Asbury Park Nursing And Rehabilitation Center

During an interview and a review of Resident 157's clinical medication records on 3/23/26 at 2:28 p.m. at the 1A medication cart, LN 4 stated the resident's blood sugar was taken around 7:00 a.m., with a result of 239.

She confirmed the Regular Insulin, scheduled for 8:00 a.m., and was administered after 10:00 a.m. LN 4 acknowledged the Regular Insulin dose was sliding scale based on the blood sugar level and should have been given sooner.

During an interview and record review on 3/25/26 at 8:21 a.m., the Director of Nursing (DON) stated the facility's standard practice is to administer insulin within 30 minutes of obtaining the blood glucose reading.

The DON reviewed Resident 157's March MAR, specifically the entry for 3/23/26, and confirmed the Regular Insulin was administered outside of this standard.

She acknowledged the Regular Insulin was given over 2 hours after the blood glucose was obtained, creating the potential for inaccurate slidingˆscale dosing based on a nonˆcurrent blood sugar result.

During a review of the facility's policy and procedure titled, Administering Medications, revised date April 2019, indicated, .4.

Medications are administered in accordance with prescriber orders, including any required time frame.

• Medication administration times are determined by resident need and benefit, not staff

convenience.

Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interaction;

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that she would

facility's policy and procedures titled, Restorative Nursing Services, revised 7/2017, indicated,

independence .Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care .

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

catheter care, and appropriate care to prevent urinary tract infections.

residents (Resident 160) received care in accordance with professional standards of practice, and

urine from the bladder through a small incision in the lower abdomen) bag was left on the floor.This failure had the potential for Resident 160 to develop infection and possible urinary catheter complications.Findings:A review of Resident 160's clinical record indicated Resident 160 was admitted March of 2026 and had diagnoses that included malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems), and obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract).A review of Resident 160's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/13/26, indicated Resident 160 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 which indicated Resident 160 had moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 160's MDS Bladder and Bowel Status, dated 2/13/26, indicated Resident 160 uses indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time).A review of Resident 160's care plan, dated 3/11/26, indicated, The resident [Resident 160] has Indwelling Catheter r/t [related to] URINARY RETENTION .The resident will show no s/sx [signs and symptoms] of Urinary infection through review date .The resident will be/remain free from catheter-related trauma through review date .A review of Resident 160's active physician's order, dated 3/12/26, indicated, SUPRAPUBIC catheter .Gravity drainage bag due to Dx [diagnosis] of OBSTRUCTIVE AND REFLUX UROPATHY.During an observation on 3/24/26 at 10:20 a.m. of Resident 160, in Resident 160's room, Resident 160 was observed lying on bed, awake and was connected to a urinary catheter tubing attached to a urinary catheter bag which was on the floor.During a concurrent observation and interview on 3/24/26 at 12:40 p.m. with Licensed Nurse (LN) 2, in Resident 160's room, Resident 160's urinary catheter bag was still on the floor. LN 2 confirmed the observation. LN 2 stated the urinary catheter bag should not be left on the floor because the catheter bag could get contaminated which may cause infection and urinary complications.

During an interview on 3/25/26 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated urinary catheter bags should be hanging on the bedside and not touching the floor.

The DSD stated there would be a risk of infection if the urinary catheter bag was left on the floor and the urine could also flow back which could cause potential urinary catheter complications.

During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that urinary catheter bags should be hanging on the bedside and should not be touching the floor.

The DON further stated that if the urinary catheter bag was on the floor, it could cause urinary complications like infection or possible back flow of the urine.A review of the facility's policy and procedures titled, Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .2. Be sure the catheter tubing and drainage bag are kept off the floor .

administering pain medications.

The DON further stated the resident's pain would not be controlled if

reflect the sources, type and severity of pain .1.

Document the resident's reported level of pain with

interventions for pain) as necessary and in accordance with the pain management program.A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .4.

Medications are administered in accordance with prescriber orders .

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

with the DON the DON reviewed Resident 67's Controlled Substance Record (CSR) for oxycodone 2.5

corresponding administration documented on March 2026 MAR.

The DON acknowledged the

documented. 3b. A review of Resident 20's clinical record indicated the following physician order,Tramadol 50 mg tablet, give 0.5 tablet (25 mg) by mouth every 6 hours as needed for moderate pain.Tramadol 50 mg tablet, give 1 tablet by mouth every 6 hours as needed for severe pain.During a concurrent interview and clinical record review on 3/25/26 at 8:46 a.m. with DON, the DON reviewed Resident 20's CSR for Tramadol 50 mg tablets, CSR for Tramadol 25 mg (50 mg, 0.5 tabs) and March 2026 MAR.

The CSR for Tramadol 50 mg indicated 1 tablet signed out on 3/14/26 at 5 p.m. and 1 tablet signed out on 3/14/26 at 10 p.m.

There were no corresponding administrations on March 2026 MAR.

The DON confirmed there were no tramadol administrations documented for 3/14/26 on the MAR and no nursing notes corresponding to the CSR removals on that date.During a review of the facility's policy and procedure titled, Controlled Substances, revised November 2022, indicated, The facility complies with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications. further review indicated, The system of reconciling the receipt, dispensing and .of controlled substances includes the following: a. records of personnel access and usage; b. medication administration records; c. declining inventory records .

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

During a medication observation on 3/23/26 at 4:25 p.m. at the 1B medication cart with LN 8, LN 8 stated Resident 112 was requesting pain medication and that she would assess the resident's pain before administering it. LN 8 returned to the cart and stated the resident's back pain was rated as a 5 [pain scale from 0 to 10].

She then prepared one tablet of acetaminophen 325 mg (an over-the-counter medication to reduce fever and mild pain) and two tablets of ibuprofen 200 mg, [400 mg] (medication to lower fever and reduce pain.) Resident 112 was observed swallowing the three tablets with water.A review of Resident 112's clinical record indicated the following physician orders, dated 3/9/26:Acetaminophen oral tablet 325 mg, give one tablet by mouth every 4 hours as needed (prn) for MILD pain (1-3 pain scale)/ Headache.Ibuprofen oral tablet 400 mg, give one tablet by mouth every 4 hours as needed for MILD (1-3 pain scale) or Moderate (4 -6 pain scale) give with food.A review of the nursing administration notes written by LN 8 on 3/23/25 at 4:39 p.m. indicated that acetaminophen 325 mg 1 tablet was administered for complaint of (c/o) back pain rated 5 out of 10.

During an interview and clinical record review on 3/25/26 at 8:11 a.m. with the DON, the DON stated pain medication is to be administered based on the physicianˆordered pain scale for mild, moderate, or severe pain.

The DON reviewed Resident 112's clinical records, including the medication administration record (MAR) and nursing notes, and acknowledged the acetaminophen administration did not follow the pain scale as ordered.

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

During an inspection of the 1 C medication cart and concurrent interview on [DATE] at 11:14 a.m. with Licensed Nurse (LN 5) the following medications were observed:One opened, undated vial of Insulin Glargine (long-acting insulin to control blood sugars) for Resident 110. LN 5 read the manufacture label that indicated, Use within 28 days after initial use. LN 5 confirmed the opened vial was not dated.One opened Breo Ellipta inhaler (medication inhaled into the lungs used for breathing problems) for Resident 161 without an open date. A review of the manufacturer's labeling with LN 5 indicated, Discard the inhaler 6 weeks after opening the .foil tray or when the counter reads 0 .whichever comes first. LN 5 confirmed no open date on the inhaler.One opened Trelegy Ellpta Inhaler (medication inhaled into the lungs used for breathing problems) for Resident 148. A review of the manufacturer's labeling with LN 5 indicated, Discard 6 weeks [after tray opened]. LN 5 confirmed the inhaler had no open date.1b.

During an interview and record review on [DATE] at 10:34 a.m. at the 1 A medication cart with LN 4, Resident 156's Epidiolex (oral solution to treat rare seizure disorders) bottle was observed open without an open date.

The manufacturer labeling indicated, Discard unused portion 12 weeks after first opening. LN 4 confirmed the opened bottle was not dated.1c.

During an inspection of the 1 B medication cart on [DATE] at 4:44 p.m. with LN 8, one multi-dose container of EvenCare, G3 Blood Glucose Test Strips (diagnostic strips used to test blood sugar) was observed open and without open date. A review of the manufacturer's label with LN 8 indicated, Use within 6 months after first opening. LN 8 confirmed there was no open date on the container.2.

During an inspection of the medication room [ROOM NUMBER] refrigerator on [DATE] at 3:42 p.m. with the Assistant Director of Nursing (ADON 2), one opened and undated Forteo pen for Resident 162 was observed.

The manufacturer labeling indicated, Throw away 28 days after first use. ADON 2 acknowledged the medication was opened and undated.

During an interview and record review on [DATE] at 9:11 a.m. with the Director of Nursing (DON), the DON stated medications are to be dated when opened in accordance with manufacturer guidelines.

After reviewing photographs of the undated medications observed, the DON acknowledged the findings and stated that undated, opened medications could expose residents to medications that may be expired or unstable.During a review of the facility's policy and procedure titled, Administering Medications, revised date [DATE], indicated, The expiration/beyond use date on the medication label is checked prior to administering.

When opening a multi-dose container, the date opened is recorded on the container.

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

During an observation on 3/24/26 at 8:30 and 11:00 a.m., Dietary Aide (DA) 2 wore a beanie in the kitchen without a hair restraint and hair was exposed in the back and sides of the head. DA 1 and [NAME] (CK) 1 had beards without beard restraints during food preparation.

During an interview on 3/24/26 at 8:45 and 11 a.m. with the Dietary Supervisor (DS), the DS confirmed DA 2 was wearing a beanie with exposed hair and was not wearing a hair net and DA 1 and CK 1 had exposed beard hair and were not wearing beard restraints.

The DS stated they should be wearing a hair net and beard restraints to prevent hair from contaminating food or getting on food prep surfaces.A review of the facility policy and procedure (P&P) titled, Dress Code, dated 2023, indicated, .PROPER DRESS: .6.

Hat for hair, if hair is short which completely covers the hair, 7.

Hair net for hair, if hair is long (over the ears or longer), 8. beards and mustaches (any facial hair) must wear beard restraint.According to the FDA Food Code 2022, Section 2-402.11, Hair Restraints, A. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.During an concurrent observation and interview on 3/25/26 at 10:30 a.m., DA 3 touched the dirty dishes on the dirty side of the dishwashing machine and then touched the clean dishes without washing hands.

The DS confirmed it was not the correct process and stated there should be two dishwashers and the person on the dirty side should not touch the dishes on the clean side without washing their hands to prevent cross contamination and spreading bacteria.

During a review of the facility P&P titled, Sanitation, dated 2023, indicated, . 18. A minimum of two employees will be used when dishes are machine washed.

One will handle soiled area, and one will handle the clean side. If an employee does need to go from soiled to dirty end, a strict hand-washing routine must be followed.

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825

During an interview with the DON, on 3/23/26 at 11:02 a.m. the DON stated her expectations from the nurses were to change the PICC Line dressing of Resident 132 every week, and as needed if the dressing got soiled or displaced.

The DON further stated, it should be labeled and dated to verify who changed the dressing and to ensure it was replaced per physician's order to prevent infections.

During a review of Resident 132's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, cefTRIAXone Sodium [antibiotics] Intravenous Solution .

Use 2 gram [unit measurement] intravenously [through the veins] at bedtime for Streptococcus Bacteremia [a serious condition often leading to high morbidity, sepsis, or mortality.

Commonly originated from infections such as skin infections].

During a review of Resident 132's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, DAPTOmycin Intravenous Solution.

Use 500 mg intravenously at bedtime for Streptococcus Bacteremia.

During a review of Resident 132's Care Plan (CP), undated, the CP indicated, Resident has PICC line to RUE [right upper extremity] .Change PICC line dressing every week and as needed for soiling or displacement.

During a review of the facility's policy and procedure, titled INTRAVENOUS THERAPY (IT), undated, the IT indicated, .To provide standards for the safe maintenance of the P.I.C.C. catheter in order to reduce the risk of infection or dislodging.TSM [transparent semi permeable membrane, adhesive dressing that covers the catheter insertion site] dressing will then be changed at least weekly .

555673 03/26/2026

Asbury Park Nursing and Rehabilitation Center 2257 Fair Oaks Boulevard Sacramento, CA 95825