Camden Postacute Care, Inc

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when:
1 One can of grape juice in the dry storage room was dented and was not removed to prevent use; and
2. One pack of open cereal with no date when it was opened and no expiration date;
3. Refrigerator #2 had the following: 12 pieces of tomatoes inside a plastic bag container, three pieces of carrots inside a plastic bag, four pieces of white onions inside a plastic bag, 2 bunches of lettuce inside a plastic bag and one bunch of celery inside a plastic bag were not labeled and no date when it was delivered to the facility; and
4. Freezer #2 in front of the kitchen, there was one pack of cauliflower, and one pack of chopped spinach with no opened date or expiration date.
These failures had the potential to result in a foodborne illness outbreak amongst a population of 55 vulnerable residents with complex medical conditions.
Findings:
1. During an initial kitchen tour on 5/12/25 at 7:48 a.m., with the Dietary Manager (DM), she confirmed one can of grape juice in the dry storage room in the other building was dented and was not removed to prevent use.
According to the United States Food and Drug Administration (FDA, a federal agency) indicated, A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam.
Review of the facility undated policy and procedure (P&P), titled, Food Storage - Dented Cans, indicated, food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility .All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund.
2. During an initial kitchen tour observation and interview on 5/12/25 at 7:44 a.m., with the DM, she confirmed one pack of open cereal had no date when it was opened and no expiration date and the DM stated that it should have been dated when it was opened and with expiration date.
3. During an initial kitchen tour on 5/12/25, at 7:53 a.m., with the DM, refrigerator #2 had 12 pieces of tomatoes inside a plastic bag container, three pieces of carrots inside a plastic bag, four pieces of white onions inside a plastic bag, 2 bunches of lettuce inside the plastic bag and one bunch of celery inside a plastic bag were not labeled and no date when it was delivered to the facility.
4. During an initial kitchen tour on 5/12/25, at 7:55 a.m., with the DM, freezer #2 in front of the kitchen, there was one pack of cauliflower, and one pack of chopped spinach with no date or expiration date.
Review of the facility undated P&P, titled, Labeling and Dating of Foods indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Based on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were identified during medication pass for two residents (Resident 16 and 41). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident.
Findings:
1. During a review of Resident 16 physician's orders dated 2/21/25, it indicated, Glipizide (is used to treat high blood sugar levels) tablet 5 milligrams (mg, unit of measurement), give 0.5 tablet by mouth in the afternoon related to type two diabetes mellitus (a chronic condition that happens with persistent high blood sugar levels), 0.5 tablet =2.5 mg. give 30 minutes prior to meals.
During a medication administration observation on 5/12/25, at 4:04 p.m., Registered Nurse (RN) B prepared half tablet of glipizide in a medicine cup after verifying the medication orders then administered to Resident 16 with a cup of water.
2. During a review of Resident 41's minimum data set (MDS, an assessment tool) dated 3/14/25, it indicated his Brief interview for Mental Status (BIMS, is a quick assessment used to gauge a person's cognitive functioning) score of 13 (score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment).
During a review of Resident 41 physician's orders dated 4/26/25, it indicated, Hydrocortisone (is used to treat a variety of inflammatory, autoimmune, and hormonal conditions) oral tablet 10 mg, give 1 tablet by mouth in the morning for low cortisol, give with food.
During a medication administration observation on 5/12/25, at 4:35 p.m., Licensed Vocational Nurse (LVN) C checked Resident 41's vital signs first and then prepared two scheduled medications including one tablet of hydrocortisone 5 mg, and administered the medications to Resident 41 without food.
During an interview on 5/12/25, at 4:43 p.m., with LVN C, she stated she thought Resident 41 already had snacks around 3 p.m. in the afternoon, so Resident 41 does not need to take food with hydrocortisone because Resident 41's stomach was not empty.
During a concurrent interview with Resident 41 in his room, Resident 41 stated that he did not take any snacks in the afternoon between 2 p.m. to 3 p.m.
During a telephone interview on 5/14/25, at 10:05 a.m., with the Consultant Pharmacist (CP), the CP confirmed glipizide would need to be given 30 minutes before meals and hydrocortisone would need to take with food to prevent gastrointestinal irritation.
During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 10/2017, the P&P indicated, Medications are administered in accordance with written orders of the attending physician. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label . if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored accordance with currently accepted professional standards for two of 15 sampled Residents( 5 and 25) when:
1. A bottle of oral liquid lorazepam (a controlled medication used to relieve anxiety [persistent worry and fear about everyday situations]) without legible expiration date was stored in the medication room for Resident 25 to be used; and
2. An unlabeled normal saline solution (NSS, 0.9% sodium chloride in water ) in a bottle was found at Resident 5's bedside table unattended.
These deficient practices could lead to unsafe and ineffective medication use for the residents.
Findings:
1. During an observation on 5/12/25, at 7:30 a.m. to 7:50 a.m., in the medication storage room with Licensed Vocational Nurse (LVN) I, Resident 25's lorazepam medication did not have a legible expiration date.
Review of Resident 25's controlled drug record indicated the last time the lorazepam medication was administered to Resident 25 was on 9/30/24.
A further review of Resident 25's initial telephone order dated 9/19/24 indicated, Lorazepam oral concentrate 2 mg/ml (Lorazepam). Give 0.5 ml by mouth every 4 hours as needed for anxiety for 14 days.
During an interview on 5/12/25, at 10:10 a.m. and 10:20 a.m., with Registered Nurse (RN) A, RN A stated the expiration date on lorazepam bottle was not clear and readable. RN A further stated that expiration date should be clear, able to be read, and it should have clarified with the pharmacy upon opening to be used on 9/30/24 for Resident 25.
During a follow-up interview on 5/16/25, at 10:50 a.m., with the Director of Nursing (DON), the DON stated license staff should have clarified and requested a new bottle of oral liquid lorazepam with clear expiration date for Resident 25.
During a review of the facility's policy and procedure (P&P) titled, Medication Ordering And Receiving From Pharmacy -Medication Labels, dated 4/2008, the P&P indicated, Each prescription medication label includes . expiration date of medication.
2. During an initial tour of the facility on 5/12/25 at 8:54 a.m., on top of Resident 5's bedside table there was one bottle of NSS unlabelled and unattended.
During concurrent observation and interview on 5/12/25 at 8:55 a.m., with Resident 5, he stated that facility staff left the bottle of NSS for them to use for his foley catheter (F/C, a thin, flexible tube inserted into bladder [body organ, that stores urine] to drain urine) flushing (a process of cleaning of obstructions) and wound (open area) treatment.
During concurrent observation and interview on 5/12/25 at 8:56 a.m., with Licensed Vocational Nurse (LVN) O, she confirmed the above observation and stated that the bottle of NSS should have been labeled and stored in the treatment cart. LVN O further stated that it should not be kept at the bedside table unattended.
During a concurrent interview and record review on 5/14/25 at 10:57 a.m., with RN A, she reviewed Resident 5's clinical records and stated that the Minimum Data Set (MDS, an assessment tool) dated 3/21/25 indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition).
Review of facility's P&P titled, Medication storage in the facility, effective date: April 2008, the P&P indicated, All nurses and aids are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and give to unauthorized medications to the charge nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility Administrator (ADMN) failed to provide consistent administrative oversight to ensure that the Social Services Department and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) implemented the facility's policy and procedure (P&P) for safe transfer and discharge for one of three residents (Resident 20) when Resident 20 was discharged to a board and care facility (smaller more intimate living option for residents who need assistance with daily activities but not nursing care 24/7).
This failure had resulted in Resident 20's having eloped (run away secretly) from the board and care facility.
Findings:
During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), unsteadiness on feet, history of falling, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hearing loss , left ear, psychotic disturbance, mood disturbance and anxiety (feeling of worry and fear). Resident 20's responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) was his granddaughter as indicated in the Resident 20's face sheet. Minimum Data Set (MDS, an assessment tool) dated 2/14/25 indicated Resident 20's cognition was severely impaired, minimal difficulty of hearing-impaired vision, usually understood by others and usually understands.
During a concurrent interview and record review on 5/15/25 at 2:21 p.m., with RN A, she reviewed Resident 20's clinical records and stated Resident 20's physician order, dated 4/24/25, indicated may discharge to board and care on Monday 4/28/25 with home health (medical care and services provided in a patient's residence rather than in a hospital or other healthcare facility) follow up, RN, (registered nurse: a healthcare provider who works with medical doctor and others to give the best possible care), Physical therapist (PT: a healthcare discipline that uses movement and physical techniques to treat illnesses), Occupational Therapist (OT: a healthcare discipline that helps individuals with participate in everyday activities). RN A stated the facility IDT did not meet with Resident 20's RP to evaluate the resident needs prior to discharge. RN A could not provide IDT documentation that IDT had a discharge meeting prior to Resident 20's transfer and discharge to a board and care facility on 4/28/25.
During an interview on 5/15/25 at 9:06 a.m., with the RP, she stated that the Social Services Director (SSD) called her on 4/24/25 to inform that Resident 20 needs to be discharge due to an alleged abuse at the facility and that the SSD will keep her in the loop of Resident 20's discharge in the coming days. The RP stated that she tried to reach out to the SSD because she did not give consent for Resident 20's discharge but did not receive any call back until the day Resident 20's discharge to the board and care on 4/28/25. The SSD told the RP on 4/28/25 the day Resident 20 was discharged , the new address and phone number of the board and care facility where Resident 20 will be transferred. The RP further stated that she was not notified about Resident 20's discharge orders, medication instructions and RP did not pick-up Resident 20's personal belongings from the facility.
During a concurrent interview and record review on 5/15/25 at 12:03 p.m., with the RP, she stated she came to the facility to get the medical records of Resident 20 especially the POLST (physician orders for life-sustaining treatment, legally valid form allow residents to specify what medical treatments they want or don't want during a medical emergency) as instructed by the board and care facility administrator because the facility did not send the POLST to the board and care. The RP further stated that the facility did not send the POLST to the board and care facility staff on 4/28/25 when they picked up Resident 20 in the facility. The RP stated that she was not notified when the board and care staff came to assess Resident 20, was not given a chance to go and check the board and care prior to Resident 20's discharge on [DATE]. The RP further stated that she received a call from the board and care facility that Resident 20 had eloped three times since his transfer to the board and care facility.
During a concurrent interview and record review on 5/15/25, at 3:16 p.m., with the SSD, she reviewed Resident 20's psychosocial notes dated 4/24/25, the notes indicated the SSD was informed that Resident 20 will need to move to a board and care facility due to an alleged abuse at the facility and the previous SSD who was the current Activity Assistant (AA) M /certified nursing assistant (CNA) informed the administrator and the SSD of a home that will accept the resident with 24 hours care and was aware of Resident 20's situation.
During a concurrent interview and record review on 5/15/25, at 3:28 p.m., with the SSD, she reviewed Resident 20's psychosocial note dated 4/29/25 at 13:55, indicated SSD was notified that Resident 20 eloped from the new home and went across the street, board and care homeowner changed Resident 20's house with a gated fence.
During an interview with the SSD, on 5/15/25, at 3:31 p.m., the SSD stated that she was not the one who initially initiated the discharge plan for Resident 20. She further stated that she started working in the facility full time as SSD on 1/20/25.
During a concurrent interview and record review on 5/16/25 at 1:08 p.m., with CNA/AA M, she acknowledged that she was the one who initiated the transfer and discharge of Resident 20 and completed the notice of transfer/discharge date d 4/24/25 using her previous title as Social Service (SS). CNA/ AA M stated that there was no MD (medical doctor)and IDT discussion and documentation that Resident 20 was danger (danger or harm) to others that needs to be transferred or discharged . She further stated that it was her own opinion that the Resident 20 was a danger to other residents.
During an interview on 5/16/25 at 1:50 p.m., with the ADMN, he stated CNA/ AA M was working as SSD on 5/2024 when he started working in the facility as ADMN. The ADMN further stated CNA/AA M status was changed on 2/2025 as CNA/ AA M until now. The ADMN stated CNA/ AA M should not have initiated and completed Resident 20's notice of transfer/discharge date d 4/24/25. The ADMN further stated that Resident 20's transfer and discharge was not safe because the SSD should be the one who was responsible for the transfer/discharge process in coordination with the IDT.
Review of the Social Service Supervisor job description revised 10/19/2018 indicated, SS reports to Administrator, performs highly responsible professional work in the administration and supervision of social services programs including the interpretation and assessment of policies and the supervision of professional and office support personnel within the social services division; supervises a unit providing services in one or more of the following program areas; adult- protective services, mental health case management, developmental- disabilities case management, family- based services, and social services; performs related work as assigned .Responsibilities /Accountabilities:3. Holds individual conferences with staff and interprets agency/state policies , rules and regulations. 4. Reviews case records to ensure that agency and state policies, rules and regulations are adhered to ensure that agency and state policies, rules and regulations are adhered to, and proper social work practices are observed 5. Monitors and evaluates the provision of client services in the program area.
Review of the facility's policy, Transfer or Discharge Notice, release date January 2018, indicated, the facility shall provide a resident or the RP with a 30 day written notice of an impending transfer or discharge. The resident or RP will be notified in writing the reason for the transfer or discharge. the effect date, the location to which the resident will be transferred/discharged . The policy and procedure further indicated the resident or the RP will be notified on how to appeal the discharge

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the following multi-resident rooms were less than 80 square feet per resident.
Findings:
Room Beds Square Feet/Room Square Feet/Resident
2 2 146 73
3 2 148 74
4, 5, 6 3 225 75
7 3 222 74
8 2 156 78
9 2 144 72
10, 11, 12, 13 2 146 73
14 2 148 74
15, 16, 17, 18 2 140 70
19 3 228 76
20 3 225 75
21 3 228 76
room [ROOM NUMBER] 6 432 72
room [ROOM NUMBER] 5 323.4 64.68
During an observation, interview with staff and resident on 5/13/25 at 11:50 a.m., on 5/14/2025 at 2:10 p.m., on 5/15/2025 at 11:06 a.m., and 12:08 p.m., there were no care or privacy issues identified with the lack of space regarding the size of resident rooms.
During an interview with the facility's administrator (ADMN) on 5/15/25 at 12:15 p.m., the ADMN confirmed the rooms indicated above had less than 80 square feet space per resident.
The residents were observed in their rooms throughout the survey. The nursing care and services were not impacted by the shortage of space for residents' rooms. The closet and storage spaces were sufficient to accommodate the needs of the residents.
Review of the facility's room variance reports recommend the waiver remain in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident's room accommodated no more than four residents when room [ROOM NUMBER] had six beds, and six residents and room [ROOM NUMBER] had five beds and five residents. Having more than four residents per room had the potential of compromising the quality of life and quality of care the residents received.
Findings:
During an observation on 5/13/25 at 11:50 a.m., there were six beds and six residents in room [ROOM NUMBER] and five beds and five residents were in room [ROOM NUMBER]. Both these rooms had an adequate space for residents to move around and for the care to be given. Each resident had a bed, a privacy curtain, a nightstand, and a closet. The beds did not block any closets, bathrooms, or exits. There was no safety hazard or privacy concerns noted.
During interviews with randomly selected residents, there were no quality of care issues identified concerning the size of the room and number of occupants in room [ROOM NUMBER] and 2.
During an interview with Certified Nursing Assistant (CNA) K on 5/15/25 at 11:06 a.m., CNA K confirmed room [ROOM NUMBER] and room [ROOM NUMBER] had more than four residents. CNA K stated there were no concerns when providing care for residents in room [ROOM NUMBER] and room [ROOM NUMBER] with more than four residents in both rooms.
During an interview with Licensed Vocational Nurse (LVN) I on 5/15/25 at 12:08 p.m., LVN I confirmed there were more than four residents in room [ROOM NUMBER] and 2. LVN I stated there were no care, privacy and safety concerns of residents in room [ROOM NUMBER] and 2.
Recommend continuance of the room waiver.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 23's admission record indicated she was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease (is a progressive movement disorder of the nervous system).
During a review of Resident 23's MDS, dated [DATE], the MDS indicated her eating (the ability to use utensils to bring food and /or liquid to the mouth and swallow food and /or liquid once the meal is placed before the resident) was dependent.
Review of Resident 23's nutrition assessment, dated 1/9/25, indicated, Resident 23 was on no added salt, puree texture, regular liquid consistency; one on one feeding assistance.
During a dining observation on 5/12/25, at 12:11 p.m., in the dining room, Resident 23 was observed sitting alone by a table facing her lunch tray. There was no staff observed providing assistance to Resident 23 while other residents had started eating their meals and were being provided assistance.
During a concurrent observation and interview on 5/12/25, at 12:15 p.m., with CNA H, in the dining room, CNA H stated Resident 23 was waiting for her daughter to come and feed her. While CNA H was explaining why Resident 23 was left behind waiting for feeding assistance, LVN I suddenly walked into the dining room and placed a spoon onto Resident 23's hand and asked to scoop food from the plate.
During another meal observation on 05/14/25, at 12:01 p.m., Resident 23 was observed sitting by the dining table next to a resident that was being fed by LVN E. Resident 23 was observed with no feeding assistance provided while the other residents were assisted. Resident 23 waited about two minutes before Activity Assistant (AA) J provided assistance to the resident.
During a concurrent interview with AA J, AA J stated Resident 23 would need assistance with feeding during mealtime.
During an interview on 5/15/25, at 9:20 a.m., with the Social Service Director (SSD), the SSD stated all the residents should be fed at the same time during mealtime in the social dining room.
During an interview on 5/16/25, at 11 a.m., with the DON, the DON confirmed that residents should be served meal at the same time in the dining room, and staff should not delay providing feeding assistance to Resident 23.
During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated 4/2018, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. Nursing staff and /or feeding assistants will feed those patients needing full assistance upon delivery of food trays.
Based on observation, interview, and record review, the facility failed to treat four of 15 sampled residents (Resident 1, Resident 18, Resident 23 and Resident 28) with dignity and respect when:
1. Housekeeping (HK) N and the dietary staff were speaking in their own language other than English in the presence of Resident 1;
2. Resident 18 and 28 urinary catheter drainage bags (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) were left uncovered; and
3. Staff did not assist Resident 23 during lunch while other residents in the same dining room were already eating with staff assistance.
These failures had the potential to negatively affect resident's emotional and psychosocial well-being.
Findings:
1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/25/25, indicated Resident 1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition).
During a concurrent observation and interview on 5/12/25 at 11:07 a.m., with Resident 1, she stated staff spoke in foreign language while providing care and working in the facility. Resident 1 further stated that Certified Nursing Assistants (CNA's) and HK staff were speaking with their own language other than English while providing care or when HK staff was working inside the room and in the hallway.
During an initial tour of the facility on 5/12/25 at 11:07 a.m., HK N was talking to the dietary staff in the hallway in a foreign language other than English.
During an interview on 5/16/25 at 9:47 a.m., with HK N, she confirmed that she was working in the facility on 5/12/25 as a janitor and she was communicating with the dietary staff in the hallway infront of Resident 1's room. HK N further stated that she should speak English while working in the facility especially when residents were present.
During concurrent interview and record review on 5/15/25 at 11:38 a.m., with Registered Nurse (RN) A, she reviewed Resident 1's clinical records and stated Resident 1 was admitted to the facility on [DATE] with diagnosis including right eye blindness, left eye low vision, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (feeling of worry and fear).
2a. During the facility tour observation on 5/12/25 at 8:27 a.m., Resident 28 was observed with an uncovered urinary catheter drainage bag hanging from his bed.
During a concurrent observation and interview on 5/12/25 at 8:28 a.m., with Resident 28, he stated that facility staff did not put cover on his urinary catheter draining bag that was hanging from his bed.
During a concurrent observation and interview on 5/12/25 at 8:59 a.m., with Licensed Vocational Nurse (LVN) O, she acknowledged the above observation and stated it should have been covered with privacy blue bag.
During a concurrent interview and record review on 5/16/25 at 9:20 a.m., with RN A, she reviewed Resident 28's clinical records and stated that Resident 28 was admitted to the facility on [DATE] with the diagnosis including neuro muscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and has supra pubic (a type of urinary catheter inserted into the bladder through a small incision in the lower abdomen, above the pubic bone) that attached to the urinary catheter drainage bag. She further stated that one of the care plan interventions for supra pubic catheter was to provide privacy bag for the catheter urinary bag.
During an interview on 5/16/25 at 10 a.m., with the Director of Nursing (DON), the DON stated all residents with urinary catheters should have privacy bags covering the urinary catheter drainage bag.
2b. During an initial room observation on 5/12/25 at 7:54 a.m., Resident 18's indwelling catheter (a thin, flexible tube inserted into bladder [a body organ that stores urine] to drain urine out) urine collection drainage bag was anchored to his bed frame not covered with privacy bag.
Review of Resident 18's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 18 was admitted to facility on 1/27/16 with diagnoses including neuromuscular dysfunction of bladder (problem with muscles controlling bladder function can lead to variety of problems including difficulty emptying the bladder).
Review of Resident 18's physician order dated 10/15/24 indicated, Suprapubic Catheter
Review of Resident 18's care plan for bladder elimination (voiding urine) indicated, Provide privacy bag for the catheter urinary bag.
During an interview with CNA L on 5/12/25 at 8:03 a.m., CNA L confirmed Resident 18's urine collection drainage bag was not covered with privacy bag.
During an interview with LVN I on 5/15/25 at 3:10 p.m., LVN I stated nursing staff should have covered Resident 18's urine collection drainage bag with privacy bag for privacy, dignity and infection control.
During an interview with the facility's Director of Staff Development (DSD) on 5/15/25 at 3:18 p.m., the DSD stated nursing staff should have covered Resident 18's urine collection drainage bag with a privacy bag for privacy, dignity and infection control.
A review of the facility's, policy and procedure (P&P) dated 1/28, titled Quality of life - Dignity the P&P indicated, each resident shall be cared for a manner that promotes and enhances quality of life, dignity, respect and individuality Residents shall be always treated with dignity and respect . Staff shall promote dignity and assist residents as needed by : Helping the resident to keep urinary catheter bags covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform interdisciplinary team (IDT, staff from different departments who coordinate the residents care) assessment and obtain a physician order for self-administration of medication for two of eight sampled residents (Resident 27 and 37) when:
1. Resident 27 had over the counter (OTC, can be purchased without a prescription from medical doctor) bottle of isopropyl alcohol (used for cleaning wounds and as disinfectant) on the bedside tray table unattended; and
2. Resident 37 had a bottle of OTC hydrogen peroxide (used for cleaning wounds and as disinfectant), and a bottle folic acid (vitamin supplement) medication on the bedside table unattended.
This failure had the potential for unsafe and improper administration of OTC and medication supplement for Residents 27 and 37.
Findings:
1. During an observation and interview with Resident 27 on 5/12/25 at 8:20 a.m., there was a bottle of isopropyl alcohol on Resident 27's tray table that was unattended and was next to the resident. Resident 27 stated he had used the isopropyl alcohol to clean his skin everyday.
Resident 27 also stated the facility did not provide the isopropyl alcohol and he had bought it himself from the store when he went outside the facility. Resident 27 further stated the facility nursing staff were aware of that he was using the isopropyl alcohol to clean his skin everyday.
Review of Resident 27's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 27 was admitted to facility on 9/5/2024. Resident 27's FS also indicated diagnosis included non-pressure chronic ulcer of left foot (persistent open sore that's not caused by prolonged pressure or friction).
Review of Resident 27's Minimum Data Set (MDS, clinical, and functional assessment tool) dated 3/11/25 indicated Resident 27's Brief Interview for Mental Status (BIMS) score was 15 of 15 (score of 0 to 7: severe cognitive impairment, 8 to 12: moderate cognitive impairment, and 13 to 15: intact cognition).
Review of Resident 27's clinical documentation indicated there was no documented evidence of the IDT's assessment for self-administration of medication.
Review of Resident 27's physician orders indicated there was no order for OTC isopropyl alcohol for self-administration.
During an interview with Licensed Vocational Nurse (LVN) I on 5/12/25 at 8:26 a.m., LVN I confirmed a bottle of isopropyl alcohol OTC medication was left on Resident 27's tray table unattended. LVN I stated the medication should not be left in the room unattended for Resident 27 to self-use.
2. During an observation and interview with Resident 37 on 5/12/25 at 12:35 p.m., a bottle of 1/4 full liquid of hydrogen peroxide, and a bottle of folic acid 1 milligram (mg, a unit of mass equal to a thousandth of a gram) tablets were on the tray table next to Resident 37's bed unattended. During a concurrent interview with Resident 37, he stated he was using stated the hydrogen peroxide to clean his teeth once a week and taking folic acid one tablet every day from the medication bottle. Resident 37 also stated his son brought the hydrogen peroxide and the folic acid to the facility months ago. Resident 37 further stated the facility nursing staff were aware of self-administration of both medications.
Review of Resident 37's FS indicated Resident 37 was admitted to facility on 1/3/25 with the diagnoses including anemia (a condition with blood doesn't have enough healthy red blood cells).
Review of Resident 37's MDS dated [DATE] indicated Resident 37's BIMS score was 15 of 15.
Review of Resident 37's clinical documentation indicated IDT's assessment for self-medication administration dated 4/7/25 indicated resident request for self-medication administration of medication was documented No.
Review of Resident 37's physician orders indicated there were no orders for hydrogen peroxide and folic acid for self-administration.
During an interview with LVN I on 5/12/25 at 12:46 p.m., LVN I confirmed a bottle of OTC hydrogen peroxide and folic acid medications were left on Resident 37's tray table unattended. LVN I stated both medications should not be left in the room unattended for self-administration for Resident 37.
During an interview with Registered Nurse (RN) A on 5/15/25 at 1:59 p.m., RN A confirmed there were no IDT assessment and physician orders for self-medication administration for Resident 27 and 37. RN A stated medications should not be at bedside unattended for both residents.
Review of the facility's policy and procedure (P&P) titled, Medications storage in the facility, effective date: April 2008, the P&P indicated, For residents who self-administer medications, the following conditions are met for bedside storage to occur:
1. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is deemed inappropriate .
Review of facility's P&P titled, Preparation and General Guidelines, effective date: April 2008, the P&P indicated, Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility's interdisciplinary team. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a routine basis

Based on interview and record review, the facility failed to ensure their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [ a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) for six of 8 sampled residents (Resident 10, 13,18,19,27, and 37). This failure could lead to the delivery of unnecessary or inappropriate medical services against sampled residents' goals and wishes.
Findings:
Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 10/24/24.
Review of Resident 10's form for physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form prepared on 10/29/24 indicated section D for AD documented No Advance Directive.
Further review of Resident 10's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 10 to execute an AD.
Review of Resident 13's FS indicated Resident 13 was admitted to facility on 7/8/24.
Review of Resident 13's POLST form prepared on 7/8/24 indicated section D for AD documented No Advance Directive.
Further review of Resident 13's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 13 to execute an AD.
Review of Resident 18's FS indicated Resident 18 was admitted to facility on 1/27/16.
Review of Resident 18's POLST form prepared on 11/21/2019 indicated section D for AD documented No Advance Directive.
Further review of Resident 18's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 18 to execute an AD.
Review of Resident 19's FS indicated Resident 19 was admitted to facility on 11/2/20.
Review of Resident 19's POLST form prepared on 10/21/20 indicated section D for AD documented Advance Directive not available.
Further review of Resident 19's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 19 to execute an AD.
Review of Resident 27's FS indicated Resident 27 was admitted to facility on 9/5/24.
Review of Resident 27's POLST form prepared on 9/6/24 indicated section D for AD documented No Advance Directive.
Further review of Resident 27's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 27 to execute an AD.
Review of Resident 37's FS indicated Resident 37 was admitted to facility on 1/3/25.
Review of Resident 37's POLST form prepared on 1/6/25 indicated section D for AD documented Advance Directive not available.
Further review of Resident 37's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 37 to execute an AD.
During a concurrent record review and interview with the facility's social service director (SSD) on 5/14/25 at 1:45 p.m., the SSD reviewed POLST form for the above residents. The SSD confirmed there was no AD for the above residents. The SSD stated she did not discuss, offer or assist the residents to execute an AD. The SSD also stated she should have offered and assisted the residents to execute an AD.
During a concurrent record review and interview with Registered Nurse (RN) A on 5/15/25 at 8:29 a.m., RN A reviewed POLST form for the above residents. RN A confirmed there was no AD for the above residents. RN A stated the SSD was responsible to follow up the AD for residents. RN A also stated SSD should have offered and provided assistance to execute an AD for residents.
Review of facility's policy and procedure (P&P) titled, Advance Directive, release date January 2018, the P&P indicated, If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere with their infection prevention and control program to ensure proper hand hygiene and personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves ) were implemented during delivery of care to residents in the facility when:
1. Facility staff did not follow the Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, is a germ that is resistant to many antibiotics] in nursing homes) wearing personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves) during wound dressing change to Resident 12 and during Foley catheter (F/C: a thin felxible tube inserted in to bladder [a body organ that stores urine] to drain urine) care to Resident 109;
2. Licensed Vocational Nurse (LVN) E did not perform hand hygiene in every glove changed during wound treatment observation;
3. Resident 25's unlabeled nebulizer (a medical device that delivers medication in the form of fine mist) container mouthpiece with tubing mask (plastic mask and tubing used as a connected to nebulizer) that was attached to the machine was exposed and touching the bedside table, the unlabeled yankauer suction tube (oral suctioning tool) tip catheter with tubing attached to the suction canister was stored inside the bedside drawer in an open plastic package; and
4. Facility staff did not perform hand hygiene prior to providing feeding assistance to Resident 23 during lunch time on 5/12/25.
These failures had the potential to result in cross-contamination and the spread of infection between 55 residents in the facility.
Findings:
1. During an initial tour observation on 5/12/25, at 7:57 and 7:59 a.m., a sign for EBP was posted on Resident 12's and 109's room door. Resident 109 was confined in bed and Resident 12 had a F/C anchored below the bladder level to the bed frame.
During a review of Resident 12's admission record indicated his initial admission date was 11/4/24 and readmission date was 12/20/25. Resident 12 had diagnoses including sepsis with unspecified organism (a life-threatening condition where the body's response to infection causes damage to its own tissues and organs, and the specific causative organism is not identified), and infection and inflammatory reaction (body's response to an illness) due to indwelling urethral catheter and Methicillin-resistant Staphylococcus aureus (MRSA, is a type of staph infection that is resistant to certain antibiotics, making it harder to treat).
During a review of Resident 109's admission record indicated he was admitted to the facility on [DATE] and Resident 109 had diagnoses including multiple sclerosis (a chronic neurological disorder) and with multiple pressure ulcer (bed sore, caused by prolonged pressure combined with shear) wounds.
During an observation on 5/15/25, at 10:50 a.m., in Resident 109's room, Certified Nursing Assistant (CNA) F assisted Licensed Vocational Nurse (LVN) E to perform wound dressing change to Resident 109's multiple wounds. Both CNA F and LVN E were observed only wearing surgical disposable facemask and gloves, both CNA F and LVN E did not wear disposable gown.
During an interview on 5/15/25, at 2:10 p.m., with the Director of Staff Development (DSD), the DSD stated when providing wound care, foley care and activities of daily living (ADL, the tasks of everyday life include eating, dressing, getting into or out of a bed or chair, taking a bath or shower) care to the residents with EBP, staff must wear PPE including gown and gloves, a facemask (optional) to perform care.
During an interview on 5/16/25, at 9:55 a.m., with CNA F, CNA F stated she did not wear gown during Resident 109's wound dressing change and ADL care. CNA F further stated she did not wear gown when emptying Resident 12's urine bag or ADL care.
During an interview on 5/16/25, at 10:02 a.m., with LVN E, LVN E stated she did not wear gown during wound dressing change to Resident 109. LVN E further stated she also forgot wearing gown during foley care to Resident 12. LVN E confirmed she should have worn PPE during wound care and foley care to both Resident 12 and 109, because they were on EBP, and a PPE cart was placed nearby their room in the hallway.
During a follow-up interview on 5/16/25, at 10 a.m., with CNA G, CNA G stated she did not wear PPE during ADL care to a resident who was on EBP because it was not required except during handling a foley catheter with urine bag.
During a follow-up interview on 5/16/25, at 11:05 a.m., with the Director of Nursing (DON), the DON confirmed staff should wear PPE during wound care, foley care and ADL care to the residents who were on EBP. The DON further stated staff had received in-services regarding PPE in the past and facility staff should follow instructions to implement appropriate PPE.
During a review of the centers for disease control and prevention (CDC) titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, it indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html
2. During a wound treatment observation on 5/16/25 at 11:07 with LVN E, after washing her hands and putting pair of gloves she started to prepare the treatment supplies infront of the treatment cart outside Resident 5's room then locked the treatment cart using the same pair of gloves, she picked up and threw a medication cup with wound barrier into the garbage can that was attached to the treatment cart. LVN E dropped it on the floor then she opened the treatment cart using the same pair of gloves, put wound cream inside the medication cup, locked the treatment cart, touched the key, touched Resident 5's privacy curtain, bedside table with treatment supplies on top without changing gloves or performing hand hygiene. LVN E took out the used pair of gloves from the start of the treatment preparation and changed it to a new pair of gloves without performing hand hygiene.
During a wound observation on 5/16/25 at 11:12 a.m., LVN E started to do the wound dressing treatment to Resident 5's different wound sites without performing hand hygiene in every change of gloves.
During an interview on 5/16/25 at 11:50 a.m., with LVN E, she acknowledged the above observation and stated that she should perform hand hygiene in every change of gloves for each wound site to prevent contamination that could cause the spread of infections.
Review of facility's P&P dated 2018, titled, Handwashing Hand Hygiene, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
3. During an initial observation tour of the facility on 5/12/25 at 8:46 a.m., Resident 25's unlabeled nebulizer container mouthpiece with tubing mask that was attached to the machine was exposed and touching the bedside table and the unlabeled yankauer suction tube tip catheter with tubing was attached to the suction canister was stored inside the bedside drawer in an open plastic package together with open wet wipes, lotion, mouth wash, paper, cardboard and an open tissue box .
During a concurrent observation and interview with LVN O on 5/12/25 at 8:48 a.m., she confirmed the above observation and stated the nebulizer container mouthpiece should be stored inside the plastic bag after cleaning, label it with a date, resident's name and discard every seven days. She stated that the suction tip catheter with tubing should be stored inside the plastic bag, labeled with resident's name and store it on top of the bedside table to prevent contamination from personal items. She further stated that these are infection control issues.
Review of the facility's policy and procedure (P&P) dated 1/2018, titled Departmental (Respiratory Therapy)- Prevention of Infection indicated, infection control considerations related to Medication nebulizers after completion of therapy: remove the nebulizer container, rinse the container, with fresh tap water, dry on a clean paper towel or gauze sponge, reconnect to the administration set - up when air dried, take care not to contaminate internal nebulizer tubes , wipe the mouth piece with damp paper towel or gauze sponge , store the circuit in plastic bag, marked with date and resident's name, between uses and discard the administration set-up every seven days
infection control considerations related to suction machines indicated after completion of suctioning : discard single-use suction catheters immediately in appropriate waste receptacle if using reusable tubing: rinse tubing with sterile water, hang tubing to air dry in a clean, designated area or store in a clean plastic bag labeled with resident's name, ensure tubing is not in contact with the contaminated surfaces , suction tubing must be replaced at least seven days or sooner if visibly soiled and thoroughly clean and disinfect the .
4. During lunch meal observation in the dining room on 5/12/25 at 12:18 p.m., noted Certified Nursing Assistant / Activity Assistant M (CNA / AA M) was feeding Resident 30. CNA / AA M got up from the chair, went to another table to Resident 23, opened lunch plate cover, and started feeding Resident 23. CNA/AA M did not perform hand hygiene between task.
During an interview with CNA / AA M on 5/12/25 at 12:24 p.m., CNA / AA M confirmed that she did not perform hand hygiene before feeding Resident 23 and after feeding Resident 30. CNA / AA M stated she should wash her hands before feeding Resident 23.
During an interview with the Director of Nursing (DON) on 5/16/25 at 10:28 a.m., the DON stated nursing staff should perform hand hygiene in between when feeding two residents.
Review of facility's P&P titled, Handwashing Hand Hygiene, release date: 2018, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
a. Before and after assisting a resident with meals

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment was provided for two of 14 sampled residents (Resident 1 and Resident 25) when:
1. The privacy curtain in Resident 25's room was left sticky, had brownish dry food particles, and dirty; and
2. In Resident 1's room, the floor was sticky when walked on and Resident 1 complained that her room was not cleaned by the housekeeper daily.
These failures increased the potential for Resident 1 and Resident 25 not attaining their highest practicable well-being.
Findings:
1. During an initial tour of the facility on 5/12/25 at 9:01 a.m., Resident 25's privacy curtain in his room was left sticky, and had brownish dry substances.
During a concurrent observation and interview on 5/12/25 at 9:02 a.m., with Licensed Vocational Nurse (LVN) O, she confirmed the above observation and stated that those brownish dry substance was food particles, sticky and dirty. She further stated that it should have been changed by the housekeeper or janitor.
2. During concurrent interview and record review on 5/15/25 at 11:38 a.m., with Registered Nurse (RN) A, she reviewed Resident 1's clinical records and stated Resident 1 was admitted to the facility on [DATE] with diagnoses including right eye blindness, left eye low vision, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (feeling of worry and fear).
Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/25/25, indicated she had a BIMS (Brief Interview for Mental Status) of 15 meaning her cognition was intact and Resident 1 could walk independently using her roller walker with set up help only.
During a concurrent observation and interview on 5/12/25 at 11:07 a.m. with Resident 1 in her room, the floor was sticky when walked on. Resident 1 stated housekeeping just came today to clean her room because the state surveyor was in the facility and did not mop the floor with a wet mop. Resident 1 further stated Housekeeper did not do a good job and she was not okay if the floor was still dirty and sticky.
During an interview on 5/14/25 at 1:05 p.m., with the Housekeeping Supervisor (HKS), he stated that housekeeping and janitor were responsible for daily cleaning and deep cleaning of the resident's room once a month. The HKS further stated that changing of residents' privacy curtain was scheduled once a month during deep cleaning and as needed.
During a concurrent interview and record review on 5/14/25 at 1:07 p.m., with the HKS, he stated that he could not provide any documentation that the residents' room were cleaned daily, and deep cleaning was done once a month because he was just doing the visual checking of each room. He further stated that he will create a Daily Room Clean sign off sheet, deep Clean Room Check list and daily clean room check list starting today 5/14/25.
A policy and procedure was requested but was not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal.
The transfer/discharge was improper and violated Resident 20's resident rights.
Findings:
During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), unsteadiness on feet, history of falling, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose), hearing loss , left ear, Psychotic disturbance, mood disturbance and anxiety (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.). Resident 20's RP was his granddaughter as indicated in the Resident 20's face sheet. Minimum Data Set (MDS, an assessment tool) dated 2/14/25 indicated Resident 20's cognition was severely impaired, minimal difficulty of hearing impaired vision, usually understood other and usually understands.
Resident 20's physician order, dated 4/24/25, indicated may discharge to board and care on Monday 4/28/25 with home health (a type of medical care provided in a resident's home to function independently) follow up, RN (registered nurse: a healthcare provider who works with medical doctor and others to give the best possible care), Physical therapist (PT: a healthcare discipline that uses movement and physical thechniques to treat illnesses), Occupational Therapist (OT: a healthcare discipline that helps individuals with participate in everyday activities). There was no documentation indicating Resident 20's the RP had been notified of resident's rights to appeal. Resident 20 had resided in the facility for more than 30 days.
During an interview on 5/15/25 at 9:06 a.m., with RP, she stated that the Social Services Director (SSD) called her on 4/24/25 to inform her that Resident 20 needs to be transferred/discharge due to an alleged abuse at the facility and will keep her in the loop of Resident 20's transfer/discharge in the coming days. The RP stated that she tried to reach out to the SSD because she did not give consent for Resident 20's discharge but did not receive any call back. The RP further stated she received a call back from the SSD on 4/28/25 the day Resident 20 was transferred/discharged in the board and care facility and that was the time the SSD told the RP the address and phone number of the receiving board care where Resident 20 was being transferred. The RP further stated that she was not given anything in writing prior to Resident 20's discharge on [DATE] and was not informed of her rights to appeal.
During an interview with the SSD, on 5/15/25, at 3:31 p.m., the SSD stated that she was not the one who initially initiated the discharge plan for Resident 20 and she did not notify Resident 20's RP in writing prior to transfer/discharge on [DATE]. The SSD stated she did not provide Resident 20's RP any advice that she could appeal. The SSD stated she called the RP on 4/24/25 to inform her that Resident 20 needs to be transferred/discharged due to an alleged abuse at the facility and will keep the RP in the loop in the coming days.
During a concurrent interview and record review on 5/16/25 at 1:08 p.m., with Certified Nursing Assistant/Activity Assistant (CNA/AA) M, she acknowledged that she was the one who initiated the transfer and discharge of Resident 20 and completed the notice of transfer/discharge date d 4/24/25 using her previous title as Social Service (SS). CNA/ AA M stated that there was no MD (medical doctor)and IDT discussion and documentation that Resident 20 was danger (danger or harm) to others that needs to be transferred or discharged . She further stated that it was her own opinion that the Resident 20 was a danger to other residents.
During an interview on 5/16/25 at 1:50 p.m., with the ADMN, he stated CNA/ AA M was working as SSD on 5/2024 when he started working in the facility as ADMN. The ADMN further stated CNA/AA M status was changed on 2/2025 as CNA/ AA M until now. The ADMN stated CNA/ AA M should not have initiated and completed Resident 20's notice of transfer/discharge date d 4/24/25. The ADMN further stated that Resident 20's transfer and discharge was not safe because the SSD should be the one responsible for the transfer/discharge process in coordination with the IDT.
During an interview on 5/16/25, at 2 p.m., with the administrator (ADMN), he stated that the SSD was responsible for initiating the process of residents transfer and discharge, and giving 30 day written notice of transfer or discharge.
Review of the facility's policy and procedure (P&P) dated 1/2018, titled Transfer or Discharge Notice indicated facility shall provide a resident and /or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge Process 1. A resident, and/or his or her representative, will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility . 3. The residents and or representative will be notified in writing of the following information I. The reason for the transfer or discharge j. the effective date of the transfer or discharge k. The location to which the resident is being transferred or discharged l. A statement of the resident's rights to appeal the transfer or discharge . information about how to obtain, complete and submit an appeal form; and how to get assistance completing the appeal process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for residents with mental disorder and residents with intellectual disability) Level 1 and Level II screening was completed for two of 15 sampled residents (Resident 9 and 13).
This failure had the potential for mentally ill sampled residents not to receive benefit from specialized health care and services.
Findings:
Review of Resident 9's admission record indicated he was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (is a mental health problem where you experience psychosis as well as mood symptoms) and major depressive disorder (is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time).
Review of Resident 9's notice of PASRR Level I screening results dated 9/3/24, indicated, A serious mental illness (SMI, is characterized as any mental health condition that impairs seriously or severely from one to several significant life activities) level II mental health evaluation was required.
During a further review of Resident 9's notice of attempted evaluation dated 9/3/24, indicated, Unable to complete level II evaluation for serious mental illness (SMI). Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening. The case is now closed. To open, the facility must resubmit a new level I screening.
During an interview on 5/13/25, at 10:40 a.m., with Registered Nurse (RN) A who was the minimum data set (MDS, an assessment tool) nurse, RN A verified and confirmed there was no PASRR level II referral and evaluation done for Resident 9 because they forgot to follow up the notice of attempted evaluation letter to resubmit a new level I screening for Resident 9.
Review of Resident 13's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 13 was admitted to facility on 7/8/24 and readmitted on [DATE].
Review of Resident 13's FS indicated Resident 13's diagnoses included delusional disorders (a serious mental illness that involves persistent false beliefs, that are not based in reality) dated 7/12/24 and schizophrenia (a serious mental illness [SMI] that interferes with affects resident's ability to think clearly, manage emotions, make decisions and relate to others) dated 8/26/24.
Review of Resident 13's discharge summary notes from an acute hospital (AH, a short-term acute care provides intense medical treatment with severe illnesses, injuries, or conditions that require rapid interventions) dated 7/8/24 indicated no SMI.
Review of Resident 13's discharge summary notes from the AH dated 8/26/24 indicated diagnosis of schizophrenia.
Review of Resident 13's Minimum Data Set (MDS, resident's clinical and functional assessment tool) assessment, dated 7/12/24, under section I for active diagnoses indicated, psychotic disorder.
Review of Resident 13's MDS dated [DATE], under section I for active diagnoses indicated, schizophrenia and psychotic disorder.
Review of Resident 13's PASRR Level 1 screening assessment dated [DATE] indicated no SMI.
Further review of Resident 13's clinical record indicated there was no documented evidence of Level 1 PASRR screening after 7/12/24 or 8/26/24 when there was a diagnoses of SMI.
During an interview with the facility's admission and Marketing Manager (AMM) on 5/14/25 at 8:32 a.m., the AMM confirmed there was no Level 1 screening completed after 7/5/24 for Resident 1. The AMM stated the admission staff was responsible for PASRR Level 1 screening. The AMM also stated the facility should have a Level 1 screening when Resident 13 was diagnosed with SMI.
During an interview with RN A on 5/14/25 at 1:06 p.m., RN A confirmed Resident 13's SMI diagnoses dated 7/12/2024 and 8/26/2024 and confirmed there was no documented evidence of Level 1 screening being done. RN A stated the facility should have completed a new Level 1 PASRR for Resident 13. RN A also stated there was a potential for Resident 13 to miss receiving specialized mental health services by not completing the Level 1 PASRR screening.
During telephone interview with the Medical Doctor (MD) on 5/15/25 at 1:45 p.m., the MD stated that the AH potentially did not capture Resident 13's diagnoses of schizophrenia during July 2024 stay. The MD also stated the diagnosis typically do not develop at late stages of life. The MD further stated that the resident had the diagnosis for long time.
During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review, dated 1/2018, the P&P indicated, It is the policy of this facility to comply with federal and state regulations regarding the Preadmission Screening and Resident Review (PASRR) process. PASRR ensures that individuals with serious mental illness (SMI), intellectual disabilities (ID: resident has difficulties with cognitive abilities of learning, reasoning, problem solving, practical and social skills), or related conditions are appropriately placed in a skilled nursing facility (SNF) and receive necessary services. If the Level I screening indicates a potential SMI . the resident must be referred for a Level II PASRR evaluation conducted by the designated state agency or contracted entity. The Admissions Coordinator must submit all required documentation to the state PASRR agency and follow up to ensure timely completion of the Level II evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one out of 15 sampled residents (Resident 5).
This deficient practice had the potential to result in not meeting the residents' needs.
Findings:
During a concurrent interview and record review on 5/15/25 at 11:10 a.m., with Registered Nurse (RN) A, RN A reviewed Resident 5's clinical records and stated that Resident 5 was admitted to the facility on [DATE] with diagnosis including paraplegia (paralysis of the legs and lower body.), Chronic kidney disease (CKD, the gradual loss of kidney function), contracture (hardening of muscles and other tissues causing rigidity to the joints of muscle) left lower leg, contracture of muscles multiple sites, pressure ulcer left and right buttock stage 4 (most severe form of bedsore, also called a pressure sore, pressure ulcer, or decubitus ulcer and is a deep wound reaching the muscles, ligaments, or bones. They often cause extreme pain, infection, invasive surgeries, or even death.), pressure ulcer of sacral region and abnormal posture.
During a concurrent interview and record review on 5/11/18 at 11:18 with RN A, RN A reviewed Resident 5's pressure ulcer care plan initiated date was 6/24/ 24 with focus problem, pressure ulcer left and right buttock stage 4, pressure ulcer of sacral region stage four, right lateral lower leg, vascular and left posterior thigh MASD (Moisture-Associated Skin Damage) were combined with the same goals and interventions. RN A stated that each pressure ulcers site should have been care planned individually with own goals and interventions to provide Resident 5 a person-centered care. RN A further stated that interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) skin meeting dated 5/1/25 indicated different measurements for each individual pressure ulcers site, change of treatments and status of the pressure ulcers site and confirmed that the pressure ulcer care plan was not individualized and person-centered care specifically for Resident 5.
Facility did not provide the policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans for two of 15 sampled residents (Resident 12 and Resident 40) when:
1. A care plan to address Resident 12's dementia (memory loss) was not updated and revised; and
2. A care plan to address Resident 40's end stage of renal disease (ESRD, a severe and irreversible condition where the kidneys have lost most of their function and are no longer able to adequately filter waste products from the blood) on hemodialysis (HD, is a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) was not updated and revised after increasing HD from three times per week to four times per week.
These failures had the potential to result in not meeting the residents' needs.
Findings:
Review of Resident 12's admission record indicated he was initially admitted to the facility on [DATE] and had diagnoses including dementia with other behavioral and disturbance (loss of memory, language, problem-solving and changes in behavior and mood).
Review of Resident 12's Minimum Data Set (MDS, an assessment tool), dated 4/20/25, indicated that his Brief Interview for Mental Status (BIMS) score was of 7 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition), severely impaired cognition.
Review of Resident 12's care plan addressing his impaired cognitive function and dementia with initial date of 11/13/24 indicated, Ask yes/no questions in order to determine the resident's needs. Cue, resident and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.
During observations on 5/13/25, at 8:38 a.m. and 5/15/25, at 10:30 a.m., Resident 12 was lying in bed most of the time. He was confused and verbally responsive to express his needs.
During an interview on 5/14/25, at 11:13 a.m. and 5/16/25, at 8:45 a.m., with the Social Service Director (SSD), the SSD stated Resident 12 spoke different language other than English and used to self-propel in his wheelchair in the facility with more vocal, after hospitalization Resident 12 became spending more time in bed than before. The SSD further stated Resident 12 had a personal cellphone at bedside and it was very important for him to speak with his family members over the phone to support his psychosocial well-being and the cellphone need to be fully charge on daily basis in order for resident to receive calls from his family members.
During an interview and record review on 5/16/25, at 12:05 p.m., with the Director of Nursing (DON), Resident 12's dementia care plan, dated 11/13/24 was reviewed. The dementia care plan did not include keeping Resident 12's personal cellphone fully charge at bedside and to assist him to receive calls from his family members. The DON confirmed Resident 12's dementia care plan should have been updated and revised in accordance with Resident 12's culture background and to have an individualized person-centered care plan.
2. Review of Resident 40's admission record indicated she was admitted to the facility on [DATE] and had diagnoses including ESRD and dependence on renal dialysis.
During an interview on 5/12/25, at 8:40 a.m., with Resident 40, Resident 40 stated she was receiving HD four times per week through a catheter on her right upper chest, which was covered with clean, dry dressing.
Review of Resident 40's ESRD HD care plan dated 5/16/23, indicated Resident 40 had HD three times per week through her right upper chest with a Perma catheter (is a type of central venous catheter used for long-term hemodialysis access).
During an interview and concurrent record review on 5/16/25, at 1:45 p.m., the DON reviewed Resident 40's ESRD HD care plan, dated 5/16/23. The DON confirmed the care plan needs to be updated and revise for the HD schedule, from three times per week increasing to four times per week. The DON stated each resident's care plan needs to be reviewed and updated every three months.
During a review of the facility's policy and procedure (P&P) titled, Care Plan Conference, dated 12/2016, the P&P indicated, Fundamental information at interval of every 90 days thereafter; with any subsequent completed assessments; and, when there is a change in resident status or condition. Care plans are reviewed to meet the needs and requests of the resident/ resident's family .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the safety of one of four residents (Residents 29) who smoke without oversight staff supervision. This failure had the potential to put Resident 29 at risk of harm.
Findings:
During a concurrent observation and interview on 5/16/25 at 10:413 a.m., Residents 29 was in the patio smoking and was not wearing a smoking apron. There was no facility staff in the patio providing supervision for Resident 29. without facility staff's supervision. Resident 29 stated facility staff was not supervising him when he was smoking except when staff provides his cigarette and light his cigarette.
During a concurrent observation and interview on 5/16/25 at 10:14 a.m., with Activity Assistant (AA) J, she confirmed the above observation and stated that Resident 29 needs supervision from the facility staff while smoking for safety.
During a concurrent interview and record review with Registered Nurse (RN) A, she reviewed Resident 29's clinical records and stated Resident 29 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including of muscle weakness, hemiplegia (paralysis that affects just one side) hemiparesis (weakness on half of the body) and hemiparesis (weakness on half of the body) following cerebral infarction (stroke, lack of blood flow to the brain, causes brain tissue to die) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose).
Resident 29's Smoking-Safety Screen initially dated 5/11/24 and smoking assessment dated [DATE], indicated interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) decision indicated Resident 29 can smoke with oversight supervision, safe to smoke with oversight supervision due to Resident 29's current physical function and diagnoses of gout, hemiplegia and hemiparesis following stroke.
During an interview on 5/16/25 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that facility staff should supervise residents who smokes during smoking schedules.
The facility did not provide a policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 05/12/25 8:40 a.m., with Resident 5, he was lying in bed with 1/2 both siderails up and stated he was using the 1/2 both rails for his turning and repositioning.
During a concurrent interview and record review on 05/14/25 at 10:57a.m., with RN A, she reviewed Resident 5's clinical records documentation and stated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 5's bed.
Review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS score was 15, intact cognition.
Review of facility's policy and procedure (P&P) titled, Bed Rails, release date July 2017, the P&P indicated, The Interdisciplinary Team (IDT: interdisciplinary team, a group of healthcare professionals from different disciplines work together to provide and coordinate care for residents) will determine whether a resident should be provided with bed rails on his/her bed, based on individual assessment which includes the risk of entrapment. The facility must attempt to use appropriate alternatives prior to installing a side/bed rail. Assess resident for risk of entrapment from bed rail prior to installation. Review the risks and benefits of bed rails with the resident or resident representative. Prior to placing a side rail on the bed, informed consent will be obtained
Based on observation, interview, and record review, the facility failed to follow their bed rails (side rails, bed rails, safety rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for six of 15 sampled residents (Resident 39,19,27,33,17, and 5) when:
1. There was no documentation that alternatives for side rails were attempted prior to installing bed rails;
2. There was no informed consent (IC, the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from resident or responsible parties (RP, individual designated to make decisions on behalf of the residents) including risks and benefits explained prior to installing bed rails; and
3. There was no documentation that an assessment for the use of bed rails and risk for entrapment prior to installing bed rails was done.
These failures resulted in the residents and RP's not being fully informed of the risks of the use of bed rails and had the potential to place the residents at risk of serious injury.
Findings:
During an observation on 5/12/25 at 8:10 a.m., noted Resident 39's bed had partial bed rails up on both sides.
Review of Resident 39's face sheet (FS, a document that gives resident's information at a quick glance) indicated Resident 39 was admitted to facility on 12/12/22.
Review of Resident 39's minimum data set (MDS, resident's clinical and functional assessment tool) assessment dated [DATE] indicated Resident 39's brief interview for mental status (BIMS) score was 15 of 15 (score of 13-15: intact cognition).
Review of Resident 39's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for the use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 39's bed.
During an observation on 5/12/25 at 8:11 a.m., Resident 19's bed was noted with one partial bed rail up at the foot of the bed on left side.
Review of Resident 19's FS indicated Resident 19 was admitted to facility on 11/2/20.
Review of Resident 19's MDS assessment dated [DATE] indicated Resident 19's BIMS score was 15 of 15, intact cognition.
Review of Resident 19's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 19's bed.
During an observation on 5/12/25 at 8:20 a.m., Resident 27's bed was noted with partial bed rails up on both sides.
Review of Resident 27's FS indicated Resident 27 was admitted to facility on 9/5/24.
Review of Resident 27's MDS assessment dated [DATE] indicated Resident 27's BIMS score was 15 of 15, intact cognition.
Review of Resident 27's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 27's bed.
During an observation on 5/12/25 at 9:08 a.m., Resident 33's bed was noted with one partial bed rail up at the head of the bed on left side.
Review of Resident 33's FS indicated Resident 33 was admitted to facility on 8/14/20.
Review of Resident 33's MDS assessment dated [DATE] indicated Resident 33's BIMS score was 4 of 15 (score of 0-7: severe impaired cognition).
Review of Resident 33's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 33's bed.
During an observation on 5/12/25 at 9:23 a.m., Resident 17's bed was noted with one partial bed rail up at the head of the bed on left side.
Review of Resident 17's FS indicated Resident 17 was admitted to facility on 3/28/17.
Review of Resident 17's MDS assessment dated [DATE] indicated Resident 17's BIMS score was 5 of 15, severe impaired cognition.
Review of Resident 17's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 17's bed.
During an interview with Registered Nurse (RN) A on 5/15/25 at 8:39 a.m., RN A confirmed the above residents had bed rail/s. RN A also confirmed there was no documented evidence for bed rails assessment, attempted alternatives, risk and benefits education, informed consent taken and risk for entrapment assessment completed before using bed rails for the above residents. RN A stated facility should have documented and followed their policy for bed rails for these residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was sufficient direct care nursing staff to provide nursing and related care and services to meet resident's needs safely for 24 hours a day during the weekend. This failure had the potential to compromise care, health, and well-being of the 55 residents residing in the facility.
Findings:
Review of facility's census and direct care service hours per patient day (DHPPD) form dated 5/10/25 (Saturday) indicated actual CNA (certified nursing assistant) DHPPD was 2.13, and actual total DHPPD (including CNA and license nurses) was 3.15.
Review of DHPPD form dated 5/11/25 (Sunday) indicated an actual CNA DHPPD of 1.99, and actual total DHPPD of 2.99.
During concurrent record review of DHPPD forms and interview with the facility's Director of Staff Development (DSD) on 5/15/25 at 10:52 a.m., the DSD reviewed the DHPPD forms above on both days. The DSD confirmed the above DHPPD for CNA and the total for both days. The DSD stated the facility did not meet sufficient DHPPD on both days on the weekend. The DSD also stated the facility should have 2.4 CNA DHPPD, and 3.5 total DHPPD for both days to provide sufficient nursing staffing to meet all resident's care needs.
During an interview with Registered Nurse (RN) A on 5/15/25, at 2:20 p.m., RN A stated facility should have provided sufficient direct care nursing staff during the weekend and provided 2.4 CNA DHPPD and 3.5 total DHPPD.
Review of facility's policy and procedure (P&P) titled, Direct Healthcare Service Hours Per Patient Day, release date [DATE], the P&P indicated, the facility will employ and schedule sufficient licensed nurses and CNAs to meet or exceed the minimum required 3.5 DHPPD and 2.4 CNA DHPPD on every calendar day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident 156's admission record indicated he was admitted to the facility on [DATE] and had diagnoses including gastro esophageal reflux disease (GERD, which is a common condition in where stomach acid flows back up into the esophagus, causing a burning sensation in the chest , often called heart burn) and other chronic pain.
Review of Resident 156's MRR dated 4/30/25, indicated the CP identified a medication form concern for gabapentin (medication used to control seizures [is abnormal electrical activity in your brain], to treat nerve pain)100 milligrams (mg, unit of measurement) with recommendations as pharmacy is sending capsules form, update your MAR (Medication administration record) and frequency issue for pantoprazole (medication used to treat damage from GERD) 20 mg, with recommendations as clarify frequency and update your order. However, the MRR did not have an evidence that it was reviewed by the nurse nor a signature that indicated it was reviewed.
Review of Resident 156 physician's orders dated 5/13/25, indicated, Pantoprazole sodium oral tablet delayed release 20 mg (pantoprazole sodium) give 1 tablet by mouth before meals for GERD. Gabapentin Capsule 10 mg, give 1 capsule by mouth every 24 hours as needed for neuropathic pain.
During an interview on 5/13/25, at 2:20 p.m., with Registered Nurse (RN) A, RN A stated Resident 156's drug regimen review with recommendations was missed and was not followed-up.
During an interview on 5/16/25, at 11:05 a.m., with the DON, the DON confirmed that Resident 156's MRR with recommendations should have acted upon when the facility received the CP's recommendations for potential clinically significant medication issues identified on 4/30/25.
Review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated 6/202, the P&P indicated, The findings are phoned, faxed, or e-mailed to the director of nursing or designee and documented and stored with the other consultant pharmacist recommendations within 72 hours. Recommendations are acted upon and documented by the facility staff and or the prescriber.
Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP, a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported the lack of blood work related to use of anticoagulant (AC, used to treat prevent or delays blood clots forming in blood vessels) medication to the facility during the monthly medication regimen review (MRR, a thorough evaluation of resident's medications) for one of three sampled resident (Resident 10); and the facility failed to follow up MRR recommendations for one of two sampled resident (Resident 156).
These failures resulted in Resident 10 not receiving a baseline and periodical blood work, and Resident 156's medication orders not clarified.
Findings:
Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 10/24/24 with diagnoses including atrial fibrillation (A Fib, an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary embolism (blood clot in lung vessels).
Review of Resident 10's physician order dated 10/24/24 indicated rivaroxaban (used to treat reduce and prevent blood clots) 20 milligrams (mg: a unit of mass equal to a thousandth of a gram) in the evening for A Fib.
Further review of Resident 10's physician orders indicated there was no laboratory (lab) work ordered to monitor kidney function and blood levels since Resident 10 was admitted to facility.
Review of the facility provided MRR reports for Resident 10 indicated there was no MRR related to the use of an AC medication and lack of lab work orders.
Review of Resident 10's care plan for AC drug therapy dated 11/11/24 indicated intervention, Monitor lab reports, and notify physician promptly of results.
During an interview with Licensed Vocational Nurse I (LVN I) on 5/16/25 at 8:56 a.m., LVN I confirmed Resident 10 receives AC medication every evening. LVN I also confirmed there were no lab work ordered for Resident 10 since admission to the facility. LVN I stated there should be a lab work order for Resident 10 due to an AC medication use. LVN I stated she will request to the MD (medical doctor) a lab work order for Resident 10.
During an interview with the Director of Nursing (DON) on 5/16/25 at 9:56 a.m., the DON confirmed there was no MRR recommendation for Resident 10 to have lab work with the use of AC medication. The DON also confirmed there were no blood work orders since Resident 10 was admitted to facility. The DON stated Resident 10 should have a baseline and periodical lab orders to monitor kidney and blood levels when receiving an AC medication.
During a telephone interview with the facility's CP on 5/16/25 at 9:56 a.m., the CP confirmed there was no MRR recommendation for Resident 10 to have lab work with the use of AC medication. The CP stated routine blood work was not recommended for the use of rivaroxaban. The CP also stated baseline and periodical blood work was needed to monitor kidney and blood levels when resident receives this medication. The CP further stated she should have identified the lack of blood work orders and recommended blood work orders during monthly MRR review for Resident 10.
Review of facility's policy and procedure (P&P) tilted, Anticoagulation-Clinical Protocol, release date: January 2018, the P&P indicated, The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking .
Review of facility's P&P titled, Consultant Pharmacist Reports, effective date: June 2021, the P&P indicated, Resident-specific irregularities and /or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber.

Based on interview and record review, the facility failed to perform a thorough investigation and report for six of six residents (Residents 1, 2, 3, 4, 5, and 6).
This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety.
Findings:
During a review of the 5-day investigation summary of an alleged abuse by a certified nursing assistant (CNA) to Residents 1 and 2, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the alleged abuse by the CNA did occur, or not.
During an interview on 4/25/25 at 3:49 p.m., with the administrator (ADM), the ADM stated that he tried to send the 5-day follow-up investigations for Resident 1 and 2 but failed. He was not able to verify if the allegations were substantiated or not. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse policy and procedure (P&P).
During a review of the 5-day investigation summary of an alleged physical altercation between Residents 3 and 4, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the physical altercation did occur, or not.
During a review of the 5-day investigation summary of an alleged physical altercation between Residents 5 and 6, the summary did not indicate the outcome for the facility's investigation of whether the facility was able to determine if they thought the physical altercation did occur, or not.
During a concurrent interview and record review on 5/9/25 at 10:47 a.m., the ADM, he reviewed the facility's 5-day follow-up for the incidents and the facility's Abuse and Neglect Prohibition policy and procedure. The ADM also stated the facility's 5-day follow-up investigation for the incidents had not followed their abuse P&P.
A review of the facility's policy and procedure (P&P) dated 6/2022, titled Abuse, Neglect, Prohibition, the P&P indicated, All reports of resident abuse .are reported to local ombudsman or local law enforcement, state, and federal agencies .and thoroughly investigated by facility management. Findings of all investigations are documented on the facility's investigation form, log and reported . The administrator or designee will report findings of all completed investigations to the Licensing and Certification Program District Office via fax and other officials in accordance with law within five (5) working days of the incident and take all necessary, corrective actions depending on the results of the investigation.

Based on interview and record review, the facility failed to assist one of three residents (Resident 1) with getting insurance when their insurance stopped. This failure had the potential to compromise Resident 1's ability to obtain quality of care and admission.
Findings:
Resident 1 was admitted to the facility with diagnoses which included heart failure, malnutrition, and pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and sepsis (a serious condition in which the body responds improperly to an infection).
During an interview on 8/15/24 at 9:12 a.m. with the administrator (ADM), he stated Resident 1 had been taken off from MediCal (state insurance) on 7/31/24.
During an interview on 8/15/24 at 11:44 a.m. with the ADM, he stated the facility did not discuss private pay with Resident 1.
During an interview on 8/15/24 at 11:57 a.m. with the ADM, he stated the facility never applied for MediCal for Resident 1.
During an interview on 8/21/24 at 2:24 p.m. with the social services (SS), she stated the previous business office manager (BOM) would fill out the MediCal redetermination, then contact her to get the bank statement from the family to send to MediCal.
During a review of the facility's policy and procedure (P&P) titled, admission to the Facility, dated 01/2023, the P&P indicated .5. b. The admission staff will refer the resident and/or responsible party to the Social Service Director or facility designee when Medicaid coverage is indicated . c. The Medicaid application can be completed during the admission process (in some states) with a copy to Social Services, or facility designee, for follow through with the local Medicaid office (refer to state regulations).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services in accordance with professional standard of practice for one of one resident (Resident 1) when the Licensed Vocational Nurse (LVN) did not follow the physician order regarding out on pass (leave the premises) for therapeutic therapy.
This failure had the potential to compromise the resident's safety.
Findings:
Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), neuralgia (severe, sharp, or burning pain that follows the path of a damaged or irritated nerve) and neuritis (inflammation of one or more nerves caused by injury, infection, or an autoimmune disorder causing pain, tenderness, numbness, weakness, or changes in sensation), hypertensive heart (heart problems that occur because of high blood pressure that is present over a long time) and chronic kidney disease with heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).
During a concurrent interview and record review on 7/2/24 at 1:46 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC confirmed that Resident 1 signed the facility's Out on Therapeutic Pass/Leave of Absence Log on 6/11/24 at 10:15 p.m. to go to 7-Eleven store. The MDSC stated Resident 1 became verbally and physically aggressive, so they let her go out that night and they notified the MD (physician). The MDSC stated there was no documentation in the progress notes that the MD was notified. The MDSC confirmed the physician order dated 3/21/24 indicated May go out on pass for therapeutic therapy. The MDSC stated Resident 1 going to 7-Eleven store was not considered a therapeutic therapy. The MDSC also stated Resident 1 going out to 7-Eleven store was going against the MD order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1.
Findings:
Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses including vascular dementia (brain damage caused by multiple strokes [occurs when blood supply going to the brain is blocked or reduced] and cognitive communication deficit (trouble participating in conversations).
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/21/24 indicated her Brief Interview for Mental Status (BIMS, a tool used to have a snapshot of a resident cognitive function) was 00 (score of 0 to 7 indicates severe cognitive impairment).
Review of Resident 2's admission record indicated he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that affects memory and other mental functions) and dementia (loss of cognitive function like thinking, remembering, and reasoning).
Review of Resident 2's MDS dated [DATE] indicated his BIMS score was 5.
Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a verbal or written communication tool used by healthcare professional) date 4/19/24, indicated at approximately 7:14 p.m., Resident 3 went to the activity room and witnessed Resident 2 putting his hands inside Resident 1's pants. Resident 3 called Registered Nurse A (RN A) and RN A went to the activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh.
During an interview with RN A on 4/25/24 at 2:30 p.m., RN A stated when Resident 3 called her attention she immediately went to activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh. RN A further stated Resident 1 was wearing above knee-length loose pants at that time.
During an interview with Licensed Vocational Nurse B (LVN B) on 4/29/24 at 1 p.m., she stated the activity room had supervision during daytime and after 6 p.m., there will be no staff supervising the activity room.
During an interview with Resident 3 on 4/29/24 at 1:40 p.m., she stated she was the first person who witnessed Resident 2 touched Resident 1's private part because there was no staff around. Resident 3 further stated Resident 2 knew what he was doing because when he saw her, he immediately stopped.
Review of Resident 3's MDS dated [DATE] indicated her BIMS score was 13 (score of 13-15 indicates cognition [process of acquiring knowledge and understanding] is intact).
During an interview with Certified Nursing Assistant C (CNA C) on 4/29/24 at 3:45 p.m., CNA C stated she worked on 4/19/24 evening shift and Resident 1 was under her care. CNA C stated at 7:14 p.m., she was taking her break and asked other CNAs to watch out the residents assigned to her. CNA C further explained that she was supposed to take her break from 6 p.m., to 6:30 p.m. but was delayed on that day and was not able to watch Resident 1.
Review of the facility's policy and procedure titled, Abuse Policy, dated 7/2025 indicated The facility will prohibit abuse including sexual abuse. To ensure that the facility staff are doing all that is within their control to prevent occurrence of abuse including neglect .for all patients.

Based on observations, interviews, and facility document review, the facility failed to ensure residents' rooms accommodated no more than four residents when 1 (Ward 1) of 23 resident rooms was occupied by six residents, and 1 (Ward 2) of 23 resident rooms was occupied by four residents but had six beds available for use when at full occupancy.
Findings included:
Review of the facility's Resident Matrix, printed 01/29/2024, revealed six residents occupied room ward 1.
During observations on 01/31/2024 beginning at 1:35 PM, six residents were observed to occupy [NAME] 1. [NAME] 2 was occupied by four residents but had six beds available for use when at full occupancy.
During an interview on 02/01/2024 at 9:40 AM, Licensed Vocational Nurse #1 stated he had never had an issue with providing care to the residents.
During an interview on 02/01/2024 at 9:45 AM, Certified Nursing Assistant #2 stated he had no issues providing proper care to the residents.
During an interview on 02/01/2024 at 10:34 AM, the Director of Nursing (DON) stated he expected residents' rooms to be large enough to be safe for the residents who resided in them, for the staff to provide care for the residents, and spacious to accommodate the residents' personal belongings.
During an interview on 02/01/2024 at 10:40 AM, the Administrator stated he believed there could be no more than four residents in a room. The Administrator stated he expected that residents' rooms would still have adequate space for their personal use and belongings, as well as space to provide adequate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 23 (Rooms 1 through 21, [NAME] 1, and [NAME] 2) of 23 resident rooms in the facility.
Findings included:
During the initial tour of the facility on 01/29/2024 at 10:25 AM, no residents voiced any concerns regarding the size of their rooms.
On 01/31/2024 at 1:35 PM, the housekeeping supervisor (HS) measured the following rooms and confirmed the following dimensions:
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In room [ROOM NUMBER], there was 78 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 72 sq ft for each resident.
-
In room [ROOM NUMBER], there was 69 sq ft for each resident.
-
In room [ROOM NUMBER], there was 69 sq ft for each resident when the facility was at full occupancy.
-
In room [ROOM NUMBER], there was 69 sq ft for each resident.
-
In room [ROOM NUMBER], there was 69 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident when the facility was at full occupancy.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In room [ROOM NUMBER], there was 74.6 sq ft for each resident.
-
In [NAME] 1, there was 70 sq ft for each resident.
-
In [NAME] 2, there was 65 sq ft for each resident when the facility was at full occupancy.
During an interview on 01/31/2024 at 2:42 PM, the HS stated he did not know how many sq ft each resident was supposed to have.
During an interview on 02/01/2024 at 9:40 AM, Licensed Vocational Nurse #1 stated he never had an issue with providing care to the residents due to the sizes of the residents' rooms.
During an interview on 02/01/2024 at 9:45 AM, Certified Nursing Assistant #2 stated the sizes of the rooms did not prevent him from providing proper care to the residents.
During an interview on 02/01/2024 at 10:34 AM, the Director of Nursing (DON) stated he did not know what the exact sizes the rooms were supposed to be, but he did know there were regulations that specified what size the rooms were supposed to be. The DON stated he expected residents' rooms to be large enough to be safe for the residents who resided in them, for the staff to provide care for the residents, and spacious to accommodate the residents' personal belongings.
During an interview on 02/01/2024 at 10:40 AM, the Administrator stated he believed there could be no more than four residents in a room, and the rooms were supposed to have 80 sq ft per resident. The Administrator stated he expected that residents' rooms would still have adequate space for their personal use and belongings, as well as space to provide adequate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to prevent one out of three residents (Resident 1) from leaving the facility without staff's knowledge and permission.
1. The facility did not implement the care plan to provide enough supervision for Resident 1's mobility;
2. The facility did not update Resident 1's care plan to provide adequate supervision post-event.
These failures compromised Resident 1's health and safety, as he was found by the police and, was admitted to the acute hospital for treatment and evaluation on 9/20/23, and had a potential risk for Resident 1's elopement in the future.
Findings:
1. Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and unspecified Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities).
During an interview with the Licensed Vocational Nurse (LVN) A on 9/21/23 at 2:53 p.m., LVN A stated that Certified Nursing Assistant (CNA) C reported that Resident 1 was not in his room around 10:30 p.m. on 9/19/23. Staff searched inside and outside the facility and reported to police around 11:05 p.m.
During a phone interview with CNA C on 1/30/24 at 10:57 p.m., CNA C stated she found Resident 1 was not in his room around 10:30 p.m. on 9/19/24. She searched the rehabilitation and activity rooms and did not find Resident 1, so she reported this to LVN A. CNA C further stated that Resident 1 had Alzheimer ' s disease and was confused. Sometimes, Resident 1 got up at midnight because he thought it was morning and she needed to redirect him for time disorientation.
Review of Resident 1's IDT post-event notes dated 9/20/23 indicated that Resident 1 was post-elopement and returned to the facility at 5:30 a.m., with an unwitnessed fall per EMTs( Emergency Medical Services ) and a 3 cm (Centimeters are metric units of measurement ) laceration (cut) above the right eyebrow.
Review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/31/23 indicated his brief interview for mental status (BIMS, cognition level) score was 6 (0 to 7 points suggests severe cognitive impairment).
Further review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/31/23 indicated that he needed supervision for a walk-in corridor, locomotion on unit (how the resident moves between locations in his room and adjacent corridor on the same floor), and locomotion off unit (how the resident moves to and returns from off-unit locations).
Review of Resident 1's Elopement Risk assessment dated [DATE] indicated the provision of frequent monitoring.
Review of Resident 1's care plan, initiated on 3/23/18, indicated Resident 1 was at risk for (Activities of daily living )ADL self-care performance deficit related to Alzheimer's disease and Dementia and required supervision with all areas of ADLs/mobility, ambulated unlimited distances without assistant device used.
During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 1/26 /24 at 5:12 p.m., the MDSC reviewed Resident 1's MDS assessment on 8/31/23 and the care plan on 8/23/23. The MDS stated that Resident 1 had Alzheimer's disease and needed supervision in all ADL areas, including mobility.
During a phone interview with LVN A on 1/30/24 at 5:39 p.m., LVN A confirmed that the police officer found Resident 1 and sent him to the hospital ER (emergency room). Resident 1 returned to the facility the following day at 5:30 a.m. LVN A also confirmed that Resident 1 had an unwitnessed fall and a 3 cm laceration above the right eyebrow.
Review of Resident 1's care plan updated post-event, dated 9/19/23, indicated Resident 1 returned to the facility via ambulance accompanied by EMTs from the hospital ER. Resident 1 was found in the Los Gatos area, where a resident had a fall incident and sustained a 3 cm laceration above the right eyebrow.
During a phone interview with the Director of Nursing (DON) on 1/26 /2024 at 11:00 a.m., the DON confirmed that Resident 1 had Alzheimer's disease with severe cognitive impairment. the DON stated that the staff should have provided frequent supervision to prevent elopement.
2. Review of Resident 1's care plan, initiated on 9/19/23, indicated to monitor resident's whereabouts every 15 minutes.
During a concurrent interview and record review with LVN B on 1/26/24 at 3:58 p.m., LVN B reviewed Resident 1's care plan initiated on 9/19/23. He stated that staff monitored Resident 1 every 15 minutes post-elopement for 72 hours. LVN B acknowledged that the licensed nurse should have updated the care plan to frequent monitoring after 72 hours.
During a phone interview with the Director of Nursing (DON) on 1/31/24 at 11:05 a.m., the DON acknowledged that licensed nurses should have updated the care plan after monitoring every 15 minutes for 72 hours.
Review of the facility's policy and procedure, dated January 2018, Elopement/Wandering Resident, indicated that The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for wandering.
Review of the facility's undated policy and procedure, Care Plans, Comprehensive Person-Centered, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a notice prior to transfer or discharge to the resident, the resident's representative and representative of the Office of the State Long-Term Care Ombudsman for one of two sampled facility-initiated discharges (Resident 1). This failure had the potential for the resident or resident's responsible party to not having an opportunity to respond or seek help from ombudsman to confer or to contest the discharge.
Findings:
Review of Resident 1's record indicated he was admitted to the facility on 12/2018 and was discharged to a board and care (BHC) home on 3/17/23. Review of a faxed documentation indicated, the ombudsman office was notified of Resident 1's discharge on [DATE].
Review of Resident 1's face sheet (document providing resident information at a quick glance) indicated a family member was a responsible party (person responsible for making healthcare and/or financial decisions on behalf of a resident).
Review of Resident 1's Minimum Data Set, (MDS, an assessment tool), dated 12/27/22, indicated the resident did not have any problems with memory or with daily decision-making skills. There was no documentation in Resident 1's record indicating he was informed of his discharge.
During a follow-up interview on 6/27/23 at 1 p.m., the SSD stated Resident 1 was a combination of family and facility-initiated discharge and the facility did not give discharge or transfer notices.
During an interview on 6/27/23 at 2:05 p.m., the administrator acknowledged understanding the transfer or discharge notices were to be provided prior to discharge.
Review of Transfer or Discharge Notice policy, dated January 2018, indicated a resident, and/or his or her representative was to be given a thirty-day advance notice of an impending transfer or discharge from the facility. A copy of the notice was to be sent to the Office of the State Long-Term Care Ombudsman.
All Facilities Letter (AFL) 17-27, dated 12/26/17 and addressed to long-term care facilities indicated, Effective January 1, 2018, AB 940 requires a LTC facility to notify the local LTC Ombudsman at the same time notice is provided to the resident or the resident's representatives when a facility-initiated transfer or discharge occurs. The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility, whether the resident agrees with the facility's decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a discharge plan of care to include the resident's participation, preferences and needs to optimally prepare and transition him to a new living environment for one of two sampled residents (Resident 1). Also, the medical record lacked documentation of Resident 1's referral and communication with the Board and Care Home (BCH). This failure had the potential for the resident not liking and/or not adjusting to his new home.
Findings:
Review of Resident 1's record indicated he was admitted to the facility on 12/2018 and was discharged to a BHC home on 3/17/23.
Review of Resident 1's Minimum Data Set, (MDS, an assessment tool), dated 12/27/22, indicated the resident did not have any problems with memory or with daily decision-making skills.
Resident 1 had a care plan, dated 1/9/20, indicating he was a long term resident with minimal and no possibility of discharge to lower level of care due to his disease status.
During an interview on 5/23/23 at 11:37 a.m., the administrator (ADM) stated the long term stay care plan should have been discontinued and a new care plan should have been developed to reflect Resident 1's current status.
Resident 1 had other care plans addressing problems of alleged sexual behavior of touching another resident's breast, dated 12/14/22; verbalization of wanting to kill himself, dated 6/18/21; impaired visual function related to legal blindness, dated 1/29/20; and episodes of spitting and continuous drooling, dated 1/29/20.
Review of Resident 1's planning note, dated 3/8/23 at 12 midnight, indicated the interdisciplinary team (IDT, group of health care members who meet to plan care for the resident) that consisted of the social services director (SSD) and family member, discussed Resident 1's daily episodes of sexual advances towards staff, touching staff, asking for hugs and kisses, purposely licking his hands and smearing saliva on carts, computer monitor, top of medication carts, and staff repeatedly redirecting resident to stop. The same note indicated a family member then asked for assistance to a BCH.
During an interview on 5/23/23 at 10:47 a.m., the certified nurse assistant (CNA) stated Resident 1 was alert, saw only shadows, used a cane to walk, spitted saliva everywhere, threw utensils outside his door, and had grabbed butt and breast of women.
There was no IDT documentation in Resident's record up to the time of discharge addressing whether the resident was involved in selecting his new living location, a trial visit was offered, any referrals were made, the BCH was informed and/or conducted an assessment to ascertain the resident's preferences, needs and problem behaviors to determine if the new living arrangement was suitable for the resident and BCH.
During an interview on 5/23/23 at 11 a.m., the SSD stated the BCH operator was a nurse and she was to assess Resident 1's status.
During an interview on 6/5/23 at 10 a.m., the SSD stated Resident 1 was alert and oriented, he used a front wheel walker to walk around the facility, and there was no documentation in the record about communication with the BCH because the facility had had been doing business with them for years.
During an onsite visit on 6/27/23, documentation of Resident 1's discharge planning prior to discharge on [DATE] was requested and not provided.
Review of Discharge Summary and Plan policy, dated January 2018, indicated when a resident's discharge was anticipated, a post-discharge plan was to be developed to assist the resident to his/her new living environment. A discharge summary was to include the resident's ability to perform activities of daily living, such as the need for staff assistance, sensory and physical limitations, such as decrease in vision, mental and psychosocial status of resident behavior and mood. The post-discharge plan was to be developed by the IDT to include a description of the resident's stated discharge goals, and factors that may make the resident vulnerable and how those factors were to be addressed.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processess and behavior) for two of five residents (21 and 5) who receives psychotropic medications when:
1. Resident 21 received Ambien (prescription medicine for the short-term treatment of adults who have trouble falling asleep) 2.5 mg (mg, unit of measurement of mass) without monitoring hours of sleep, as indicated in the care plan; and
2. Resident 5 received prn (as needed) Lorazepam Intensol (used to treat anxiety) beyond 14 days without documentation of its rationale and specific duration in the resident's clinical record.
These failures resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the resident's physical, mental, and psychosocial well being.
Findings:
1. Review of Resident 21's physician's order, dated 4/6/21, indicated Ambien 2.5 mg by mouth at bedtime for insomnia (difficulty sleeping).
Review of the resident's care plan, dated 3/29/21, indicated the resident is on sedative/hypnotic therapy (Ambien) related to insomnia. Hours of sleep monitored every shift.
During an interview and concurrent record review with licensed vocational nurse B (LVN B) on 5/20/21 at 10:02 a.m., she stated the staff only monitored for the side effects of Ambien, but could not find the staff monitoring for the number of hours of sleep. LVN B further stated that the hours of sleep should be monitored because the resident is on Ambien.
2. Review of Resident 5's physician's order, dated 10/25/2020, indicated Lorazepam 2 mg/ml (mg/ml, measurement of solution's concentration) 0.5 ml by mouth every 6 hours prn for anxiety.
Review of Resident 5's physician's order, dated 4/10/21, indicated Ativan 0.5mg every 6 hours prn for anxiety.
Review of Resident 5's Hospice Visit and Communications, dated 4/7/21, no documentation of rationale for Ativan's prn order beyond 14 days and its specific duration.
Review of MD progress notes, dated 12/17/2020, 1/29/21, 2/19/21, no documentation of rationale for Ativan's prn order beyond 14 days and its specific duration.
During an interview and concurrent record review with LVN A on 5/21/21 at 2:00 p.m., she stated that per the hospice nurse, there was no need for 14 days, since the resident is on hospice. She reviewed the resident's chart and could not find the documented rationale for exceeding the prn order beyond 14 days and its specific duration.
During an interview and concurrent record review with the Minimum Date Set Coordinator (MDSC) on 5/21/21 at 2:13 p.m., she did not find the documentation either and stated previous orders were given only for 14 days. Ativan prn order was renewed on 4/10/21. MDSC called hospice and will have hospice document the rationale and specific duration for the PRN Ativan.
Review of the facility's policy, dated 10/2017, Psychotropic Medication Use indicated If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record.

Based on observation, interview, and record review, the facility had a 7.14 percent medication error rate when two medication errors out of 28 opportunities were identified during medication pass for one resident (Resident 30). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident.
Findings:
1. During a medication pass observation on 5/17/21 at 9:53 a.m., licensed vocational nurse B (LVN B) was preparing and administering multiple medications, including a tablet of Protonix (blocks the production of acid in the stomach) 20 milligrams (mg, unit of measurement) to Resident 14. During the observation, LVN B said the internet was down so she used the resident's paper physcian orders to check for scheduled medications to administer to the resident.
On 5/17/21, a review of Resident 14's medical record indicated a physician's order, dated 8/29/20, for Protonix 20 mg 1 tab one time a day for gastroesophageal reflux disease (a digestive disorder in which stomach acid or bile irritates the food pipe lining).
On 5/17/21, a review of Resident 14's medication administration record (MAR) indicated Protonix was scheduled to be given daily at 6 a.m. The MAR indictated another nurse had already administered Protonix to the resident that morning at 6 a.m.
During an interview with LVN B, on 5/17/21 at 2:31 p.m., LVN B acknowledged she gave an extra dose of Protonix to Resident 14 when it was already given earlier that morning. She stated that she should have used the paper MAR to check for scheduled medications when the internet was down.
During an interview with the director of staff development (DSD), on 5/18/21 at 8:52 a.m., she stated that paper MAR should be used during medication administration when the internet was down.
2. During the same medication pass observation, LVN B administered to Resident 14 one puff orally of the Incruse Ellipta (an oral inhaler, used to prevent airflow obstruction and reduce flare-ups in adults with chronic obstructive pulmonary disease). LVN B instructed the resident to inhale one puff but did not instruct the resident to hold his breath after the inhalation. Consequently, the resident did not hold his breath but exhaled right away after inhaling the medication. The manufacturer's instructions on the Incruse Elliipta indicated to hold the breath for about 3 to 4 seconds or as long as comfortable, and then breathe out.
During an interview shortly after the medication observation, LVN B acknowledged the above observation and stated that she did not know to instruct the resident to hold his breath.
Review of the facility's 8/2014 policy, Specific Medication Administration Procedures: Oral inhalation Administration, indicated Instruct resident to hold breath for 10 seconds after receiving medication.

Based on observation, interview, and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions when:
1. Resident 14's Incruse Ellipta (an oral inhaler, used to prevent airflow obstruction and reduce flare-ups in adults with chronic obstructive pulmonary disease) was opened without an open date;
2. Two of two Xalatan (or Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Residents 13 and 23 were being used past the discard date; and
3. Lorazepam Intensol (medication used to treat anxiety) 2mg/ml (mg/ml, measurement of a solution's concentration) bottle for Resident 5 did not have an open date and was being used past the discard date.
These deficient practices had the potential for residents to receive medications from two out of two medication carts. Medications that are unlabeled and past their discard date could lead to unsafe and ineffective medications for the residents.
Findings:
1. During an inspection of medication cart #2 on 5/17/21 at 9:53 a.m., with licensed vocational nurse (LVN) B, an opened Incruse Ellipta inhaler was found without an open date. The pharmacy label indicated it was filled on 3/28/21 (7 weeks prior). The manufacturer's label indicated: Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0, whichever comes first.
During a concurrent interview with LVN B, she verified the Incruse inhaler did not have an open date. LVN B further stated it would be difficult to know when it was first opened without the open date.
During an interview with the Director of Staff Development (DSD), on 5/18/21 at 8:45 a.m., the DSD stated that inhalers should be dated with an open date when it was first opened.
2. During an inspection of medication cart #1 on 5/17/21 at 11:20 a.m., with LVN A, two opened Xalatan eyedrops for Residents 13 and 23 had the open date of 4/11/21. The label on each Xalatan eyedrop indicated to discard after 5/9/21.
During a concurrent interview with LVN A, she acknowledged both Xalatan eyedrops should be discarded after 5/9/21.
During an interview on 5/18/21 at 8:45 a.m., the DSD stated eyedrops were good for 30 days after opening.
3. During the same inspection of medication cart #1 with LVN A, an opened Lorazepam Intensol bottle for Resident 5 was identified without the open date. LVN A stated the nursing staff opened it on 10/25/2020, based on the controlled drug record (an inventory sheet that kept record of use for this medication). The manufacturer's label on the bottle indicated, Discard opened bottle after 90 days. LVN A verfied the Lorazepam Intensol was undated and being used past the discard date, which would have been 1/25/21.
During a concurrent interview and record review with LVN A, she confirmed that the Controlled Drug Record (CDR) indicated the Lorazepam Intensol was used 30 times since 1/25/21, and it was last given on 5/11/21.
Review of the facility's policy, dated April 2008, Preparation and General Guidelines: Vials and Ampules, indicated The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose).

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when:
1. Dietary staff did not cover their hair completely with a hairnet;
2. The uncleaned fan blew air directly onto the clean meal trays, plates, plate covers and food preparation area (area to prepare for hot food);
3. There were opened liquid eggs stored with other food items in the refrigerator;
4. Toaster had multi-colored substances;
5. The can opener had multi-colored substances;
6. Kitchen staff did not correctly check the sanitizer concentration level;
7. Dietary manager (DM) did not wash his hands or perform the hand hygiene when he was in the kitchen.
These failures had the potential to cause food-borne illness for the residents. There were 49 of 51 residents consuming the food from the kitchen.
Findings:
1a. During an initial kitchen tour on 5/17/21 at 8:46 a.m., [NAME] G and dietary aide H (DA H) worked in the kitchen, their hair on the sides and the back were not completely covered with a hairnet. Their hair on the sides and the back were sticking out of the hairnets. Both [NAME] G and DA H stated they should have covered their hair completely with a hairnet.
1b.During a kitchen inspection on 5/18/21 at 11:30 a.m., [NAME] I, DA H and dietary manger J (DM J) did not completely cover their hair with a hairnet. Their hair from the sides and the back were sticking out of the hairnets. DM J stated their hair should have been completely covered with a hairnet.
1c. During a kitchen inspection on 5/18/21 at 3:56 p.m., DA K's hair on the side and the back were not completely covered with a hairnet.
Review of the facility's revised policy, DRESS CODE FOR WOMAN AND MEN dated 2015, indicated .Appropriate dress in the dietary department . Personal hygiene and appropriate dress are a very important part of the total appearance of the Dietary Department . The policy indicated women should wear .Hair net or hat which completely covers the hair . and men should wear .Hat for hair, if hair is short .Hair net for hair, if hair is long (over the ears or longer) .
2. During an observation on 5/17/21 at 9:02 a.m., a fan was blowing air directly onto the clean meal trays, plates, plate covers, meal carts and the food preparation area. The fan had a grey fluffy substance on the coil area and sticky oily black substance on the interior area .
During an interview with [NAME] G on 5/17/21 at 9:08 a.m., she stated the fan should not be used in the kitchen to blow the air directly onto the cleaned utensils and the food preparation area. She stated the fan was used to cool down the temperature in the kitchen.
During an interview with the DM on 5/18/21 at 11:44 a.m., he stated it was okay to let the uncleaned fan blow air directly onto the cleaned meal cart, meal trays, plates and plate covers. The DM stated it was okay to let the uncleaned fan blow air directly onto the cleaned utensils .as long as it (fan) did not blow the mold .as long as there was no food in the meal carts .
Review of the facility's undated policy, DISH WASHING, indicated .Dishes are to be air dried in racks before stacking and storing .
3. During an initial kitchen tour with [NAME] G on 5/17/21 at 9:08 a.m., an opened and unsealed carton of liquid whole eggs were stored with eggs and meats in the refrigerator.
During an interview with [NAME] G on 5/17/21 at 9:14 a.m., she stated the opened liquid eggs should be sealed when stored in the refrigerator.
4. During an initial kitchen tour with [NAME] G on 5/17/21 at 9:23 a.m., the toaster had orange, black and grey colored substances on the interior and exterior areas. [NAME] G stated there was only one toaster in the kitchen. She stated the staff should clean the toaster after each use. [NAME] G further stated the toaster was old and the facility should get a new one.
Review of the facility's undated policy, ELECTRICAL FOOD MACHINES, indicated Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, slicers, and toasters. The policy indicated to clean the toaster daily and .Remove crumbs from the crumb tray daily and wipe the toaster case with a soft damp cloth. If the case is greasy, use non-abrasive cleaning compound to clean it .
5. During an initial kitchen tour with [NAME] G on 5/17/21 at 9:25 a.m., black, orange and grey colored substances were observed on the can opener and the can opener holder. [NAME] G stated there was only one can opener in the kitchen and staff should have cleaned the can opener and the holder after each use.
Review of the facility's policy, CAN OPENER AND BASE, dated 3/13, indicated Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn out cogwheel .The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently .
6a. During an observation on 5/17/21 at 8:50 a.m., DA H demonstrated how to wash a tray of dishes via the dish machine. Her wet gloved fingers removed one test strip from the test strip bottle, the wet gloved hand put the extra test strips back into the strip bottle, then DA H dipped the test strip into the sanitizer solution for three seconds and checked the test strip with the color chart on the test strip bottle to obtain the dishwasher's sanitizer concentration level.
6b. During an observation on 5/17/21 at 8:55 a.m., [NAME] G demonstrated how to wash a tray of dishes via the dish machine. She dipped the test strip into the sanitizer solution for three seconds and checked the test strip with the color chart on the test strip bottle to obtain the dishwasher's sanitizer concentration level.
During an interview with both [NAME] G and DA H on 5/17/21 at 8:59 a.m., they both stated they should follow the test strip guide to use a dry hand to take out the test strip out and dip the test strip into the sanitizer for one second test time.
Review of the dish machine sanitizer test strip guide indicated to use dry fingers to remove the test strip from the vial, dip strip into solution to be tested. Test time is one second. Compare strip with color chart on the label to obtain the sanitizer concentration.
6c. During an observation on 5/19/21 at 3:52 p.m., [NAME] L checked the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and also used to manually sanitize dishes at three compartment sinks area) by dipping the test strip into the sanitizer for 10 seconds and compared the strip with color chart.
6d. During an observation and interview on 5/19/21 at 3:56 p.m., DA K checked the quaternary sanitizer by dipping the test strip into the sanitizer for one second and immediately compared the strip with the color chart on the strip bottle. DA K stated she did not know she needed to follow the test strip instruction to test the quaternary sanitizer.
Review of the quaternary sanitizer test strip guide on the strip bottle indicated PRECISION QAC QR5 . Use dry fingers to remove strip paper from vial, Remove one strip and dip strip for one second into solution to be tested. Allow 5 to 10 seconds to develop, then compare to color chart below .
7. During an observation on 5/18/21 from 11:44 a.m. to 11:58 a.m., the DM did not wash his hands or perform hand hygiene when he entered the kitchen beyond the marked red line on the kitchen floor (staff need to perform hand hygiene and wear a hairnet when entering the kitchen beyond the red line). The DM walked around in the kitchen and stood behind the cook when the cook checked the hot food temperature in the food preparation area.
During an interview with the DM on 5/18/21 at 11:58 a.m., the surveyor asked the the DM if staff need to wash hands once entering the kitchen beyond the marked red line. The DM raised his voice to the surveyor and stated, It's your fault that I forgot to wash hands. I am distracted .
During an interview with the senior administrator on 5/21/21 at 10:30 a.m., she stated there were 49 of 51 residents consuming the food from the facility's kitchen.

8. During the initial tour on 5/17/21 at 10:23 a.m., a small cart with gowns and gloves was observed outside of room D. There were also signs which indicated the residents in the room were on droplet precautions (a type of isolation where anyone entering the room was supposed to wear a mask, face shield, gown, and gloves to protect them from droplets in the air).
During an interview on 05/17/21 at 3:15 p.m., with licensed vocational nurse A (LVN A), LVN A stated everybody who entered Room D should have on full PPE (personal protective equipment).
During an interview on 5/20/21 at 8:45 a.m. with the senior administrator (SADM), Residents 97, 100, and 101, all in Room D, had been vaccinated and had a PCR test (polymerase chain reaction test, performed to detect genetic material from COVID-19 virus) prior to admission and an antigen test (detects the presence of the COVID-19 virus) upon admission. Their tests were negative for COVID-19. The residents in Room D all were from green facilities meaning no positive cases of COVID-19 in those facilities. The three residents should not have been in the yellow (observation) zone, but should have been on the green (safe) zone.
During an interview on 5/17/21 at 3:19 p.m. with the director of staff development (DSD), DSD stated
all the residents in Room D were fully vaccinated, had negative test results, and they were asymptomatic. DSD stated everybody entering Room D should wear goggles or face shield, gown, N95 mask, and wash their hands. DSD stated she gave in-services for COVID-19 updates on 3/10/21.
During an interview on 5/17/21 at 3:15 p.m. with LVN A, she stated everybody who entered Room D should have on full PPE.
During an interview on 5/17/21 at 4:23 p.m. with the social service assistant (SSA), SSA stated he was not sure if the three residents were positive or negative for COVID-19. SSA stated the residents said they had their vaccines for COVID. SSA stated he was not sure if the residents had any symptoms.
During an interview on 5/21/21 at 11 a.m. with the infection preventionist (IP), IP stated the three residents in Room D did not need to be in quarantine because of the new mitigation.
During the initial tour on 5/17/21 at 10:23 a.m., a small cart with gowns and gloves was observed outside room D. There were also signs which indicated the residents in the room were on droplet precautions (a type of isolation where anyone entering the room was supposed to wear a mask, face shield, gown, and gloves to protect them from droplets in the air).
During an interview on 05/17/21 at 3:15 p.m., with licensed vocational nurse A (LVN A), LVN A stated everybody who entered Room D should have on full PPE (personal protective equipment).
During an interview on 5/20/21 at 8:45 a.m. with the senior administrator (SADM), Residents 97, 100, and 101, all in room D, had been vaccinated and had a PCR test (polymerase chain reaction test, performed to detect genetic material from COVID-19 virus) prior to admission and an antigen test (detects the presence of the COVID-19 virus) upon admission. Their tests were negative for COVID-19. The residents in Room D all came from green facilities meaning no positive cases of COVID-19 in those facilities. The three residents should not have been in the yellow (observation) zone, but should have been ok the green (safe) zone.
During an interview on 5/17/21 at 3:19 p.m. with the director of staff development (DSD), DSD stated all the residents in room D were fully vaccinated, had negative test results, and they were asymptomatic. DSD stated everybody entering room D should wear goggles or face shield, gown, N95 mask, and wash their hands. DSD stated she gave in-services for COVID-19 updates on 3/10/21.
During an interview on 5/17/21 at 3:15 p.m. with LVN A, she stated everybody who entered room D should have on full PPE.
During an interview on 5/17/21 at 4:23 p.m. with the social service assistant (SSA), SSA stated he was not sure if the three residents were positive or negative for COVID-19. SSA stated the residents said they had their vaccines for COVID. SSA stated he was not sure if the residents had any symptoms.
During an interview on 5/21/21 at 11 a.m. with the infection preventionist (IP), IP stated the three residents in room D did not need to be in quarantine because of the new mitigation.
9. During an observation and subsequent interview on 5/20/21 at 2:19 p.m. with CNA E, CNA E rinsed a urine measuring container in the shared bathroom sink. CNA E stated she rinsed the urine measuring container in the sink.
During an interview on 5/21/21 at 2:52 p.m. with the director of clinical services (DCS), DCS stated if the toilet does not have a washer arm, the urine measure container needs to be rinsed in the utility room.
Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when:
1. Licensed vocational nurse A (LVN A) did not follow infection control practice during residents' wound treatment for sampled Residents 8 and 28;
2. The janitor/Housekeeper did not know the environmental disinfectant contain time (wet time, disinfectant maintain wet on the surface in order to kill the micro-organism) when cleaning the resident's room;
3. The facility did not implement the effective infection control practice when Resident 8 refused to do the wound treatment and shared the room with four residents;
4. Multiple residents did not wear mask or did not properly wear masks when leaving their room; multiple residents did not keep social distancing of at least six feet apart in the hallway;
5. COVID-19 screen concerns for visitor/staff;
6. LVN C did not perform hand hygiene and change gloves before starting a new task;
7. The facility failed to educate staff regarding proper cohorting (group of residents with the same infection are placed together) of newly admitted residents;
8. Staff were not aware of the COVID-19 cleared status of three residents placed in an observation room on droplet precautions;
9.Urine measuring container was rinsed out in resident bathroom sink.
These failures had the potential to result in cross-contamination and the spread of infections among the residents and staff.
Findings:
1a.During an observation on 5/18/2021 at 9:10 a.m., LVN A's gloved hand touched Resident 8's left foot when LVN A checked Resident 8's left lower leg wound. LVN A did not perform hand hygiene or change to a new pair of gloves. She continued to push Resident 8's wheelchair and table with the same gloved hands. Resident 8's uncovered breakfast tray was on the table.
During an interview with LVN A on 5/18/2021 at 9:15 a.m., she stated she should have performed hand hygiene after touching Resident 8's foot.
1b. During an observation on 5/18/2021 from 9:43 a.m. to 9:50 a.m., LVN A did the wound treatment for Resident 28. LVN A brought the whole box of clean gauze and gloves to the resident's bed during the wound treatment. The boxes of gauze and gloves were next to the trash bag that held the soiled wound dressing. LVN A also brought a tube of treatment medication, a packet of treatment dressing and a bottle of normal saline (to clean and disinfect the wound) to Resident 28's bedside table. LVN A did not perform hand hygiene after each glove removal during the treatment. After the treatment, LVN A put the used and uncleaned boxes of gloves from Resident 28's bed to the treatment cart next to a clean box of gloves. LVN A cleaned the used treatment medication tube, the treatment dressing packet and the normal saline bottle (from the resident's room) and then put these possibly contaminated supplies next to the clean supplies inside the treatment cart. LVN A put the used box of gauze (8/9 of gauzes remained inside the box) from the resident's room next to the clean supplies inside the treatment cart.
During an interview with LVN A on 5/18/2021 at 10 a.m. she stated she should have performed hand hygiene after each glove removal during the wound treatment for Resident 28. LVN A stated she should not have put the contaminated supplies next to the clean supplies in the treatment cart.
2. During an interview with the janitor M (also worked as a housekeeper) on 5/20/2021 at 2:50 p.m., he stated he also worked as a housekeeping to clean and disinfect the residents' rooms including the tables, bed side rails, TV remote controls, doorknobs, windows , sinks, toilets and floors. He stated he did not know the disinfectant's wet time. Janitor M stated he left the disinfectant wet on the surfaces for two to three minutes.
During an interview with the housekeeping supervisor (HKS) on 5/20/2021 at 3:50 p.m., he checked the disinfectant contact time and stated the disinfectant's wet time (same as contact time) is 10 minutes. HKS stated the staff should leave the disinfectant wet on the surface for 10 minutes when cleaning the residents' rooms.
3. Review of Resident 8's physician order dated 4/22/2021 indicated to soak the left lower leg with warm water, .allow resident to clean her own wound . every day shift related to cellulitis of left lower limb for 28 days. The physician's order dated 4/21/2021 indicated Resident may do her own wound care independently. Nursing may assist with getting the supplies upon request.
Review of nurses notes dated on 11/4/2020, 11/5/2020,11/7/2020, 11/10/2020, 1/7/2021, 2/11/2021, 4/25/2021, 4/26/2021, and 4/28/2021 indicated the facility nurses offered the wound treatment to Resident 8, however, the resident refused the wound treatment from the nurses.
During an observation on 5/17/2021 at 11:45 a.m., Resident 8 lay in bed with the black-brownish dry wound drainage on the left lower leg. The yellow-brownish wound drainage was noted on the bed sheet and on the room's floor.
During an observation on 5/17/2021 at 1:30 p.m., Resident 8 walked with a walker from the room to the hallway toward to the kitchen. Resident 8's left lower leg open wound was not covered .
During an observation on 5/18/2021 at 9:10 a.m., LVN A attempted to do the wound treatment for Resident 8. Resident 8 stated No, no, no. Resident 8 stated she could do the wound treatment by herself and did not want the nurse to do the wound treatment. Resident 8's left lower leg wound did not have a cover and had dry blood and brown drainage.
During an observation on 5/19/2021 at 10 a.m., Resident 8 sat on the edge of the bed. The open wound on the left lower leg was not covered. Brownish slough drainage was noted on the left lower leg.
During an observation on 5/20/2021 at 9:35 a.m., Resident 8 sat on the bed, her wound on the left lower leg was not covered and there was brown wound drainage noted on the lower leg.
During multiple observations from 5/17/2021 to 5/21/2021, Resident 8 shared the room with four residents. Residents 2 and 37 wheeled themselves in the room and the hallway. Resident 31 walked in the room and the hallway. The room had less than 80 square feet per person and required a room waiver.
Review of the Resident 8's room change record from 11/2020 to 5/19/2021, revealed there was no room change for Resident 8 due to infection control since Resident 8 had the uncovered open wound and shared the same room with four roommates.
During an interview with the senior administrator (SADM) on 5/21/2021 at 10 a.m., she stated the facility was focusing on Resident 8's care and the wound treatment refusal. However the facility should look at the whole picture of considering four other residents' infection control concerns because Resident 8's open wound was not covered, the wound drainage might be on the room floor and in the hallway. SADM stated the facility always had four to five empty rooms since 11/2020. SADM stated the facility should have arranged a room change for Resident 8 for the purpose of infection control.
4a. During an observation and concurrent interview in the hallway on 5/17/2021 at 11:14 a.m., Resident 37 wore a facial mask under her nose. Resident 37 stated the mask was too big and she forgot to cover her nose.
4b. During an observation on 5/17/2021 from 11:00 a.m. to 11:30 a.m., Resident 28 sat in the wheelchair in the hallway with a facial mask under the nose.
4c. During an observation on 5/17/2021 at 11:20 a.m., Resident 2 sat in the wheelchair in the hallway with a facial mask under her nose. Resident 2 stated the mask was too big and she was unable to cover her nose.
4d. During an observation and concurrent interview with LVN B on 5/17/2021 at 11:37 a.m., Residents 2, 37 and 38 sat next to each other in wheelchairs in the hallway. They did not maintain social distancing of six feet apart. LVN B stated these residents did not keep social distancing of at least six feet apart. LVB B stated when the residents were out of the rooms, they should wear facial masks to cover their noses, mouths and chins.
4e.During an observation on 5/18/2021 at 10:58 a.m., Resident 30 sat in the chair next to Resident 43 less than one foot apart in the lobby while in front of the nurse station. The senior administrator stated the two residents should keep at least six feet apart.
4f. During an observation on 5/20/2021 at 3:00 p.m., Resident 28 sat in the hallway in a wheelchair without a facial mask. Resident 28 stated he forgot to wear a mask.
4g. During an observation on 5/20/2021 at 3:15 p.m., Resident 37 sat in the wheelchair in the hallway with a facial mask under her nose. Resident 37 stated the facial mask was too big.
5. During the entrance to the facility on 5/17/2021 at 8:05 a.m., registered nurse supervisor (RNS) screened visitors A, B, C, and E, by checking their temperatures. RNS did not individuallyask visitors A, B, C, D and E if they were experiencing symptoms of COVID-19.
During a concurrent observation and interview with the RNS on 5/18/221 at 8:45 a.m., she acknowledged that she checked the temperatures of the two facility staff by the entrance door and did not ask each question regarding COVID-19 symptoms listed on the screening form.
During multiple observations on 5/18/2021 at 9:00 a.m., 5/19/21 at 10:30 a.m., 5/20/21 at 9:30 a.m., and 5/21/21 RNS screened visitors A, B, C, D & E by checking their temperatures. RNS did not ask visitors A, B, C, D & E each question regarding COVID-19 symptoms listed on the screening form.
During a concurrent interview and record review with the IP/DSD on 5/21/2021 at 1:20 p.m., the IP reviewed the facility's COVID-19 screening form and mitigation plan and stated the staff should ask visitors and employees the specific questions listed regarding COVID-19 symptoms.
Review of the Centers for Disease Control and Prevention's (CDC) guidance titled, Preparing for COVID-19 in Nursing Homes, updated 11/20/2020 indicated, Screen visitors for fever (T?100.0oF), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility.
6. During a medication pass observation on 5/17/2021, at 4:32 p.m., with Resident 20's room, LVN C moved the trash can, then put on gloves, touched the bathroom doorknob and closed the door with gloved hands. LVN C then proceeded to administer Resident 20's medication without performing hand hygiene and changing gloves.
During an interview with LVN C on 5/17/2021, at 4:45 p.m., he agreed that his hand might have been contaminated after touching the trash can, and with gloved hands touched two door handles (front and back) to close it. LVN C stated he should have performed hand hygiene and changed gloves before proceeding with the medication administration.
Review of the facility's policy, dated January 2018, indicated, All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. And, . Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
7. During a med pass observation on 5/17/2021, at 8:55 a.m., LVN A did not don full personal protective equipment (PPE, gown, mask or respirator, face shield, gloves) upon entry into Resident 97's room. LVN A was wearing gloves, goggles and an N95 (respirator). Signage was posted on the appropriate use of PPE to be used and the type of transmission-based precautions (TBP, isolation precaution) near the entrance of the resident's room.
During an interview on 5/17/2021, at 9:29 a.m., LVN C stated that she forgot to wear full PPE before entering the resident's room. She further stated that new admissions should be in the yellow zone (newly admitted residents who are being observed and monitored for signs and symptoms of respiratory infection).
During an interview with the Director of Staff Development (DSD), on 5/18/2021, at 8:45 a.m., DSD stated that newly admitted residents are put on isolation for 14 days and staff entering the resident's room are required to put on full PPE.
During an interview with the Senior Administrator (SADM) and DSD on 5/18/2021, at 10:05 a.m., SADM stated that newly admitted residents, who are fully vaccinated and COVID-19 (a respiratory disease caused by a virus called SARS-COV-2) negative do not require quarantine. DSD stated that Resident 97 was admitted during the weekend and facility staff were aware that Resident 97 should not be quarantined because the resident tested negative for COVID-19 and was fully vaccinated.
Review of an undated policy, titled, COVID-19 Mitigation Plan: New Admission indicated, AFL 20-53:3 Resident readmitted from the hospital or from other health care facility with laboratory confirmed negative COVID-19. Testing and Quarantine are not required unless there is a suspected or confirmed COVID-19 transmission at the outside facility.

Based on observation and interview, the facility failed to ensure a resident room accommodated no more than four residents when Room A had six beds and six residents, and Room B had five beds and five residents. Having more than four residents per room has the potential of compromising the quality of life and quality of care the residents receive.
Findings:
During the survey, six residents were observed in Room A and five residents were observed in Room B. The room had adequate space for the residents to move about and for care to be given. Each resident had a bed, a privacy curtain, a nightstand, and a closet. The beds did not block any closets, bathrooms, or exits. There was no safety hazard or privacy concerns.
During interviews with randomly selected residents and staff, there were no quality of care issues identified concerning the size of the room and the number of occupants.
Recommend continuance of the room waiver.

Based on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident.
Findings:
Room Beds Sq Ft/Rm Sq Ft/Res
2 2 146 73
3 2 148 74
4, 5, 6 3 225 75
7 3 222 74
8 2 156 78
9 2 144 72
10, 11, 12, 13 2 146 73
14 2 148 74
15, 16, 17, 18 2 140 70
19 3 228 76
20 3 225 75
21 3 228 76
Room A 6 432 72
Room B 5 323.4 64.68
During multiple observations and staff and resident interviews on 5/17/21 at 9:00 a.m., 5/18/21 at 10:00 a.m., 5/19/21 at 2:00 p.m., 5/20/21 at 2:30 p.m., and on 5/21/21 at 10:10 a.m., there were no care issues identified with the lack of space or privacy regarding the size of the resident rooms.
The residents were observed in their rooms throughout the survey. The nursing care and services were not impacted by the shortage of space. The closet and storage spaces were sufficient to accommodate the needs of the residents.
Review of the facility's room variance reports recommend the waiver remain in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit the completed Minimum Data Set (MDS, an assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for one of three sampled (Resident 2). This failure resulted in non-compliance with regulatory requirements.
Findings:
During a concurrent interview and record review with the MDS Coordinator (MDSC) on 05/21/21 at 9:20 a.m., MDSC reviewed the MDS and stated that Resident 2's quarterly MDS dated [DATE] was completed. She acknowledged after the 14 days of completion date there was no record of transmission or submission electronically to CMS for the quarterly MDS.
Review of Resident 2's CMS Submission Report dated 5/21/21 indicated Resident 2's quarterly MDS dated [DATE] was submitted to CMS more than 14 days after the MDS assessment completion date.
A review of the CMS website (https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October-1-2018-R.pdf) indicated, The quarterly assessment would be scheduled within 92 days after the assessment reference date (ARD, the date that signifies the end of the look back period) and the next comprehensive assessment would be scheduled within 366 days after the ARD Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on interview and record review, the facility failed to ensure an interdisciplinary team (IDT) meeting was held to start the discharge planning of four of four residents. This failure could potentially affect the residents' health and wellness upon discharge from the facility.
During the initial tour on 5/17/21 at 10:23 a.m., Resident 40 stated the facility staff wanted to send him home, but he said he was not ready. Resident 40 stated he just started to walk a few days ago. Resident 40 stated he had filed an appeal, because his insurance ran out.
During an interview on 5/20/21 at 3:04 p.m. with the social services staff (SS), the SS stated there was not an IDT note about Resident 40's future discharge. The SS stated no IDT meeting was held to discuss Resident 40's discharge plan.
During an interview on 5/20/21 at 3:08 p.m. with the SS, the SS stated there was no IDT meeting yet for Resident 97's discharge. She also stated neither Residents 100 nor 101 have had IDT meetings for discharge planning either. The SS stated IDT meetings for discharges should be held within 24 to 48 hours after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an observation on 5/17/2021 at 11:28 a.m., Resident 198 walked in the hallway without wearing a pair of pants. Resident 198 wore a white incontinent brief (an underwear shape of pad for incontinence). There were six other residents and four staff in the hallway while Resident 198 walking without wearing a pair of pants.
During a concurrent interview with certified nursing assistant F (CNA F), he stated Resident 198's assigned CNA should help the resident to put on a pair of pants before Resident 198 left his room.
During an interview with the licensed vocational nurse B (LVN B) on 5/17/2021 at 11:37 a.m., LVN B stated it was not okay to let Resident 198 walk in the hallway wearing an incontinent brief without a pair of pants. LVN B stated the CNA should make sure the resident wore a pair of pants before leaving his room.
Review of the facility's policy, Quality of Lift-Dignity dated [DATE], indicated .Residents shall be treated with dignity and respect at all times .
Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for five of 13 sampled residents (46, 7, 31, 33, and 198) when:
1. Resident 46's urinary catheter drainage bag (urinary catheter a thin, flexible tube used to drain urine from the bladder) was left uncovered;
2. Residents 7 and 31's body parts were exposed to public view;
3. Resident 33's name were written on the back of his clothes and
4. Resident 198 wore only an incontinent brief while walking in the hallway.
This failure resulted to residents rights not being maintained.
Finding:
1. During an observation on 5/17/21 at 12:38 p.m., Resident 46 was observed with an uncovered urinary catheter drainage bag hanging from his wheelchair while in the hallway outside his room.
During a concurrent observation and interview on 5/17/21 at 12:40 p.m., with the director of staff development (DSD)/infection preventionist (IP), she confirmed the above observation. She further stated that if the urinary catheter drainage bag was not covered it is a dignity issue. The DSD also acknowledged it was a dignity issue.
During a concurrent observation and interview with Resident 46 on 5/17/21 at 12:45 p.m., Resident 46 stated he felt embarrassed regarding his urinary catheter bag being uncovered while in the hallway with visitors and other residents around.
Review of Resident 46's Minimum Data Set (MDS, a clinical assessment tool) dated 4/13/21, indicated his BIMS score is 15 and cognitively intact.
2. During an observation on 5/17/21 at 9:13 a.m., Resident 7 was lying in bed inside his room with the privacy curtain not drawn. Resident 7 was visible from the hallway with no clothes on except for an adult diaper.
During an observation and concurrent interview with licensed vocational nurse B (LVN B) on 5/17/21 at 9:14 a.m., she confirmed the above observation and immediately drew the curtain and helped Resident 7 put on his clothes. She stated that the staff should regularly check the resident to make sure his clothes were on and that he had privacy.
During an observation on 5/17/21 at 9:13 a.m., Resident 31 walked in the hallway together with the activity director (AD) with her body parts (from lower back down to her legs) and incontinent brief (an underwear shape of pad for incontinence) was exposed. There were four other residents and three staff in the hallway when Resident 31 was walking with her body and incontinent brief were exposed.
During an observation and concurrent interview on 5/17/21 at 1:03 p.m., with certified nursing assistant F (CNA F), he stated that AD was not aware that Resident 31's body parts and incontinent brief was exposed when AD and resident 31 were walking in the hallway. He further stated that Resident 31 should had been treated with respect and dignity.
3. During an observation on 5/20/21 at 3:25 p.m., Resident 33 was walking in the hallway and his name written on the back of his shirt, each letter approximately 3 inches in height.
During a concurrent observation and interview on 5/20/21 at 3:30 p.m., with the DSD/IP, she confirmed the above observation and stated Resident 33's shirt should be labeled inside his shirt and should not be showing in public view because it is a dignity issue.
Review of the facility's policy, Quality of Lift-Dignity dated [DATE], indicated .Residents shall be treated with dignity and respect at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment for limited range of motion (ROM, the full movement potential of a joint) was implemented consistently for one of 13 sampled (Resident 197) when a carrot/hand roll was not applied to both of Resident 197's hands every shift. This failure had the potential to decrease the range of motion and function of Resident 197's hands.
Findings:
During multiple observations on 5/17/21 at 9:53 a.m., 12:00 p.m., and 2:30 p.m., Resident 197 had no carrot/hand roll in her hands.
During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 5/18/21 at 9:55 a.m., she confirmed that Resident 197 had no carrot/hand roll in either hand. LVN B further stated that Resident 197 should have a carrot/hand roll in both hands applied every shift.
Review of Resident 197's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), cerebral infarction due to embolism (obstruction in the arteries supplying blood and oxygen to the brain typically caused by a blood clot or an air bubble), and contracture of muscle- multiple sites.
Review of Resident 197's Minimum Data Set (MDS, an assessment tool) dated 5/5/21, indicated she had short and long term memory problems; her cognitive skills for daily decision making were severely impaired; and she had an impairment of both sides of upper and lower extremities.
During a concurrent interview and record review with the registered nurse supervisor (RNS) on 5/20/21 at 9:16 a.m., she reviewed the doctor's order dated 5/15/21 and indicated both hand/digit orthotic (carrot and hand roll) apply every shift seven times a week for twelve weeks.
Review of the facility's policy and procedure, Resident Mobility and Range of Motion, dated 1/2018, indicated residents with limited range of motion will receive treatment and service to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply food, fluids, and medications) placement was checked prior to administering medications for one out of 28 opportunities (Resident 20). This failure had the potential to compromise the residents's care and could cause health complications.
Findings:
During a medication pass observation on 5/17/21 at 4:33 p.m., while at Resident 20's bedside, licensed vocational nurse C (LVN C) inserted a syringe in the GT. Then pulled the plunger and obtained 50 ml (ml, a metric unit of volume) of gastric residual (volume of fluid remaining in the stomach). After instilling the gastric residual, he poured 50 ml of water into the syringe, then proceeded with the medication administration. LVN C did not check the GT placement.
During an interview shortly after the medication pass observation, LVN C acknowledged that he did not check the GT placement prior to administering Resident 20's medication.
During an interview with the Director of Staff Development (DSD) on 5/18/21 at 8:45 a.m., the DSD stated GT placement should be checked by using a stethoscope before administering medication.
Review of the physician's order, dated 5/18/21, Enteral Feed Order: Check tube placement every shift (started on 9/9/2020).
Review of the facility's policy, dated 10/2017, Enteral Tube Medication Administration, indicated Verify tube placement. Insert a small amount of air into the tube with syringe and listen to stomach with stethoscope for gurgling sounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure communication with the dialysis facility was properly coordinated when dialysis communication records (DCR) for one of four (Resident 46) was not completed. This failure may affect the quality of dialysis care being provided to the resident.
Findings:
Review of Resident 46's clinical record indicated he was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function). He was scheduled for dialysis every Monday, Wednesday and Friday.
During concurrent interview and record review with the registered nurse supervisor (RNS) on 5/20/21 at 10:30 a.m., she reviewed Resident 46's clinical record and confirmed that DCR's dated 2/1/21, 2/18/21, 2/25/21, 3/1/21, and 4/29/21 were not completed by the dialysis center. The RNS further stated licensed nurses should have followed-up with the dialysis center and completed the DCRs for Resident 46's continuity of dialysis care.
A review of the facility's policy, End- Stage Renal Disease, Care of Dialysis Resident dated 1/2018, indicated agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: How the information will be exchanged between the facilities. Resident's care plan will reflect the resident's needs related to dialysis care, Communicate with contracted ESRD facility information needed for the resident's plan of care.