pressure Injury/Ulcer Progress Report dated 11/4/21, showed the resident's pressure injury was still an ongoing wound and not healed.
On 11/9/21 at 0835 hours, an interview was conducted with Resident 4. Resident 4 stated she still had a pressure injury and had it since 2015.
On 11/10/21 at 1144 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 4's plan of care and stated the resident's pressure injury was a long term wound and for it to be resolved within 30 days would not be realistic. The DON stated the plan of care should have been revised with a more realistic goal, once the first goal was not achieved.
2. Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE].
Review of Resident 25's History and Physical examination dated 10/4/21, showed the resident was admitted to an acute care hospital for COVID pneumonia.
Review of Resident 25's plan of care showed a care plan problem dated 10/2/21, addressing COVID-19 positive requiring contact/droplet isolation. An intervention to implement transmission based precautions was still active in the care plan.
On 11/9/21 at 0828 hours, an observation was made of Resident 25. Resident 25 was in their room located in the green, non COVID-19 zone.
On 11/10/21 at 1138 hours, an interview was conducted with the Administrator. The Administrator stated Resident 25 was admitted to the red COVID-19 zone when they were readmitted to the facility; however, they were cleared and transferred to the green, non-COVID-19 zone on 10/23/21.
On 11/10/21 at 1139 hours, and interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 25's plan of care and stated the resident no longer had COVID-19 and the care plan for COVID-19 isolation should have been discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injury for one of 18 final sampled residents (Residents 11). Resident 11 was on a low air loss mattress for wound management. The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 11. This failure could result in delayed wound healing for Resident 11 and development of new pressure injuries.
Findings:
According to the facility's P&P titled Mattresses revised 1/1/12, the facility will provide mattresses to provide pressure reduction to residents at risk for skin breakdown; and to check air mattress routinely to ensure it is working properly and record the use of the mattress and resident outcome in the medical record.
Review of Resident 11's medical record was initiated on 11/8/21. Resident 11 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 11 weighed 137 pounds. Resident 11 was totally dependent on staff with his ADL care. Resident 11 had a Stage 3 pressure injury when he was admitted to the facility.
Review of the Physician's Orders list dated 11/2021 showed an order dated 8/14/21, to provide a low air loss mattress for wound management. Another order showed for the staff to monitor the low air loss mattress setting every shift and may adjust the low air loss mattress based on weight and comfort.
Review of the plan of care showed a care plan problem dated 8/14/21, addressing pressure injury at the lower back. The goal was to minimize the risk for skin breakdown. Interventions included the use of pressure redistributing device and assess for effectiveness.
Review of the TAR dated November 2021 showed multiple missing entries for the low air loss mattress settings.
On 11/8/21 at 1006 hours, Resident 11 was observed lying in bed. Resident 11 had a low air loss mattress with a pressure setting of 6. Resident 11's low air loss mattress control panel showed the pressure controls buttons based on the resident's weight as follows:
- Settings 1 and 2 -100 pounds
- Setting 3 - between 100 and 200 pounds
- Settings 4 and 5 - 200 pounds
- Setting 6 - between 200-300 pounds
- Settings 7 and 8 - 300 pounds
- Settings 9 and 10 - 400 pounds
On 11/09/21 at 0852 hours, Resident 11 was observed lying in bed. Resident 11's low air loss mattress pressure setting was at 6.
On 11/10/21 at 0951 hours, a wound treatment observation was conducted with LVN 3 for Resident 11. Resident 11's low air loss mattress pressure setting was still at 6. When asked what the appropriate setting for Resident 11, LVN 3 stated the setting had to be based on Resident 11's weight. LVN 3 stated based on the resident's weight, Resident 11's low air loss mattress pressure setting should have been set at 2. When asked about the importance of being in the correct setting, LVN 3 stated it was to help in preventing the development and deterioration of pressure injury.
On 11/12/21 at 0931 hours, a concurrent interview and medical records review was conducted with LVN 3. LVN 3 verified Resident 11's low airloss mattress setting was not monitored by the staff. LVN 3 stated the low air loss mattress settings had to be check to ensure it was appropriate for the Resident 11. Cross reference to F842, example #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one nonsampled resident (Resident 365). This had the potential to increase the risk of injury to the resident.
Findings:
Medical record review for Resident 365 was initiated on 11/15/21. Resident 365 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 365 had severe cognitive impairment and needed assistance from the staff for her ADL care.
On 11/8/21 at 1024 hours, Resident 365 was observed sitting in a wheelchair next to her bed. Resident 365 was observed to have uncontrolled body movements. Resident 365's arms were observed banging against the armrests of the wheelchair. Resident 365 was observed to have small red areas and bruising on her right forearm which was the same area observed hitting the arm of the wheelchair. Resident 365 stated, my arm hurts.
On 11/8/21 at 1033 hours, a concurrent observation and interview was conducted with the DSD. The DSD verified the bruising on Resident 365's right arm was from Resident 365's arm hitting the wheelchair. When asked what interventions were in place to prevent bruises from Resident 365's arms hitting the wheelchair, the DSD stated there was none.
On 11/15/21 at 1413 hours, a concurrent observation and interview was conducted with CNA 3. CNA 3 acknowledged Resident 365 had developed bruising and mild swelling on the right forearm from the continuous hitting against the armrest of the wheelchair. CNA 3 stated she had not been putting pillows on Resident 365 while the resident was in her wheelchair to prevent her from developing bruising and swelling on her right arm. Cross reference to F656.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 18 final sampled residents (Resident 25) with an indwelling urinary catheter. The facility failed to ensure Resident 25's urinary catheter drainage bag was changed weekly as ordered by the physician. This failure had the potential for complications related to indwelling urinary catheter use.
Findings:
Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 25 had severe cognitive impairment. Resident 25 had an indwelling urinary catheter and needed extensive assistance with his ADL care.
Review of the Physician Orders list for November 2021 showed an order dated 10/3/21, to place an indwelling urinary catheter for urinary retention and change the resident's urinary catheter drainage bag weekly.
Review of the Resident's TAR for October 2021 and November 2021 failed to show documented evidence when the drainage bag was changed.
On 11/10/21 at 1349 hours, an interview and concurrent medical record review were conducted with LVN 5. LVN 5 verified there was no documentation to show when the urinary drainage bag was changed in October. LVN 5 stated she had not changed Resident 25's urinary drainage bag yet for the current week. When asked when the urinary catheter drainage bag was last changed, LVN 5 and stated their initials were circled for each day which meant it had not been done for the month of November.
On 11/12/21 at 1101 hours, a follow-up interview was conducted with LVN 5. LVN 5 stated the purpose of changing the urinary drainage bag weekly was to decrease bacterial growth and help prevent a urinary tract infection. Cross reference to F842.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for two of 18 final sampled residents (Residents 22 and 515).
* The facility failed to ensure Resident 22 was administered oxygen as ordered by the physician.
* Resident 515 continued to receive oxygen when it had been discontinued by the physician.
These failures had the potential for the residents to receive unnecessary supplemental oxygen.
Findings:
According to the facility's P&P titled Oxygen Therapy revised 4/1/12, showed to administer oxygen per the physician's orders.
1. Medical record review for Resident 22 was initiated on 11/8/21. Resident 22 was admitted to the facility on [DATE].
Review of the Resident 22's Physician Orders list for November 2021 showed the following orders dated 9/21/21:
- Oxygen at 2 lpm continuously for shortness of breath/desaturation.
- Monitor oxygen saturation level (oxygen level in the blood) every shift and may titrate oxygen from 3-4 lpm if oxygen saturation level below 92%.
Review of the MAR dated October 2021 showed Resident 22's oxygen saturation levels were between 92-98%. Resident 22's oxygen desaturation levels on 10/6 and 10/12/21, 7-3 shifts were 70% and 60%, respectively. Further review of the MAR failed to show documented evidence of the oxygen titration when Resident 22's oxygen saturation levels below 92% as ordered.
On 11/9/21 at 0831 hours, Resident 22 was observed in bed receiving supplemental oxygen at 3.5 lpm via nasal cannula.
On 11/9/21 at 1616 hours, a concurrent observation an interview was conducted with LVN 7. LVN 7 stated he was in charge of Resident 22 for the 1500 to 2300 hours shift. When asked how much oxygen Resident 22 was on, LVN 7 replied Resident 22 should be on 2 lpm of oxygen. LVN 7 verified Resident 22's oxygen therapy was currently at 3.5 lpm.
On 11/12/21 at 0759 hours, a follow-up interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified Resident 22's oxygen saturation levels were within the 92-98% range and stated Resident 22's oxygen therapy was to be at 2 lpm and would be increased only when the oxygen saturation level less than 92%. Cross reference to F842.
2. Review of Resident 515's medical record review was initiated on 11/10/21. Resident 515 was admitted to the facility on [DATE].
Review of Resident 515's Physician Order dated 11/12/21, showed to discontinue the oxygen therapy.
Review of Resident 515's Medication Administration Record dated 11/1/21-11/30/21, showed oxygen via nasal canula at 2 lpm was ordered on 11/6/21, and discontinued on 11/15/21.
On 11/8/21 at 1312 hours, 11/10/21 at 1544 hours, and 11/15/21 at 0808 hours, Resident 515 was observed receiving oxygen on via nasal cannula at 2 lpm.
On 11/15/21 at 0927 hours a concurrent interview and medical record review was conducted with LVN 11. LVN 11 acknowledged Resident 515 was still on the oxygen therapy and Resident 515's oxygen was discontinued by the physician on 11/12/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure appropriate pain management for one of 18 final sampled residents (Resident 25).
* Resident 25's pain was not appropriately assessed, communicated to their charge nurse, and managed prior to wound care and catheter care treatments. In addition, Resident 25's pain was not being monitored and documented every shift. These failures could result in the resident's pain not being accurately monitored, assessed, and managed.
Findings:
Review of the facility's P&P tiled Pain Management revised November 2016 showed the facility will ensure the assessment and management of the resident's pain to the extent possible when such services are required. The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale, the shift pain score will indicate the highest pain level that occurred on that shift. Nursing staff will implement timely interventions to reduce an increase in severity of pain.
Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 25 had severe cognitive impairment. Resident 25 had a Stage 3 pressure ulcer when he was admitted to the facility.
Review of the plan of care showed a care plan problem dated 10/2/21, addressing Resident 25's risk for pain. The goal was for Resident 25 to verbalize pain and show decreased signs and symptoms of pain. Interventions included to administer pain medication as ordered, assess pain medication and treatments for effectiveness, and assess level of pain using the pain rating scale of 1-10.
a. Review of Resident 25's TAR for November showed the following:
- An order dated 10/3/21, for daily urinary catheter care.
- An order for wound care for the sacrococcxy (the joint in the tailbone formed between the sacrum and the coccyx)pressure injury (sores that happen on areas of the skin that are under pressure) to be completed daily.
- To monitor for pain prior to, during, and after treatments. The TAR showed 0 for all entries from 11/1/21 through 11/9/21, with LVN 5's initials for 11/1, 11/2, 11/3, 11/4, 11/5, 11/8, and 11/9/21.
Review of Resident 25'sMAR dated November 2021, showed the following orders:
- Norco (a narcotic pain medication) 5-325 mg one tablet by mouth every 24 hours for moderate-severe pain
-
Acetaminophen 325 mg 2 tablets by mouth for mild pain
On 11/12/21 at 0909 hours, during the wound treatment and catheter care observation for Resident 25 with LVNs 5 and 10, Resident 25 stated, I'm in so much pain. Resident 25's requested to stop the treatment.
On 11/12/21 at 1101 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 25 always complained of pain during wound treatments. LVN 5 stated Resident 25 was premedicated prior to the wound treatment observation.
Further review of the MAR and Pain Assessment Flow Sheet for November 2021 showed no documented evidence Resident 25 was provided with the non-pharmacological interventions and pain medications when he complained of pain during the wound treatment and catheter care observation conducted on 11/12/21.
On 11/12/21 at 1106 hours, an interview was conducted with LVN 6. LVN 6 stated she was the medication nurse assigned for Resident 25 for the past three days. When asked if Resident 25 had complained of pain prior to the wound treatment, LVN 6 stated no. LVN 6 stated she had not been notified by LVN 5 when Resident 5 complained of pain. When asked if Resident 25 had received a pain mediation prior to wound treatment, LVN 6 denied administering the pain medications to Resident 25 for the past three days and prior to the wound treatment observation.
On 11/12/21 at 1126 hours, a follow-up interview was conducted with LVN 5 regarding Resident 25's statement of having pain. LVN 5 stated Resident 25 always complains and argues that he had pain. When asked how she assessed Resident 25's pain, LVN 5 stated Resident 25 got mad at her everytime she asked about his pain level. When asked how Resident 25 expressed pain, LVN 5 stated he said ouch ouch. When asked what the nurse should do when Resident 25 complained of pain, LVN 5 stated she should notify Resident 25's nurse. LVN 5 acknowledged she did not notify Resident 25's nurse when he complained of pain during wound treatment. When asked to clarify if Resident 25 was assessed for pain and had received his pain medication prior to the wound treatment observation, LVN 5 stated she just assumed Resident 25 had received his pain medication prior to wound treatment.
b. Review of the Pain Assessment Flow Sheet for November 2021 showed Resident 25 had complained of generalized body pain with pain levels of 8 and was given Norco for pain.
Review of the MAR dated November 2021 showed Resident 25 had received Norco 5-325 mg for pain on 11/2, 11/3,11/4, 11/5, and 11/7. However, there was no documentation to show Resident 25 was assessed for pain every shift.
On 11/10/21 at 1009 hours, an interview and concurrent medical record review were conducted with LVN 6. LVN 6 verified the Resident 25 was not monitored for pain every shift.
On 11/10/21 at 1014 hours, an interview was conducted with the Administrator. The Administrator stated if a resident had an order and received the pain medication, the pain levels had to be monitored every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents needs.
* The facility failed to ensure the administration of hydrocodone- acetaminophen (an opioid medication used for moderate to severe pain) for Residents 25, 28, and 51a were accurately documented to ensure accurate reconciliation and prevent the medication administration errors. These failures post the risk for loss or diversion of controlled medications.
* The facility failed to ensure the incoming and outgoing licensed nurses assigned were consistently signed the Medication Cart A's controlled medication accountability record. This failure post the risk for loss or diversion of controlled medications.
* The facility failed to ensure the glucometer for Medication Cart A was calibrated on a regular basis. The glucometer calibration logs had multiple missing entries. This posed the risk for inaccurate blood glucose test results and inappropriate treatments.
Findings:
1. On 11/12/21 at 1106 hours, an inspection of Medication Cart B was conducted with LVN 6. LVN 6 stated the process for administering the controlled medications was to remove the medication from the supply, sign it out on the Controlled Medication Count Sheet, and document administration on the MAR; and if administering a pain medication, also document on the Pain Assessment Flowsheet.
a. Medical record review for Resident 25 was initiated on 11/8/21. Resident 25 was readmitted to the facility on [DATE].
Review of Resident 25's Narcotic and Hypnotic Record for hydrocodone- acetaminophen 5-325 mg tablets showed the medication tablets were removed from the supply on 11/1/21 at 0400 hours, 11/3/21 at 0100 hours, and 11/4/21 at 0200 hours.
However, review of Resident 25's Pain Assessment Flow Sheet and MAR for November 2021 failed to show the medications were administered to the resident at the above times when they were removed.
b. Medical record review for Resident 51a was initiated on 11/8/21. Resident 51a was admitted to the facility on [DATE].
Review of Resident 51a's Narcotic and Hypnotic Record for hydrocodone- acetaminophen 5-325 mg tablets showed the medication tablets were removed from the supply on 11/1/21 at 0500 hours, 11/2/21 at 0300 hours, and 11/11/21 at 0800 hours.
However, review of the Pain Assessment Flow Sheet and MAR for November 2021 failed to show the medications were administered to the Resident 51a at the above times when they were removed.
c. Medical record review for Resident 28 was initiated on 11/12/21. Resident 28 was admitted to the facility on [DATE].
Review of Resident 28's Narcotic and Hypnotic Record for hydrocodone-acetaminophen 5-325 mg tablets showed the medication tablets were removed from the supply on 11/3/21 at 0200 hours, and 11/4/21 at 0000 hours. However, review of Resident 28's Pain Assessment Flow Sheet and MAR for November 2021 failed to show the medications were administered to the resident at the above times when they were removed.
LVN 6 verified the above findings and stated the administration record should account for the medications removed from the supply.2. According to the facility's P&P titled Controlled Medication Storage dated 8/1/2010, showed the medication included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The Procedures section showed at each shift change, a physical inventory of all controlled medications including the emergency supply is conducted by two licensed nurses and documented on the controlled medication accountability record.
Review of the Medication Cart C controlled medication accountability record showed the List of Narcotics section with multiple missing licensed nurses' signatures on 11/10/21, for the 7-3 outgoing shift and 3-11 incoming shift.
On 11/12/21 at 1045 hours, an interview and concurrent facility document review was conducted with LVN 8. LVN 8 verified multiple licensed nurses' signatures were missing on the List of Narcotics log. LVN 8 stated the licensed nurses were supposed to sign the List of Narcotics log after counting the controlled medications during the shift changes. When asked what the shift count log was for, LVN 8 stated the incoming and outgoing nurses counted the medications at the end of shift to ensure the controlled medication counts were reconciled.
3. According to the Assure Platinum Blood Glucose Monitoring System Quality Assurance/ Quality Control Reference Manual revised date 10/19, the Assure Dose Control Solution checks if the meter and test strips are working correctly as a system and if you are testing correctly.
Review of Medication Cart A's Quality Control Record Assure Platinum Blood Glucose Monitoring System: Quality Control Record showed the calibration for glucometer (a small, portable machine that's used to measure how much glucose [a type of sugar] is in the blood) with missing entries as follows:
* For 2020:
- 10/1, 10/2, 10/3, 10/4, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/17, 10/18, 10/19, 10/20, 10/21, 10/25, 10/27, 10/30, and 10/31/20.
- 11/1, 11/2, 11/3, 11/7, 11/8, 11/9, 11/10, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, 11/28, 11/29, and 11/30/20.
- 12/1, 12/2, 12/4, 12/5, 12/6 12/7, 12/8, 12/18, 12/19, 12/20, 12/21, and 12/28/20
* For 2021:
- 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/16, 1/17, 1/18, 1/20, and 1/21/21
- 3/15, 3/17, 3/20, 3/21, 3/26, 3/27, 3/28, 3/29, and 3/31/21
- 4/26/21 and 5/27/21
- 7/16, 7/17, 7/22, and 7/23/21
- 8/11, 8/12, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28 and 8/29/21
- 9/2, 9/3, 9/9, 9/10, 9/11, 9/12, 9/15, 9/16, 9/17, 9/18, 9/19, 9/29, and 9/30/21
- 10/14 and 10/15/21
On 11/12/21 at 1031 hours, a concurrent interview and facility document review was conducted with LVN 8. When asked who was responsible for calibrating the glucometer, LVN 8 stated the 11-7 shift nurses were responsible for calibrating the glucometer as well as completing the log daily. LVN 8 verified the missing entries for the months of October to December 2020 and January to October 2021. When asked about the missing entries in the Quality Control Record Form, LVN 8 did not answer. When asked the purpose of calibrating the glucometer, LVN 8 stated it was to ensure the glucometer was functioned well and accurate blood glucose readings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Residents 34) was free from unnecessary psychotropic medications.
* The facility failed to ensure Resident 34's episodes of behaviors for the use of risperidone (antipsychotic medication to treat certain mental or mood disorders) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. This had the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents.
Findings:
According to the facility's P&P titled Behavior/Psychoactive Drug Management dated 11/2018, under Procedure: III Evaluation showed monthly, the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrences of adverse reaction.
Review of Resident 34's medical record was initiated on 11/9/21. Resident 34 was admitted to the facility on [DATE].
Review of Resident 34's MAR for November 2021 showed a physician's order dated 9/21/21, to administer risperidone 0.25 mg by mouth daily and risperidone 0.5 mg by mouth at bedtime for schizophrenia manifested by delusions of grandeur (false belief in one's importance or greatness) as evidenced by stating people are out to get her, she is the princess of [NAME], part of Central Intelligence Agency (CIA), and part of Mexican mafia.
Review of Resident 34's MAR for the months of September, October, and November 2021 showed monitoring of the behaviors every shift. Further review of the medical record failed to show Resident 34's episodes of behavior for schizophrenia were tallied and summarized for the months of September, October, and November 2021.
On 11/10/21 at 1003 hours, an interview and concurrent medical record review for Resident 34 was conducted with RN 1. RN 1 stated Resident 34 was being monitored for schizophrenia every shift. RN 1 verified Resident 34's episodes of behavior for schizophrenia were not tallied on a monthly basis.
On 11/10/21 at 1019 hours, an interview and concurrent medical record review for Resident 34 was conducted with MDS Nurse 2. MDS Nurse 2 stated Resident 34 was being monitored for schizophrenia every shift. MDS Nurse 2 verified Resident 34's episodes of behavior for schizophrenia was not tallied.
On 11/10/21 at 1343 hours, and interview and concurrent medical record review for Resident 34 was conducted with the DON. The DON verified the monthly behavior log for Resident 34 was not done for the months of September, October and November 2021. The DON also stated the tallied summary of behaviors would make it faster and readily available for the physician to review Resident 34's behavior and ensure the proper dose of antipsychotic medication and treatment provided.