Based on interview and record review, the facility failed to ensure the accurate provision of medication for one out of five sampled residents (Resident 1) when Resident 1 did not receive hypoglycemia (low blood sugar) medication as ordered by the prescriber. This failure had the potential for Resident 1 to experience symptoms of hypoglycemia, including confusion and dizziness. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and b. Glutose 15 gel (brand name for glucose (sugar) 15 grams, a medication to treat low blood sugar) by mouth as needed for blood sugar (BS) less than 80, dated 12/10/24. A review of Resident 1's January through April 2025 Medication Administration Records (MAR) indicated Resident 1's BS was less than 80 on the following dates and times: - 1/3/25 at 6:00 a.m. BS 70 - 3/11/25 at 6:00 a.m. BS 76 - 4/21/25 at 6:00 a.m. BS 78 The January through April 2025 MARs indicated Resident 1 did not receive Glutose 15 as ordered on any of the above dates. During a concurrent interview and record review on 5/1/25 at 2:47 p.m. with the Director of Nursing (DON) 1, Resident 1's January, February, March, and April 2025 MARs and physician's orders were reviewed. DON 1 stated Resident 1 was supposed to receive Glutose 15 on 1/3/25, 3/11/25, and 4/21/25 because Resident 1's blood sugar was less than 80. DON 1 verified the physician's orders were not followed. A review of the facility's policy and procedure titled, Administering Medications, reviewed 2/1/25, indicated, .Medications must be administered in accordance with the orders .

Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when two boxes of eye drops were found in a bin labeled and full of ear drops in one of one sampled medication rooms. This failure had the potential for residents to receive the wrong medication, which could result in the residents experiencing negative health outcomes. Findings: During a concurrent observation and interview on 4/28/25 at 11:56 a.m., with the Director of Staff Development (DSD) 1, a tour of the Skilled Nursing Facility (SNF) unit medication room was conducted. Eight boxes of ear drops were observed in a black bin labeled, EAR DROPS. Two boxes of eye drops (one box of Refresh and one box of Visine, both used to treat dry eyes) were also stored in the same bin. DSD acknowledged two eye drops were in the ear drop bin. During a concurrent interview and record review on 5/1/25 at 2:27 p.m., with the Director of Nursing (DON) 1, the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed by the facility on 5/31/24 was reviewed. The P&P indicated, .Medication Storage Requirements .Eye medications are kept separate from ear medications . DON 1 acknowledged eye drops and ear drops should be stored separately from each other.

Based on interview and record review, the facility failed to document non-pharmacological interventions for five of five sampled residents (Residents 1, 21, 24, 25, and 31) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Alprazolam (generic for Xanax, a medication for anxiety) 0.5 milligrams (mg) OD (orally disintegrating, dissolves in the mouth), take one tablet by mouth and allow to dissolve daily for anxiety, manifested by mood changes, irritability, negative thoughts. Monitor for behavior and side effects every shift, dated 2/13/25; b. Bupropion (generic for Wellbutrin XL, extended release, a medication for depression) 150 mg, take one tablet by mouth daily for depression disorder m/b (manifested by) verbalization of hopelessness and sadness. Monitor for behaviors and side effects every shift, dated 12/10/24; and c. Olanzapine (generic for Zyprexa, a medication to treat psychiatric conditions) 5 mg, take one tablet by mouth daily at bedtime for schizophrenia (a psychiatric condition) m/b hallucinations and delusions. Monitor side effects and behaviors every shift, dated 12/10/24. A review of Resident 1's medical records included March 2025 Behavior Monitoring Records (BMR) for alprazolam, bupropion, and olanzapine. The following behaviors were documented for alprazolam: one episode of irritability on 3/3/2025 and one episode of mood changes on 3/3/25. The following behaviors were documented for bupropion: one episode of sadness on 3/20/25. The following behaviors were documented for olanzapine: one episode of delusions on 3/30/25. The medical record also included a blank form, Resident 1's March 2025 Non-Pharmacological Intervention (NPI) Flow Sheet for Psychotropic Medication (NPI Flow Sheet). A review of Resident 1's medical records included a care plan for depression, created 7/13/24. The depression care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. The care plan interventions, updated 7/13/24, also indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. A review of Resident 1's medical records included a care plan for schizophrenia, created 7/13/24. The schizophrenia care plan intervention, updated 7/13/24, indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with the Director of Nursing (DON) 1, Resident 1's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 1 in March 2025 as required. 2. A review of Resident 24's medical records indicated the following physician's orders: a. Fluoxetine (generic for Prozac, a medication for depression) 20 mg, take one capsule by mouth daily for depressive disorder, dated 10/15/24; and b. Olanzapine 5 mg, take one tablet by mouth daily for depressive disorder with anxiety, dated 10/15/24. A review of Resident 24's medical records included March 2025 BMR for fluoxetine and olanzapine. The following behaviors were documented for fluoxetine: one episode of anxiousness on 3/12/25 and 3/26/25. The following behaviors were documented for olanzapine: one episode of anxiousness on 3/12/25. The medical record also included a blank form, Resident 24's March 2025 NPI Flow Sheet. A review of Resident 24's medical records included a care plan for mood disorder manifested by anxiousness, created 8/25/24. The anxiousness care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. A review of Resident 24's medical records included a care plan for depressive disorder, created 8/25/2024. The depression care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 24's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 24 in March 2025 as required. 3. A review of Resident 25's medical records indicated the following physician's orders: a. Escitalopram (generic for Celexa, a medication for depression) 10 mg, take one tablet by mouth daily for depression m/b verbalizations of sadness, dated 5/30/24; b. Lorazepam (generic for Ativan, a medication for anxiety) 0.5 mg, take one tablet by mouth daily for anxiety disorder, m/b agitation and irritability, dated 1/28/25; and c. Quetiapine (generic for Seroquel, a medication for psychiatric conditions) 50 mg, take one tablet by mouth daily at bedtime for depressive disorder with psychosis m/b hallucinations and angry outbursts, dated 5/30/24. A review of Resident 25's medical records included March 2025 BMR for escitalopram, lorazepam, and quetiapine. The following behaviors were documented for lorazepam: two episodes of agitation on 3/25/25, and one episode of irritability on 3/3/25, 3/28/25, and 3/30/25. The following behaviors were documented for quetiapine: one episode of angry outbursts on 3/25/25. The medical record also included a blank form, Resident 25's March 2025 NPI Flow Sheet. A review of Resident 25's medical records included a care plan for anxiety disorder, created 4/18/24. The anxiety care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. The care plan interventions, updated 4/18/24, also indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 25's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 25 in March 2025 as required. 4. A review of Resident 31's medical records indicated the following physician's orders: a. Divalproex sodium (generic for Depakote, a medication used to treat various psychiatric and neurological conditions) 250 mg DR (delayed release) tablet. Take one tablet by mouth every 12 hours for bipolar disorder m/b mood swings. Monitor behaviors and side effects . dated 10/8/24; and b. Olanzapine 5 mg tablet. Take one tablet by mouth every morning for schizophrenia m/b auditory hallucinations/hearing voices. Monitor for behaviors and side effects every shift dated 10/8/24. A review of Resident 31's medical records included February 2025 Behavior Monitoring Records (BMR) for divalproex sodium, mirtazapine, and olanzapine. The following behaviors were documented for divalproex sodium: one episode of mood swings on 2/1/25, 2/16/25 and 2/19/25. The following behavior was documented for olanzapine: one episode of auditory hallucinations on 2/27/25. The medical record also included a blank form, Resident 31's February 2025 NPI Flow Sheet. A review of Resident 31's medical records included a care plan for bipolar, updated 3/7/25. The bipolar disorder care plan intervention indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. A review of Resident 31's medical records included a care plan for schizophrenia updated 3/7/25. The schizophrenia care plan intervention indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 31's February 2025 BMRs and February 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 31 in February 2025 as required. 5. A review of Resident 21's medical records indicated the following physician's order: risperidone (generic for Risperdal, a medication to treat psychiatric conditions) 1 mg tablet. Take one tablet by mouth every morning and one tablet by mouth every evening for schizoaffective disorder m/b angry outburst and believing people are out to get him, monitor behaviors and side effects every shift dated 1/7/2025. A review of Resident 21's medical records included February 2025 BMR for risperidone. The following behaviors were documented for risperidone: two episodes of angry outbursts on 2/27/25 and two episodes on 2/28/25. The medical record also included a blank form, Resident 21's February NPI Flow Sheet. During an interview on 5/1/2025 at 8:56 AM with the Supervising Registered Nurse (SRN) 1, SRN 1 stated NPIs are documented whenever a resident is exhibiting a behavior. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 21's February 2025 BMRs and February 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 21 in February 2025 as required. During an interview on 5/1/2025 at 3:05 PM, DON 1 stated there should be an entry on the NPI Flow Sheet whenever there is an episode of behaviors. DON 1 stated non pharmacologic interventions are important to reduce the unnecessary use of medications. DON 1 stated unnecessary use of psychotropic medications have the risk of side effects of the medications, such as groggy in the morning and falls with injury. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Management, last reviewed by the facility on 11/12/2024, the P&P indicated, Resident's care plan will include behavioral interventions implemented in an attempt to decrease the target behaviors.

2. During a review of Resident 31's Physician Orders on 4/30/25 at 9:11 a.m., the physician's orders indicated Resident 31 had three active orders for blood pressure medications: a. Amlodipine (generic for Norvasc, a medication for high blood pressure) 5 milligram (mg, a unit of measure) tablet. Take one tablet by mouth daily, hold for SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110, dated 9/10/24. b. Chlorthalidone (generic for Thalitone, a medication for high blood pressure) 25 mg tablet. Take one tablet by mouth every morning for hypertension (blood pressure), hold if SBP less than 110 or if DBP (diastolic blood pressure, the bottom number in a blood pressure reading) less than 50, dated 9/10/24. c. Metoprolol succinate (generic for Toprol XL, a medication for high blood pressure) 50 mg ER (extended release). Take one tablet by mouth every evening. Hold if SBP less than 110, DBP less than 50 or HR (heart rate) less than 50, ordered 9/10/24. The holding parameters were updated to hold if SBP less than 105, HR less than 50 on 2/7/25. During an interview on 5/1/25 at 8:56 a.m., with Supervising Registered Nurse (SRN) 1, SRN 1 stated nurses administer blood pressure medications upon receiving physician orders and ensuring it meets the prescribed parameters. SRN 1 stated the process for documenting held medications is for nurses to initial the MAR, circle their initials and write the reason why it was held (not given) on the back of the MAR. A review of Resident 31's January 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a metoprolol succinate dose on the following date: - 1/31/25 at 5 p.m., blood pressure 100/50 A review of Resident 31's February 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a metoprolol succinate dose on the following date: - 2/5/25 at 5 p.m., blood pressure 105/54 A review of Resident 31's April 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a dose of amlodipine and chlorthalidone on the following date: - 4/16/25 at 8 a.m., blood pressure 109/57 A concurrent interview and record review was conducted on 5/1/25 at 11:38 a.m., with the Director of Staff Development (DSD) 1 of Resident 31's February 2025 MAR. Resident 31's blood pressure was documented as 105/54 on 2/5/25 at 5 p.m. An initial without a circle was observed on the MAR for 2/5/25 for the metoprolol succinate dose. DSD 1 stated, If I don't see [initials] circled, I'd have to assume [the medication] was given. DSD stated the 2/5/25 metoprolol succinate dose was not held. A concurrent interview and record review was conducted on 5/1/25 at 2:38 p.m., with the Director of Nursing (DON) 1 of Resident 31's January through April 2025 MARs. DON 1 stated the metoprolol succinate was given on 1/31/25, but should have been held because the SBP was less than 110. Resident 31's February MAR indicated that Resident 31's blood pressure was 105/54 on 2/5/25 at 5 p.m. DON 1 stated that the 2/5/25 metoprolol succinate dose should've been held. Resident 31's blood pressure on 4/16/25 at 8 a.m., was documented as 109/57 on Resident 31's April 2025 MAR. DON 1 stated the amlodipine and chlorthalidone doses were not held because no circle. A drug literature review of amlodipine on Daily Med (an electronic drug information source) updated 12/15/08, indicated amlodipine side effects include, but are not limited to edema (swelling), flushing (increased blood flow to the surface of the skin) and palpitations (feeling one's own heartbeat, which may feel like its racing or pounding). A drug literature review of chlorthalidone on Daily Med updated 10/9/24, indicated chlorthalidone side effects include, but are not limited to dizziness, muscle weakness, nausea, vomiting, orthostatic hypotension (a drop in blood pressure upon standing from a seated or lying position). A drug literature review of metoprolol succinate on Daily Med updated 2/14/25, indicated metoprolol succinate side effects include, but are not limited to dizziness, bradycardia (slow heart rate), tiredness and hypotension. A review of the facility's policy and procedures (P&P) titled, Administering Medications, last reviewed by the facility on 2/1/25, indicated: .Medications must be administered in accordance with the orders . and .if a drug is withheld .the individual administering the medication will ensure their initials are circled on the MAR and the reason why the medication was not administered will be documented in the space provided . Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 31) were free of unnecessary medications when blood pressure (BP) and blood sugar (BS) hold parameters were not followed with the administration of medications. This failure had the potential for unnecessary medications for Residents 1 and 31, which can lead to side effects such as low blood pressure and low blood sugar. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Hold diabetes medications if BS is less than 110 at 6:00 a.m., dated 12/10/24; b. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and c. Januvia (brand name for sitagliptin, a medication for diabetes) 100 milligrams (mg), take one tablet by mouth daily at 6:00 a.m. for diabetes, dated 12/10/24. A review of Resident 1's January 2025 Medication Administration Record (MAR) indicated Resident 1's BS was less than 110 at 6:00 a.m. on the following dates: - 1/25/25 BS 107 - 1/28/25 BS 90 The January 2025 MAR indicated Resident 1 received a Januvia dose on both dates. A review of Resident 1's February 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m. on the following dates: - 2/13/25 BS 86 - 2/15/25 BS 90 The February 2025 MAR indicated Resident 1 received a Januvia dose on both dates. A review of Resident 1's March 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m on the following dates: - 3/11/25 BS 76 - 3/22/25 BS 95 - 3/26/25 BS 83 - 3/27/25 BS 100 The March 2025 MAR indicated Resident 1 received a Januvia dose on the above four dates. A review of Resident 1's April 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m on the following dates: - 4/21/25 BS 78 - 4/29/25 BS 90 The April 2025 MAR indicated Resident 1 received a Januvia dose on both dates. During a concurrent interview and record review on 5/1/25 at 10:02 a.m. with the Director of Staff Development (DSD) 1, Resident 1's physician orders and MAR were reviewed. DSD 1 stated the physician's orders to hold diabetes medication for BS less than 110 at 6:00 a.m. meant Januvia was supposed to be held on those days. DSD 1 stated if the physician's orders to hold diabetes medications are not followed, there is a risk of blood sugar dropping too low which can cause the resident to fall. During a concurrent interview and record review on 5/1/25 at 2:47 p.m. with the Director of Nursing (DON) 1, Resident 1's January, February, March, and April 2025 MARs and physician's orders were reviewed. DON 1 stated the physician's orders indicated to hold Januvia for 6:00 a.m. blood sugar reading less than 110. DON 1 acknowledged the resident incorrectly received Januvia on two dates in January 2025, two dates in February 2025, four dates in March 2025, and two dates in April 2025 (total 10 doses) when the medication was supposed to be held. DON 1 verified the physician's orders were not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy for Theft and Loss Reporting and Investigation for one of three sampled residents (Resident 1), when the Report of Suspected Dependent Adult-Elder Abuse (Form SOC 341) for Resident 1 was not completed and sent to the ombudsman. This failure had the potential to result in an inadequate investigation of the loss of Resident 1's property. Findings: On 1/6/25 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident loss of one hundred dollars and a fifty dollar gift card. Resident 1, an [AGE] year-old male admitted on [DATE], with diagnoses of Hypertension, and Emphysema. During an interview on 1/6/25 at 10:50 a.m. with the Health and Safety officer (HS 1), HS 1 stated the incident was reported on 12-29-24 by the CNA (CNA 1) for Resident 1. CNA 1 verified the resident had one hundred dollars and a fifty dollar gift card in his wallet and the money and gift cards were now missing. The resident can access the nightstand lockbox by himself. The resident cannot remember what happened to the money or gift card because of memory issues. Form SOC 341 (Report of Suspected Dependent Adult-Elder Abuse) was not completed. During an interview on 1/7/25 at 10:20 a.m. with the Ombudsman (Omb1), Omb1 stated the facility did not submit a SOC 341 (Report of Suspected Dependent Adult-Elder Abuse) regarding Resident 1's loss of property. During a review of the facility's policy and procedure titled, Theft and Loss Reporting and Investigation, dated 12/17/2024, indicated Theft or losses $100 or greater will be reported by Security to 1. Highway Patrol, 2. California Department of Public Health, 3. Ombudsman for Skilled Nursing Facility Residents (Form SOC 341).

Based on observation and interview , the facility failed to ensure a safe, clean, and comfortable environment, when the wheelchair of one of 15 sampled residents (Resident 29) was not found in good working condition with a torn, cracked, and frayed armrest. This failure had the potential to violate Resident 29's rights to a safe, clean, and comfortable environment. Findings: During a concurrent observation and interview on 6/5/2024 at 8:42 a.m. with Resident 29, Resident 29 was observed sitting in their wheelchair. The wheelchair had a large tear on the right armrest with the cushion exposed. In addition, the armrest had a large worn area consisting of multiple rough raised cracks and the edges were frayed with white lining showing through the black armrest cover. Resident 29 stated that the armrest was torn when they received the wheelchair from the facility. Resident 29 further stated that the worn armrest bothered them, was not comfortable, and did not look nice. During an interview on 6/5/2024 at 3:20 p.m. with Lead Registered Nurse (LRN), the LRN stated the armrest was torn, and Resident 29 needed a new wheelchair. The facility was unable to provide a policy and procedure related to maintaining residents' wheelchair in good working condition during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to date an opened bottle of Polyethylene Glycol (medication to treat constipation) for unsampled Resident 30. This failure had the potential for Resident 30 to receive expired and less than optimal medications. Findings: During a review of Resident 30's Face Sheet (resident demographics), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language and problem-solving abilities that are severe enough to interfere with daily life) and chronic pain. During a review of Resident 30's Quarterly Minimum Data Sheet (MDS, standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 30 had a severe cognitive impairment. During a concurrent medication storage observation and interview on [DATE] at 10:11 a.m. with Licensed Vocational Nurse (LVN) 3, the medication cart for the 600 POD had an opened bottle of Polyethylene Glycol for Resident 30 which was not labeled with the open date. LVN 3 confirmed the bottle was not labeled with the open date. LVN 3 stated she gave the Polyethylene Glycol to Resident 30 on [DATE]. During a review of Resident 30's Medication Administration Record (MAR, a record of all medications administered to a resident), dated [DATE], the MAR indicated the medication was administered. During an interview on [DATE] at 10:53 a.m. with the Director of Nursing (DON), the DON stated the nurse should date the medication (Polyethylene Glycol) when it was opened. The DON stated any licensed staff who administered medication was responsible for checking the medication cart to make sure all opened medications were labeled with an open date. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], the P&P indicated, When opening a multi-dose container, the date opened will be recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR, a record of all medications administered to a resident) was accurately documented on 6/2/2024 for two of 15 sampled residents (Residents 19 and 48) when: 1. For Resident 19, a licensed nurse did not document that medications were administered for the 8 a.m. dose on 6/2/2024. 2. For Resident 48, a licensed nurse did not document that medications were administered for 10 a.m. dose on 6/2/2024. These failures had the potential to result in inaccurate medication administration including underdosing or overdosing Residents 19 and Resident 48. Findings: 1. During a review of Resident 19's Face Sheet (resident demographics), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses of high blood pressure and urinary incontinence. During a review of Resident 19's MAR, dated June 2024, the MAR indicated, on 6/2/24, for the 8 a.m. administration time, there were no staff initials in the box to reflect medications were administered for the following medications: a. Amlodipine (treatment for high blood pressure) b. Aspirin (treatment to prevent blood clots) c. Coenzyme Q10 (treatment for high cholesterol) d. Docusate Sodium (treatment for constipation) e. Eliquis (treatment to prevent blood clots) f. Finasteride (treatment to decrease size of the prostate) g. Gabapentin (treatment for nerve pain) h. Glucosamine/Chondroitin (treatment to slow the breakdown of cartilage in the joints) i. Mag Oxide (treatment for magnesium deficiency) j. Metamucil Powder (treatment for constipation) k. Metoprolol succinate tablet (treatment for high blood pressure) l. Oyster Shell (treatment for bone health) m. Sertraline (treatment for depression) n. Vitamin D-3 (treatment for Vitamin D deficiency) During an interview on 6/5/2024 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I forgot to sign the medications for [Resident 19] that were given on 6/2/2024. During an interview on 6/6/2024 at 10:57 a.m. with the Director of Nursing (DON), the DON stated, The expectation is for the nurse to prepare the medication, pass to the resident, and sign the MAR. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/18/2024, the P&P indicated, Documentation of Medication Administration .As required or indicated for a medication, the individual administering the medication will record in the Resident's medical record .The signature and title of the person administering the drug. 2. During a review of Resident 48's Face Sheet (resident demographics), the Face Sheet indicated Resident 48 was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (long term high blood pressure that causes changes to the heart) and type 2 diabetes mellitus (disease in which blood glucose levels are higher than normal). During a review of Resident 48's MAR, dated June 2024, the MAR indicated, on 6/2/24, for the 10 a.m. administration time, there were no staff initials in the box to reflect medications were administered for the following medications: a. Amlodipine (treatment for high blood pressure) b. Docusate Sodium (treatment for constipation) c. Furosemide (treatment for fluid retention) d. Glipizide (treatment for type 2 diabetes mellitus) e. Propranolol (treatment for high blood pressure) During an interview on 6/5/2024 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I forgot to sign for medications for [Resident 48] that were given on 6/2/2024. During an interview on 6/6/2024 at 10:57 a.m. with the Director of Nursing (DON), the DON stated, The expectation is for the nurse to prepare the medication, pass to the resident, and sign the MAR. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/18/2024, the P&P indicated, Documentation of Medication Administration .As required or indicated for a medication, the individual administering the medication will record in the Resident's medical record .The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to maintain the kitchen dishwasher in a safe operating condition. This failure had the potential to result in safety concerns. Findings: During a concurrent observation and interview on 6/4/2024 at 9:00 a.m. with Food Service Technician (FST) 2 in the kitchen, the dishwasher was spraying water resulting in a pool of water on the floor. FST 2 stated the spraying started when the machine was turned on. During an interview on 6/5/2024 at 8:40 a.m. with Chief Plant Operations (CPO), CPO stated the dishwasher machine was spraying water because it was missing the multi-flap curtains. During an interview on 6/5/2024 at 8:50 a.m. with the Food Manager (FM), FM stated the expectation was to prevent the water spraying out of the dishwasher machine, due to infection control and safety issues. During a review of the dishwasher's manual, [undated], the manual indicated, Multi-flap curtains are used throughout the dishwasher to keep moisture inside and reduce the potential of hot water injury. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services-Equipment (All Homes), dated 11/5/2023, the P&P indicated, Equipment will be provided and maintained in good working order. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operating condition.

Based on observation, interview, and record review, the facility failed to ensure that food was stored in a safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe. 2. The kitchen freezer contained foods that were not dated and labeled. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During a concurrent observation and interview on 6/4/2024 at 9:02 a.m. with Food Manager (FM) in the kitchen, there was a spatula (kitchen utensil used to mix ingredients) with cracks on the right lower side and a yellow dried substance on the top edges. FM confirmed the spatula was not safe to be used due to the risk of food contamination and food-borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services-Sanitation (All Homes), dated 11/5/2023, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair (i.e. free from breaks, corrosion, open seams, cracks, and chipped areas). 2. During a concurrent observation and interview on 6/5/2024 at 9:05 a.m. with Food Service Technician (FST) 1 in the Skilled Nursing kitchenette's freezer, six out of six popsicles were not dated and labeled. FST 1 stated, I don't know why it was not labeled. It was usually inside the box with date on it and needs to be labeled to prevent food-born illnesses. During a concurrent observation and interview on 6/5/2024 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1 in the Skilled Nursing kitchenette's freezer, a meatball package was opened, not dated, and not labeled. LVN 1 stated, This one does not have a label and date. It is not supposed to be like this, or the resident can get sick. During an interview on 6/5/2024 at 11:30 a.m. with the Director of Dietetics (DOD), DOD stated the expectation was for staff to label and date all foods to prevent food-borne illnesses. DOD further stated the date was important to ensure the residents consumed a safe food product. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services-Leftover and Extra Food, dated 11/5/2023, the P&P indicated, Labeling, dating, and monitoring refrigerated food, including but not limited to, leftovers, so it is used by its used-by date or frozen were applicable or discarded.

Based on observation, interview, and record review, the facility failed to ensure a safe and comfortable working environment for staff when the water temperature of the kitchen's hand washing station was 156.1 degrees Fahrenheit (unit used to measure temperature). This failure had the potential for staff burning their hands and poor handwashing practices, leading to a potential spread of infection. Findings: During a concurrent observation and interview on 6/4/2024 at 11:06 a.m. with the Director of Dietetics (DOD) and the Food Manager (FM) in the kitchen, the Surveyor checked the water temperature at the hand washing station using a thermometer (a device that measures temperature), and the water temperature registered at 156.1 degrees Fahrenheit. DOD and FM confirmed the water temperature was too hot and had the potential for staff to burn their hands. DOD stated the hot water has always been out of range, and there was no work order to fix it. FM stated the hand washing water temperature should be 120 degrees Fahrenheit, but there was no work order. During a review of the facility's policy and procedure (P&P) titled, Plumbing and Water Supply Maintenance, dated 2/9/2024, the P&P indicated, If water temperature exceeds 120 degrees Fahrenheit during normal business hours, a work order is submitted. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, dated 1/18/2023, Section 5-202.12, titled, Handwashing Sink, Installation, indicated, An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide properly tempered water for handwashing. The International Plumbing Code (IPC) states that tempered water is having a temperature range between 29.4°C (85°F) and 43°C (110°F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident 55's Minimum Data Set (MDS, a resident assessment and care-screening tool) accurately reflected the resident's status regarding an indwelling catheter (a flexible plastic tube (a catheter) inserted into the bladder, to provide continuous urinary drainage). This failure had the potential to result in inadequate monitoring of the resident's care and support needs. Findings: During a review of Resident 55's face sheet (demographics) indicated, Resident 55 was admitted to the facility on [DATE] with a diagnosis of obstructive uropathy (which occurs when urine cannot drain through the urinary tract). During a concurrent observation and interview on 7/11/23 at 9:32 a.m. with Resident 55 in his room, he was observed lying on his bed and did not have an indwelling catheter. Resident 55 stated he had a catheter for about a year but no longer had one. During a review of Resident 55's Physician Orders, dated 3/23/23 at 10:30 a.m. the Physician Orders indicated to discontinue Foley Catheter (indwelling catheter) per Urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) status post Urolift (procedure that lifts enlarged prostate tissue, so it no longer blocks the flow of urine). During a concurrent interview and record review on 7/13/23 at 9 a.m. with the MDS Coordinator, Resident 55's MDS-Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set, dated 5/3/23 was reviewed. The MDS, under section H for Bladder and Bowel, indicated Resident 55 had an indwelling catheter. The MDS Coordinator stated that the Bladder and Bowel section which included the indwelling catheter was missed. During a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, Section 2.1 Introduction to the Requirements for the RAI, indicated the RAI process is the basis for the accurate assessment of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement Resident 6's care plan (detailed plan for a resident which includes specific interventions) when a floor mat was not used when Resident 6 was in her bed. This failure had the potential for injury for Resident 6. Findings: During a review of Resident 6's Falls: Morse Fall Scale dated 7/5/23, the scale indicated she had a history of falling and was at a high risk for falls. Resident 6's Plan of Care dated 6/17/23, indicated to prevent falls Place floor mat next to bed when using low bed. During an observation on 7/12/23 at 9:55 a.m. of Resident 6's room and in the presence of Certified Nursing Assistant (CNA) 1, there was no floor mat in her room. CNA 1 stated, I don't think she has it [mat] because she transfers herself and we help her. She is very vocal too, and will shake her head and say [NAME]. CNA 1 further stated, The wheelchair would get in the way. During an observation on 7/12/23 at 10 a.m. with Registered Nurse (RN) 1, he confirmed there was no floor mat in Resident 6's room, and stated, If she [Resident 6] requested to take it [mat] away we should have removed it from the care plan. This is an oversight. During a review of the facility policy and procedure titled, Comprehensive SNF [skilled nursing facility] /ICF [intermediate care facility] Care Plans (All Homes), dated 7/10/23, it indicated, An individualized plan of care designed to ensure a systematic and compreshensive approach for meeting a Resident's specific needs. It further indicated the care planning process includes, 4. Implementation: Delivery of actual nursing care, nursing activities, putting approaches or solutions to work.

Based on interview and record review, the facility failed to ensure Resident 39's clinical record was maintained in accordance with accepted professional standards and practices, when the hospice (a program providing compassionate comfort care for people facing a terminal illness with a prognosis of six months or less) agency care plan was not contained in the clinical record. This failure resulted in the hospice agency care plan not being available for review by all health care providers, and the potential to adversely affect coordination of care. Findings: During a review of Resident 39's face sheet (demographics), the face sheet indicated Resident 39 had returned from the acute care hospital on 5/2/23. Resident 39's admitting diagnoses upon readmission to the facilty included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and acute and chronic respiratory failure. During a review of Resident 39's physician's (MD) orders, dated 5/3/23, the MD orders indicated Resident 39 was admitted to hospice agency. During a concurrent interview and record review on 7/11/23 at 9:59 a.m. with Registered Nurse (RN) 1, Resident 39's hospice care plan was reviewed. RN 1 stated the facility had developed Resident 39's hospice care plan. RN 1 was unable to locate a care plan developed by the hospice agency. RN 1 stated, We have our own care plan for him and the hospice agency usually follows it. I think they're following our care plan. During a concurrent interview and record review on 7/11/23 at 2:54 p.m. with Nurse Instructor (NI), NI stated facility staff developed a hospice care plan, and the hospice agency developed their own care plan. NI reviewed Resident 39's clinical record and stated she did not know why the hospice agency's care plan was not in the clinical record. NI stated, It's not in the chart. We need to make sure it's in the chart. That's how we coordinate care. During a review of the facility's policy and procedure (P&P) titled, Medical Records, dated 6/19/23, the P&P indicated, . 3. Medical records will be current and kept in detail consistent with good medical and professional practice based on the service provided to each Resident. 4. All current clinical information pertaining to the Resident will be centralized in the medical record .

Based on observation, interview and record review, the facility failed to provide a safe environment, when the hot water temperature of a hand washing sink registered above 165 degrees. This failure had the potential for the facility residents to burn their hands. Findings: During the initial kitchen tour on 7/10/23 at 10:43 a.m., a hand washing sink (with foot pedals) was observed directly behind the resident serving area (a cafeteria style service area used for resident meals). The sink appeared approximately 10 feet from the resident serving area. Near the resident serving area and directly in front of the sink, was a movable rack with chips on it, in which the residents could get their own chips/snacks. Next to the resident serving area a red line was painted on the floor which indicated, Employees Only. However, there were no physical barriers between the resident serving area and the hand wash sink. A sign posted above the sink indicated, Caution Water Temperature Exceeds 120 Degrees. On 7/10/23 at 10:44 a.m., when Surveyor accessed the water it was immediately very hot to touch. During a concurrent observation and interview on 7/10/23 at 11:35 a.m., the temperature of the hand washing sink was checked, using the facility's thermometer in the presence of the Food Service Manager (FSM) and the Registered Dietician (RD). The hot water of the sink registered 165.4 degrees Fahrenheit, and had steam coming from the running water. The FSM confirmed the water was hot. During a concurrent observation and interview on 7/12/23 at 3:24 p.m. with the Food Service Technician (FST), she stated in the evening around 6 p.m. they have a single chain they put across one of the two entrances to the food service area to block the residents from entering after hours where the handwashing sink was located. The FST stated the other entrance was Open all night, but I've never seen them go back there. During a review of the policy and procedure (P&P) titled, Plumbing and Water Supply Maintenance, dated 2/9/2023, the P&P indicated under the section titled Hot Water, .Hot water temperature controls will be maintained to automatically regulate temperature of hot water delivered .to attain a hot water temperature between 105 degrees and 120 degrees Fahrenheit during normal business hours, a work order is submitted. Plant Operations staff will be dispatched to the area for corrective action.

Based on interview and record review, the facility failed to properly electronically transmit the Minimum Data Set (MDS, a resident assessment and care-screening tool) to the Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES), for eight out of 17 sampled residents (Residents 8, 13, 14, 36, 43, 50, 56, and 58). This failure had the potential to result in inadequate monitoring of the residents' progress and lack of resident-specific information being provided to CMS for payment and quality measure monitoring. Findings: During an investigation of a triggered task related to Assessment Completed Late, the MDS coordinator was asked to provide CMS submission reports of Residents 8, 13, 14, 36, 43, 50, 56, and 58. A review of the iQIES Report MDS 3.0 Final Validation Reports for Residents 8, 13, 14, 36, 43, 50, 56, and 58 indicated a warning message, Assessment Completed Late: an Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or quarterly) was due every quarter, unless the resident is no longer in the facility. A prior record within 92 days of the submitted record could not be found. During a concurrent record review and interview on 7/13/23 at 8:25 a.m. with the MDS Coordinator, the MDS Coordinator reviewed the transmission data for Residents 8, 13, 14, 36, 43, 50, 56, and 58 in the computer. The MDS Coordinator confirmed the MDSs were submitted timely. However, upon submitting the MDS to IQIES database, she received a warning message indicating failure of transmission for those residents, meaning that the residents' assessments did not synchronize with the iQIES database. The MDS Coordinator stated the transmission system was new and she hoped it will work in the future. The MDS Coordinator stated synchronization with iQIES was always a problem. During a follow-up interview on 7/13/23 at 9:42 a.m. with the MDS Coordinator, when asked what to do when CMS sends a warning message indicating that the MDS transmission was submitted late, the MDS Coordinator stated she should have contacted CMS for a ratification. Review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, under the section for Validation Edits, indicated the Internet iQIES provides validation edits to monitor the timeliness and accuracy of MDS record submissions. If the transmission of the MDS's records did not meet the edit requirements, the system will provide error and warning messages on the provider's Final Validation Report. Each time a user accesses the iQIES and transmits an MDS file, the iQIES performs three types of validation including Warnings which flags missing or questionable data such as timing errors. The provider must evaluate each warning to identify necessary corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 17's face sheet (demographics), the face sheet indicated Resident 17 had been readmitted to the facility on [DATE], with diagnoses that included hearing loss. During a concurrent observation and interview on 7/10/23 at 11:23 a.m. in Resident 17's room, Resident 17 was observed lying in bed watching television. Resident 17 stated to talk louder because he was hard of hearing in both ears. Resident 17 was questioned if he had hearing aids that he could wear. Resident 17 stated he had hearing aids that did not work. Resident 17 stated the staff, Know but don't care. During a concurrent observation and interview on 7/12/23 at 8:18 a.m. in Resident 17's room, Resident 17 was observed lying in bed without wearing hearing aids. Resident 17 stated his hearing aids were in a box and, I would show them to you if I knew where they were. During a review of Resident 17's Progress Note, dated 5/23/23, the Progress Note indicated, Resident 17 had completed an audiology appointment on 8/5/22. During the appointment, Partially occluding cerumen (earwax) was removed, and the tubing was replaced on Resident 17's hearing aids. The Progress Note further indicated, RTC (return to center) 4-5 months for tubing replacement. During a review of Resident 17's care plan titled, Communication Deficit R/T (related to) Moderate Hearing Problem, dated 10/30/22, the care plan indicated, Resident referred to (name of facility) to check hearing aids evaluate if new ones are needed. During a concurrent interview and record review on 7/12/23 at 8:39 a.m. with Registered Nurse (RN) 1, RN 1 stated there was not an audiology progress note in Resident 17's clinical record dated 8/5/22. In addition, RN 1 stated he did not know if Resident 17 wore hearing aids. During a concurrent interview and record review on 7/12/23 at 2:02 p.m. with the Nurse Instructor (NI), Resident 17's Past Clinic Visits, were reviewed. The Past Clinic Visits, indicated Resident 17 had completed an audiology appointment on 8/5/22, and was a NO-SHOW for the 12/7/22 audiology appointment. NI stated there had not been follow up to reschedule the missed 12/7/22 appointment. The facility was unable to provide a policy and procedure for rescheduling missed appointments. 2. During a review of Resident 48's medical record, it indicated he was admitted to the facility on [DATE] with diagnoses which included Chronic A-fib (atrial fibrillation- an irregular heart rate that can cause decreased blood flow), legal blindness and that Resident 48 was hard of hearing. During a review of physician's order dated 7/1/23 at 10:20 a.m., indicated LLVA [[NAME] Veterans Administration] Audiology; Annual hearing test and to obtain new hearing aids .Schedule resident to LLVA audiology . During an interview on 7/12/23 at 11:47 a.m, with Office Technician (OT) 1, she was unable to locate where Resident 48's audiology referral was processed. OT 1 stated, she was the person to input the information and stated, I don't see it, I will put it in now. During an interview on 7/12/23 at 2:01 p.m., with Resident 48 and with the assistance of Certified Nursing Assistant (CNA) 2, CNA 2 had to speak loud to ask Resident 48 if he had hearing aids in his possession. Resident 48 stated he did not. CNA 2 stated she had not seen him with hearing aids, and stated he was hard of hearing. During a review of the policy and procedure titled, Physician Orders and Progress Notes, dated 10/24/22, it indicated, .All orders, written by a person lawfully authorized to prescribe, will be carried out unless contraindicated. The facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities, for three out of 17 sampled residents (Residents 63, 48, and 17): 1. For Resident 63, the facility failed to notify the physician to obtain an optometrist (eye doctor) referral to replace or fix his broken prescription glasses and his backup (second pair of glasses). This failure had the potential for Resident 63 not being able to see things clearly, read, or watch television. 2. For Resident 48, the facility failed to process an audiology (hearing doctor) consult. This failure had the potential for a decrease in his quality of life when Resident 48 was in need of hearing aids. 3. For Resident 17, the facility failed to reschedule a missed audiology appointment. This failure had the potential for Resident 17 not to attain his highest practicable physical, mental and psychosocial well-being. Findings: 1. During a review of the admission face sheet record, indicated Resident 63 was admitted to the facility on [DATE]. During a review of Resident 63's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date 5/31/23, indicated the resident had a Brief Interview for Mental Status (BIMS), score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident 63 had moderate limited vision, and used corrective lenses (glasses). During a review of Resident 63's care plan to address Visual Problems related to macular degeneration (vision impairment resulting from deterioration of the central part of retina), the approaches included to schedule eye checks as needed. During an observation and interview with Resident 63 on 7/10/23 at 3:33 p.m., Resident 63 inquired about getting a new pair of glasses. Resident 63 was wearing a pair of spare glasses, the spare glasses were broken and unrepaired with (missing nose pads, a safety pin was holding the missing screws to keep the hinge together, and no temple protection, adhesive tape was applied around the frame). Resident 63 stated his prescription glasses and lenses were accidentally broken, two weeks ago. Resident 63 stated he gave the glasses to the nurses, who informed him they would either make an appointment with an optometrist, or send the glasses to be fixed. The resident reported the accident occurred at least two weeks ago; however, as of the current date, no action had been taken to repair or replace the broken glasses. During an interview with RN 1 on 7/10/23 at 10 a.m., RN 1 stated Resident 63's broken glasses were kept in a plastic bag at the nurses' station. An observation of the broken prescription glasses indicated the lens were entirely cracked and fragmented, and the frame was broken in multiple places, no parts of the glass were intact. RN 1 stated they forgot to request a referral for an optometrist consultation, or to send the glasses for repair. There was no documented evidence a follow up had occurred over a two week period. During an interview with RN 2 on 7/13/23 at 10:09 a.m., when asked for the facility's Policy & Procedures related to vision appointments and follow ups, RN 2 stated there was no policy in place. RN 2 stated they typically ask for a referral from the physician, schedule appointments, and provide transportation for the residents.