Every finding on record at Alameda Oaks Nursing Center

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, 1 of 1 nutrition room, and 1 of 1 dining room reviewed for storage, preparation, and sanitation. 1. The facility failed to ensure all spice containers were not open to air. 2. The facility failed to ensure the shelf above the stove was clean. 3. The facility failed to ensure plastic cups were clean. 4. The facility failed to ensure all items in the refrigerator were labeled and dated. 7. The facility failed to ensure boxes of products were not stacked to the ceiling in the walk-in freezer. 8. The facility failed to ensure items in the nutrition room refrigerators were labeled and dated. 9. The facility failed to ensure items in the nutrition room refrigerators were not expired. 10. The facility failed to properly read and record the chemical sanitation strips for the washing machine. 11. The facility failed to properly train non-kitchen staff who serve residents' food in the dining room. These failures could place residents who received meals and/or snacks from the kitchen and dined in the dining room at risk for food contamination and food-borne illness. Findings were: Observation of the kitchen and interview with the DM on 09/08/26 beginning at 9:00 am revealed as follows:5 of 25 containers of spices were open to air. The DM closed the lids and one of the containers would not close. She said cross contamination could occur from whatever was in the air and ruin the spices, causing the flavor of the food to become off.The underside of the shelf directly over food on the stove had a thick, dark brown substance that was hanging down in some areas. The DM touched the substance on the shelf and said it was grease and could fall into the food. She said cross-contamination could result from foreign objects falling into the food and making residents sick.There was a clean rack identified by the DM with 12 trays of plastic bowls and cups. One of the trays had 16 of 28 plastic cups with a removable whitish substance inside them. The DM said she was responsible for checking the dishes to make sure they were clean before using them because dirty dishes should not be used and make residents sick.There was a cart in the walk-in refrigerator with 7 trays of beverages. One tray with 30 glasses of a light brown liquid, identified as tea by the DM, was unlabeled and undated. The DM said she could only do so much to get kitchen staff to follow through with tasks because all of the other trays of beverages were labeled and dated. The facility's food storage policy was requested at this time but not received.There were boxes of products stacked to the ceiling in the walk-in freezer with empty space on the lower shelves. The DM said the facility had a delivery, and she was in the process of arranging the boxes of products and did not use the lower shelves. She said boxes should be at least 18 inches from the ceiling to prevent obstruction of fire sprinklers.The chemical sanitation strip log had the same 50 PPM for the months of August and September 2026. A sample chemical sanitation strip conducted by the DM showed 200 PPM but she read it as 50 PPM. The DM said the proper range of sanitation required for the washing machine was 50-200 PPM. She said, arguably, the chemical sanitation logs had not varied because the chemical sanitation strips always showed 50 PPM. In-services for kitchen staff were requested at this time but not received. In an interview with the RD on 09/10/26 at 11:07 am, she said the DM was put on a PIP for her attitude in July 2026. She said the DM had worked at the facility for 10 years and never accessed the tools available to her for teaching, following cleaning schedules and regulations consistently. She said there were no cleaning supplies when she replaced the previous RD in June 2026.Record review of PIP-Kitchen Sanitation Initiated 07/29/26 weekly department review (DM/designee), Daily cooks closing check list (pm cook 5x per week), Quick rounds by DM 5x per week, Educations/huddles completed, RD monthly sanitation report.Observations of the WCN on 09/08/2026 beginning at 11:43 am revealed while removing food and beverage items from resident's trays, she picked up drinking glasses and bowls by the rim with her bare hands. Between trays, she utilized ABHR but only rubbed her hands together for 5-9 seconds. Observations of the DON on 09/08/2026 beginning at 11:45 am revealed while removing food and beverage items from resident's trays, she picked up drinking glasses and bowls by the rim with her bare hands. Between trays, she utilized ABHR but only rubbed her hands together for 4-8 seconds. Once, she was observed handling trays in the cart, stopped, rubbed her hands together again then continued to handle the trays. Observations of CNA A on 09/08/2026 beginning at 11:47 am revealed while removing food and beverage items from resident's trays, she picked up drinking glasses and bowls by the rim with her bare hands. Between trays, she utilized ABHR but only rubbed her hands together for 5-10 seconds.In an interview with CNA A on 09/08/2026 beginning at 11:48 am, she said she had been trained on removing items from meal trays about one year ago. She said the process for removing glasses and bowls from trays was, once the lid was removed, don't touch the top. She said she was handling the glasses and bowls by the rims. She said staff were to use ABHR after every tray and wash their hands after every third tray. She said she did not remember exactly how long to rub her hands together, and she only rubbed her hands for 5-10 seconds. She said it was important to have clean hands when serving because the residents could get sick if staff passed germs to them. In an interview with the ICP on 09/08/2026 at 11:55 am, she said she had conducted a 2-day all-staff infection control in-service/skills check in August 2026. She said the in-service/skills check covered handwashing and utilizing a glowing substance that was invisible without black light. She said it was rubbed onto the hands after washing and when illuminated with black light, the places 'missed' glow. She said staff were taught to pick up glasses and bowls from the sides and ABHR should be done for at least 20 seconds and until dry. Observation of the nutrition room refrigerators on 09/10/26 at 1:40 pm revealed two, 11.2 oz. bottles of non-alcoholic beer, and one, 14oz. container of a flavored drink in the 'black refrigerator'. None of the items were labeled or dated. The two beers had expiration dates of November 2025, and the flavored drink expired May 2026. The 'brown refrigerator' had an open 46oz. carton of thickened orange juice that expired August 09, 2026. In an interview with the DON on 09/10/26 at 1:42 pm, she said she had labeled the beer bottles, but it must've rubbed off. In an interview with LVN B on 09/10/26 at 1:45 pm, she said the nurses, CNAs, and staff were responsible for labeling, dating, and checking the expiration dates on all resident items for the refrigerators. She said the snacks from the kitchen were in the brown refrigerator and resident items were in the black refrigerator. She said staff were responsible because there was a keypad on the door that only staff had access to so residents did not wander in there and maybe get and consume something that did not belong to them or something they might be allergic to. Record review of the ICP's 2-day all-staff infection control in-service/skills check in August 2026 revealed topics covered included hand hygiene. The skills check list consisted of hand washing vs. ABHR: To wash or sanitize hands according to the standard of care. Hand sanitizing: Apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all the products have dried; about 30 seconds. Record review of the facility kitchen policy reviewed on 05/22/26 titled, Ware Washing-Dish Machine/Manual Process revealed under policy: The director of food and nutrition services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state, and local requirements. Under definitions: cross-contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned .Under 2. Chemical contamination: Under procedure: 1. Food and Nutrition Services associates are trained in the proper use, cleaning and sanitation of ware-washing equipment and sinks. 2. Procedures for cleaning are readily available to all associates . 5. All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. Under Low Temp Dish Machine 2. The temperature and parts per million (PPM) of the sanitizer (50-100 ppm for chlorine) will be recorded on the Low Temperature Dish Machine Log a minimum of three times per day. 5. Staff will be trained on how to operate and clean the machine and how to rinse, wash, dry, and store items appropriately. Record review of the facility policy revised 05/16/26 titled, Safe Food Handling revealed under definitions: Cross-contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food and then touch ready-to-eat foods. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods. Food Contamination - means the unintended presence of potentially harmful substances, including, but not limited to microorganisms, chemicals, or physical objects in food. Under procedure: 8. Local, state and federal regulations are followed when handling food. 10. Associates do not touch areas of utensils, dishware or flatware where the food or mouth is placed. Record review of the facility policy revised 05/06/2025, Chapter 4; Dining; Food from outside sources under General Guidelines on Keeping Food Safe for Residents: 6. Food stored in refrigerator should be labeled with the resident's name and room number. 7. Adhere to expiration date on prepackaged food items; Items should be discarded if past expiration date.Record review of the FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: (E) .foods are protected from contamination . 2-4 Hygienic Practices 2-401 Food Contamination Prevention of food; clean equipment, utensils, or other items needing protection cannot result. (B) A food employee may .handle a beverage container if the container is handled to prevent contamination of: (1) the employee's hands; (2) the container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment, food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. If used with time/temperature control for safety food, equipment food-contact surfaces, and utensils shall be cleaned throughout the day at least every 4 hours.

Based on record reviews and interviews, the facility failed to ensure that the discharge date and notification was documented in the resident's medical record for two residents (Resident #8 and #46) of five residents reviewed for discharge notification.Facility failed to record the discharge in the residents' medical record.These failures could place the residents at risk of not ensuring residents receive safe and effectivetransition of care.Findings Included:Review of Resident #8's admission record dated 09/10/26 revealed he was a [AGE] year-old male admitted on 07/17/26 and an initial admission date of 04/21/20. He's diagnosies were Acute Chronic RespiratoryFailure (a long-term condition where the lungs cannot properly exchange oxygen and carbon leading tolow oxygen and high carbon dioxide levels), Chronic Obstructive Pulmonary Disease ( a long-term lungcondition that makes it progressively harder to breathe), Hemiplegia (a medical condition that causesparalysis on one entire side of the body, and Hemiparesis (a medical condition that causes weakness orpartial loss of movement on one entire side of the body), Cerebral Infarction ( the death of brain tissuecaused by sudden loss of blood flow and oxygen), affecting left non dominant side.1. Record Review of Resident's #8's Quarterly MDS assessment dated [DATE] revealed aBIMS score of 15. A BIMS score of 15 indicated a person's thinking and memory are normal with nocognitive impairment.Record review of Resident #8's Progress Note, dated 07/08/26, revealed, Resident #8 was transferred tothe E.R. on 06/08/26.2. Review of Resident #46's admission record dated 09/09/26 revealed a [AGE] year-old male admitted on [DATE] and an initial admission date of 11/08/24. He's diagnoses were Chronic Obstructive PulmonaryDisease (a long-term lung condition that makes it progressively harder to breathe), Respiratory Failure(happens when your respiratory system cannot pump enough oxygen into your blood or remove enoughcarbon dioxide from it), Heart Failure (happens with the heart muscle does not pump blood as well as thebody needs).Record Review of Resident's 46's Quarterly MDS assessment dated [DATE] revealed aBIMS score of 15. A BIMS score of 15 indicated a person's thinking and memory are normal with nocognitive impairment.Record review of Resident #46's Progress Note, dated 08/13/26 revealed, Resident #46 was transferredto the ER on [DATE].In an interview on 09/10/26 at 1:40 p.m., the DON stated Resident #8 had been discharged on 06/08/26from the facility. She stated she did not know the Resident needed to be notified of his discharge. Shestated she had not found discharge notification in his medical record. The DON stated Resident #46 hadbeen discharged on 08/17/26 from the facility. She stated she did not find documentation of his dischargenotification in his medical record. The DON stated the facility's process for discharging a resident includeda discharge summary and resident notification of discharge. She stated failure to notify the residents ofdischarge would result in lack of continuum of care and patient education.In an interview on 09/10/26 at 2:26 p.m., the ADON stated resident #8 was discharged on 06/8/26 andthere was no documentation of his written discharge notification in his medical record. The ADON statedResident #46 was discharged on 08/17.26 and he had not received written notification of his discharge.She stated the lack of discharge notification could affect the residents' health and well-being.Record review of the facility's policy dated 08/25/26 titled Transfers and Discharges reflected:Federal RegulationsF628483.14(C) (2) Documentation.When the facility transfers or discharges a resident under any of the circumstances specified inparagraphs (C)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge isdocumented in the residents medical record and appropriate information is communicated to the receivinghealth care institution.The facility did not provide a copy of their Discharge Summary Policy.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 Residents (Resident #10) reviewed for comprehensive care plans.The facility failed to remove Resident #10's indwelling urinary catheter from the comprehensive care plan after the urinary catheter was discontinued on 09/02/2026.This failure could place residents at risk of not receiving accurate or required care.The findings included:Record review of Resident #10's face sheet, dated 09/10/2026, revealed a [AGE] year-old male with an admission date of 09/30/2026. Resident #10's pertinent diagnoses included Open Wound of Scrotum (external area of testicles) and Testes (male reproductive glands) and Unspecified Urethral Stricture (narrowing of the urethra, restricting normal urine flow). Record review of Resident #10's Annual MDS Assessment, dated 08/25/2026, revealed a BIMS score of 13, which indicated intact cognition. The MDS assessment also revealed Resident #10 had urinary incontinence (loss of bladder control causing leakage of urine) and an indwelling catheter (drains urine from the bladder). Record review of Resident #10's Physician Order Summary, dated 09/09/2026, revealed no current order for a urinary catheter. There was a previous order for an indwelling catheter which started 08/07/2026 and ended 09/02/2026.Record review of Resident #10's care plan focus, revised 08/24/2026, revealed a Urinary Tract Infection (an infection in any part of the urinary system [kidneys, ureters, bladder, and urethra]). Interventions included catheter care at least every shift. Record review of Resident #10's care plan focus, revised 08/10/2026, revealed an alteration in skin integrity due to surgical incision to the scrotum. Interventions included indwelling catheter placed to assist with wound healing.Record review of Resident #10's care plan focus, revised 08/10/2026, revealed a risk for alteration in psychosocial well-being related to. urinary catheter insertion. Interventions included allow Resident #10 time to answer questions and to verbalize feelings, perceptions, and fears as desired. In an observation on 09/09/2026 at 9:45 AM, Resident #10 was observed to have no indwelling urinary devices. In an interview on 09/09/2026 at 3:47 PM, the DON stated Resident #10's urinary catheter was removed 09/02/2026 because Resident #10 requested to have it removed. The DON stated the care plan was used to plan and guide the care of the residents, and Resident #10's urinary catheter should not still be on the care plan. She stated the MDS nurse usually updated the care plans, but any nurse could have updated it. In an interview on 09/09/2026 at 11:43 AM, the MDS nurse stated she typically updated the care plans so they were up to date with the care the resident needed, and if Resident #10's catheter had been discontinued, it should have been removed from the care plan. She stated it may have been overlooked. Record review of the facility's Comprehensive Care Plan Policy, dated 08/25/2026, revealed Policy: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised. Procedure: 1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. 2. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery.

Based on interview and record review, the facility failed to provide nursing services to assure resident's safety and attain or maintain the highest practicable physical well-being for one (Resident #8) of five residents' records reviewed for of Nursing Services. The facility failed to assess, evaluate, plan and implement resident care for Resident #8's hypertension (a common condition where blood pushes too forcefully against your artery walls) on 01/01/26, 01/07/26, 01/08/26 and 01/09/26. The failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical well-being. Findings Included: Review of Resident #8's admission record dated 09/10/26 revealed he was a [AGE] year-old male admitted on [DATE] and an initial admission date of 04/21/20. His diagnoses were Acute Chronic Respiratory Failure (a long-term condition where the lungs cannot properly exchange oxygen and carbon leading to low oxygen and high carbon dioxide levels), Chronic Obstructive Pulmonary Disease (a long-term lung condition that makes it progressively harder to breathe), Hemiplegia (a medical condition that causes paralysis on one entire side of the body, and Hemiparesis (a medical condition that causes weakness or partial loss of movement on one entire side of the body), Cerebral Infarction (the death of brain tissue caused by sudden loss of blood flow and oxygen), affecting left non dominant side. A record review of Resident's #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15. A BIMS score of 15 indicated a person's thinking and memory are normal with no cognitive impairment. * Record review of Resident #8's Vital Sign Record revealed the following BP: * 01/01/26 at 2:55 a.m. BP 217/83 BP reassessed at 01/01/26 at 5:18 a.m. BP 188/98 * 01/07/26 at 11:01 a.m. BP 198/112 BP reassessed 01/07/26 at 20:07 p.m. BP 167/89 * 01/08/26 at 6:02 a.m. BP 213/96 BP reassessed 01/08/26 at 1:00 p.m. BP 170/90 * 01/09/26 at 3:10 p.m. BP 194/89 BP reassessed 01/09/26 at 7:35 p.m. BP 138/74 Record review of Resident #8's MAR dated 01/01/26 revealed: Clonidine HCl oral tablet 0.1mg give 1 tablet by mouth every 6 hours as needed for HTN administer for systolic >160 or diastolic > 100 was provided to the resident 01/01/26 at 2:56 a.m. Clonidine prn was administered for BP of 217/83. 01/08/26 at 6:03 a.m. Clonidine prn was administered for BP 213/96. Record review of Resident #8's Progress Notes dated 01/01/26, 01/07/26, 01/08/26 and 01/09/26 did not indicate assessment, evaluation, planning or implementation of Nursing Services to address the HTN. In an interview on 09/10/26 at 1:40 p.m. the DON stated, on 01/07/26 the Resident #8's BP was 198/112 at 11:01 a.m. and she stated there was no documentation of nursing interventions applied to treat his HTN. She stated that on 01/08/26 Resident #8's BP was 213/96 at 6:02 a.m. and his MAR indicated he received a prn Clonidine at 6:03 a.m. The DON stated on 01/09/26 Resident's #8's BP was 194/89 at 3:10 p.m. and there was no documentation of BP being reassessed in Resident #8's medical record. The DON stated that elevated BP left untreated could lead to altered mental status, dizziness, and more serious health conditions. In an interview on 09/10/26 at 2:26 p.m., the ADON stated on 01/01/26Resident # 8's BP was 217/83 and he had received his prn Clonidine but there was no documentation by Nursing of Resident #8 being reassessed or if the Clonidine had been effective. She stated Resident #8's BP on 01/07/26 was 198/112. She stated he had received all his schedule BP medications, and she was not sure if the Nurse had rechecked is BP because there was nowhere on the MAR to document a recheck of the BP. The ADON stated there was no documentation of a follow up assessment or reassessment of his BP. The ADON stated resident #8 BP 01/08/26 was 213/96 he had received his prn clonidine but there was no follow up assessment done or a BP recheck by the nurse. She stated a check mark on the MAR indicated the medication was effective. The ADON stated on 01/09/26 resident #8's BP was 194/89. She stated he had not received any extra medications, but he had received his clonidine patch. The ADON stated there was no documentation of a follow up assessment or a recheck of his BP. She also stated the nurse did not have an order to notify the physician therefore he was not notified of the HTN episodes. ADON stated Resident #8 had a history of CHF and CVA. She stated an elevated BP being left untreated could cause residents to have another CVA and all types of health problems. Review of Life Care Centers of America training materials Titled Blood Pressure Measurements (no date provided) reflected: Documentation: In the patient's medical record, record blood pressure.Record who you notified about the blood pressure results, the date and time of notification, prescribed interventions, and the patient's response to those interventions. Review of Facility's in Service Title Blood Pressure Measurements, Reporting Abnormal Values dated 07/13/26 reflected: Medication Aides are to report any. high blood pressure (Systolic>160/Diastolic >90) to their charge nurse immediately. The Charge Nurse is to follow up and reassess the patient's blood pressure. If the blood pressure is still abnormal, the charge nurse is to then contact the MD/NP to report the abnormal values and document appropriately. If the patient has PRN medication for . hypertension, the charge nurse is to administer prn medication, document prn medication, & then reassess patient in 1 hr.and the appropriate progress note must be entered by the Charge Nurse.

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 8 residents (Resident #15) reviewed for pharmacy services in that: MA C did not measure Resident #15's blood pressure and pulse before administration of metoprolol (blood pressure lowering medication) at 8:40 AM on 09/09/26. This failure could place residents at risk of hypotension (low blood pressure) and bradycardia (low heart rate).The findings included:Record review of Resident #15's face sheet dated 09/10/26 revealed a [AGE] year-old female with an initial admission date of 06/25/26 and a current admission date of 08/07/26. The pertinent diagnosis included Hypertensive Hear Disease with Heart Failure (long-term, unmanaged high blood pressure forces the heart to work too hard, causing the heart muscle to thicken, weaken, and fail to pump blood efficiently). Record review of Resident #15's PPS MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #15's Comprehensive Care Plan dated 09/10/26 revealed The resident has hypertension [elevated blood pressure] initiated on 08/03/26. Interventions listed included Give anti hypertensive medications as ordered. Observe for side effects such as orthostatic hypotension [a sudden drop in blood pressure that happens when you stand up from sitting or lying down] and increased heart rate (Tachycardia) and effectiveness initiated on 08/03/26. Record review of Resident #15's Order Summary dated 09/10/26 revealed an active order for Metoprolol Succinate Extended-Release Oral Tablet Give 1 tablet by mouth two times a day for HTN initiated on 08/07/26. During an observation of medication administration by MA C at 8:40 AM on 09/09/26, MA C prepared medications to administer to Resident #15. MA C did not measure Resident #15's blood pressure or pulse before handing Resident #15 the medication to swallow. Resident #15 vomited the medication back up approximately 1 minute after ingesting. During an interview with MA C at 8:42 AM on 09/09/26, MA C stated she did not measure Resident #15's blood pressure or pulse before administering the metoprolol. MA C stated she knew metoprolol was a blood pressure medication that lowered a resident's blood pressure. MA C stated her computer system did not prompt her to take the resident's blood pressure. MA C stated according to the order in the MAR she did not need to take Resident #15' blood pressure before administering metoprolol. MA C stated that administering blood pressure medications to a resident when their blood pressure was already low could cause hypotension. During an interview with the DON at 9:25 AM on 09/09/26, the DON stated the resident's blood pressure and pulse should be checked before administration of metoprolol. The DON stated MA C should have checked Resident #15's blood pressure and pulse before administering her metoprolol. The DON stated any medication used for hypertension should not be administered without checking the resident's blood pressure. The DON stated it was important to know the resident's blood pressure before administering a medication for hypertension because the medication could lead to hypotension. Record review of the facility policy Administration of Medications last reviewed 08/25/26 revealed the following policy: .g. Right Assessment.Note the resident's history and any parameters around drug administration.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 8 residents (Resident #32) reviewed for medication errors. The facility failed to administer Resident #32's midodrine (medication that raises blood pressure) when Resident #32's blood pressure was inside the physician's parameters on 08/07/26. This failure could place residents at risk for complications such as lowered blood pressure and exacerbation of symptoms. The findings included: Record review of Resident #32's face sheet dated 09/08/26 revealed a [AGE] year-old female with an original admission date of 02/17/23 and a current admission date of 03/12/26. Resident #32's pertinent diagnosis included Unspecified Hypotension (abnormally low blood pressure, but the exact underlying cause has not been identified). Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #32's Comprehensive Care Plan dated 09/08/26 revealed the focus Resident #32 has a h/o hypotension initiated on 06/09/25. An intervention listed for this focus included Give medications as ordered initiated on 09/29/25. Record review of Resident #32's order summary dated 09/08/26 revealed an active order for midodrine oral tablet Give 5 mg by mouth every 8 hours as needed for Administer for SBP <110 related to HYPOTENSION, UNSPECIFIED initiated on 06/09/26. Record review of Resident #32's blood pressure log from August 2026 revealed Resident #32's blood pressure was measured 108/69 on 08/07/26 by RN A. Further review revealed no other blood pressure was taken for Resident #32 on 08/07/26 Record review of Resident 32's MAR for August 2026 revealed midodrine was not administered to Resident #32 on 08/07/26. During an interview with RN A at 2:47 PM on 09/09/26, RN A stated she documented Resident #32's blood pressure as 108/69 on 08/07/26. RN A stated she should have administered midodrine to Resident #32 on 08/07/26 based on the blood pressure she documented. RN A stated the August MAR for Resident #32 showed midodrine was not administered to Resident #32 on 08/07/26. RN A stated it was possible she did administer midodrine to Resident #32 and did not record it in the MAR. RN A stated it was important to administer midodrine to residents per the physician's order to prevent hypotension. During an interview with the DON at 3:55 PM on 09/09/26, the DON stated that based on the blood pressure taken for Resident #32 on 08/07/26, she should have been administered midodrine. The DON stated it was important to follow the physician's orders. The DON stated failing to administer midodrine when a resident's blood pressure was low could lead to hypotension and dizziness. Record review of the facility policy Administration of Medications last reviewed 08/25/26 revealed the following policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Medication Error - This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: The prescriber's order;

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Resident #5) reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN B documented the amount of insulin she administered on the MAR to Resident #5 before lunch on 09/04/26. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included: Record review of Resident #5's face sheet dated 09/09/26 reveled an [AGE] year-old female with an initial admission date of 02/17/22 and a current admission date of 05/29/26. The pertinent diagnosis included Type 2 Diabetes Mellitus (chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood). Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review revealed Resident #5 received insulin injections on each of the 7 days prior to the assessment. Record review of Resident #5's Comprehensive Care Plan dated 09/09/26 revealed the focus [Resident #5] has Type 2 Diabetes Mellitus with hypoglycemia (low blood sugar) initiated on 02/17/22. An intervention listed for the focus included Medication as ordered initiated on 02/17/22. Record review of Resident #5's Order Summary dated 09/09/26 revealed an active order for Novolin Insulin Inject as per sliding scale: if 0 - 150 = 0; 151 - 199 = 4 units; 200 - 249 = 6 units; 250 - 299 = 8 units; 300 - 349 = 10 units; 350 - 400 = 12 units, subcutaneously (layer of tissue beneath the skin and above the muscle) before meals and at bedtime related to Type 2 Diabetes Mellitus with hypoglycemia without coma initiated on 05/29/26. Record review of Resident #5's MAR for September 2026 revealed LVN B measured Resident #5's blood sugar as 492 before lunch on 09/04/26. Further review revealed LVN B signed the MAR at the time she administered insulin to Resident #5 but did not include the number of units she administered to Resident #5. During an interview with LVN B at 2:58 PM on 09/09/26, LVN B stated she remembered measuring Resident #5's blood sugar before lunch on 09/04/26 and subsequently administering her insulin. LVN B stated she administered 12 units of insulin to Resident #5 at that time and notified the doctor since her blood sugar was elevated outside of the physician's parameters. LVN B stated she forgot to put the number of units she gave to Resident #5 in the MAR for that administration. LVN B stated it was important to document the amount of insulin administered to residents to ensure the correct dose was given and because the wrong dose of insulin could be dangerous to residents. During an interview with the DON at 3:55 PM on 09/09/26, the DON stated nurses should always document the amount of insulin given to residents on the MAR. The DON stated LVN B should have documented how much insulin she administered to Resident #5 before lunch on 09/04/26 when Resident #5's blood sugar was 492. The DON stated it was important to document the amount of insulin given to ensure there was a continuum of care and to verify the physician's order was followed appropriately. Record review of the facility policy Administration of Medications last reviewed 08/25/26 revealed the following policy: .f. Right Documentation. Make sure to write the time and any remarks on the chart correctly. Medication administrations should be documented timely following the administration to the resident.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #10) reviewed for infection control practices. The facility failed to ensure the WCN did not grab or touch clean items, supplies or equipment with contaminated gloves during a wound care observation on 09/09/2026. The facility failed to ensure the WCN knew the appropriate technique for cleaning a wound during a wound care observation on 09/09/2026.The facility failed to ensure the WCN knew to use appropriate PPE prior to touching contaminated items during a wound care observation on 09/09/2026.These failures could place residents at risk for cross-contamination and infection.The findings included:Record review of Resident #10's face sheet, dated 09/10/2026, revealed a [AGE] year-old male with an admission date of 09/30/2026. Resident #10's pertinent diagnoses included Open Wound of Scrotum (external area of testicles) and Testes (male reproductive glands). Record review of Resident #10's Annual MDS Assessment, dated 08/25/2026, revealed a BIMS score of 13, which indicated intact cognition. The MDS assessment also revealed Resident #10 had a surgical wound and surgical wound care. Record review of Resident #10's care plan focus, revised 08/10/2026, revealed an alteration in skin integrity due to an incision to the scrotum for debridement of an abscess. Interventions included treatment as ordered. Record review of Resident #10's Physician Order Summary, dated 08/18/2026, revealed: Surgical incision to perineum - cleanse wound with normal saline, pat dry with gauze (a woven fabric used in wound care); apply collagen powder (a topical powder which supports wound healing) to wound bed; apply silver alginate (an absorbent part of the dressing which helps manage and heal wounds) to wound bed; apply non-absorbent dressing. In a wound care observation on 09/09/2026 at 9:45 AM, after performing hand hygiene and applying PPE, the WCN assisted the CNA with incontinent care, in which she grabbed the package of wipes from the CNA. She pulled wipes from the package and cleaned Resident #10. She moved the package of wipes to the bottom of the bed, grabbed the previously sanitized bedside table (where the clean wound care field was located), and moved it out of the way so she could go to the bathroom to wash her hands. The WCN then continued with Resident #10's wound care, in which she cleaned the wound by wiping from top to bottom across the wound. She then used the same contaminated gloves to grab clean gauze to pat dry. The WCN went to the bathroom and performed hand hygiene again, and after applying clean gloves, she grabbed around the contaminated edges of the bedside table to move the wound care supplies closer to her. After completing wound care, the WCN discarded contaminated gloves, performed hand hygiene, then came back into Resident #10's room and grabbed the contaminated wipes with her clean bare hands, and put the wipes away. She then continued to pull the residents blankets up, pulled the divider curtain around, moved the bedside table around, discarded unused supplies into trash, and took the contaminated trash out, all done with bare hands after performing hand hygiene. In an interview on 09/10/2026 at 10:00 AM, the WCN stated she should not have touched the clean sanitized table containing her wound care supplies with gloves which were contaminated after touching and cleaning Resident #10 during incontinent care. She also stated she should not have grabbed and moved the contaminated package of gloves with clean, gloved hands, then performing wound care, as well as grabbing the contaminated package again after removing her gloves and performing hand hygiene, then adjusting Resident #10's blankets and curtain with bare hands after handling the contaminated package of wipes. The WCN stated the appropriate technique for cleaning a wound was to clean from inner to outer to avoid cross contamination. She stated all of this cross contamination could have increased the resident's risk for infection. In an interview on 09/09/2026 at 2:21 PM, the ICP stated ABHS was the preferred method for hand hygiene in most clinical situations. She stated the appropriate way to clean a wound was from inside to outside, cleanest to dirtiest, and if the wound was just wiped from top to bottom across the wound, it could have introduced bacteria back into the wound and created cross contamination. She also stated if the WCN helped with incontinent care and touched the package of wipes, the bedside table, the resident or anything in the resident's environment with her contaminated gloves, it was cross contamination and could increase the resident's risk of infection. The ICP stated no staff should touch anything clean with contaminated gloves, and they should not touch anything contaminated without clean, gloved hands. Record review of the facility's Hand Hygiene policy, revised 06/13/2023, revealed Procedure: 1. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations. 2. Associates perform hand hygiene (even if gloves are used) in the following situations: A. Before and after contact with the resident; B. After contact with blood, body fluids, or visibly contaminated surfaces; C. After contact with objects and surfaces in the resident's environment. D. After removing personal protective equipment. C. Before performing a procedure. dressing care.Record review of the facility's Interdisciplinary Team Approach to Skin and Wound Care policy, revised 08/07/2021, revealed Policy: Per regulation the facility must ensure that a resident receives care consistent with professional standards of practice.Record review of the facility's Infection Prevention and Control Program policy, revised 05/22/2026, revealed Policy: The facility has an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection. Definitions: Personal Protective Equipment refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect the residents from cross-transmission. General Procedures: 7. Ensure associates follow the IPCP's standards, policies and procedures (hand hygiene and appropriate use of PPE).Record review of the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed Core Practices Table: Core Practice Category: 2. Education and Training of Healthcare Personnel on Infection Prevention; Core Practices: 2. Develop processes to ensure that all healthcare personnel understand and are competent to adhere to infection prevention requirements as they perform their roles and responsibilities. Core Practice Category: 5. Hand Hygiene References and Resources; Core Practice: 2. Use an alcohol-based hand rub or was with soap and water for the following clinical indications: A. Immediately before touching a patient, B. Before performing an aseptic task. C. Before moving from work on a soiled body site to a clean body site on the same patient. D. After touching a patient or the patient's immediate environment. E. After contact with blood, body fluids or contaminated surfaces. https://www.cdc.gov/infection-control/hcp/core-practices/index.html

Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #3 ) of 5 residents reviewed for abuse/neglect.The facility failed to report to the State Survey agency within the allotted time frame of 2 hours on 02/05/2026 around 12:52 PM when Resident #2 hit Resident #3 twice in the eye. This failure could place residents at increased risk for potential abuse due to unreported allegations of abuse.The findings included:Resident #2Record review of Resident #2's admission record dated 04/04/2026 revealed Resident #2 was a [AGE] year-old male who was admitted on [DATE]. Resident #2 was admitted with multiple diagnoses including dementia (cognition deficit), personal history of traumatic brain injury, and cognitive communication deficit. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 12 which indicated moderate cognitive impairment and was independent for majority of his ADLs. Resident #2 was not coded for behaviors. Record review of Resident #2's care plan revealed Date Initiated: 02/05/2026 Resident #2 has had an episode of physical aggression towards another male resident r/t dementia with agitation, irritability, and poor impulse control Goal: The resident will verbalize understanding of need to control physically aggressive behavior through the review date. Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalate behavior and document. Assess and address for contributing sensory deficits. The resident will have no further episodes of physical aggression through the review date. Document observed behavior and attempted interventions in behavior log. Emergency detention warrant for psych evaluation ordered. Give the resident as many choices as possible about care and activities. Medication adjustment ordered. Observe and report PRN any s/sx of resident posing danger to self and others. PCS group to evaluate and treat as indicated. When the resident becomes agitated: Intervene before agitation escalate; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Record review of the Resident #2's progress note dated 02/05/2026 12:52PM written by LVN F (did not witness the incident) revealed resident was witnessed in the dining room hitting another resident twice to the left eye, resident was redirected by staff and told to stop, resident left the dining room and went to his room, RP notified by ADON, MD notified, DON notified. Resident #3Record review of Resident #3's admission record dated 04/06/2026 revealed Resident #3 was a [AGE] year-old-male who was admitted on [DATE]. Resident #3 was admitted with multiple diagnoses including hemiplegia(paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side and aphasia (communication deficit) following cerebral infarction (stroke).Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 7 indicating severe cognitive impairment and needed partial/moderate assistance with ADLs. Record review of Resident #3's care plan revealed [Resident #3] has impaired cognition r/t prior CVA revision on: 07/13/2025 Goal: [Resident #3] will be able to communicate basic needs through the review date. Interventions: allow extra time for resident to respond to questions and instructions. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents capabilities and needs. Communication: use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers). Observe for and report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.Record review of the incidents and accidents report from 01/03/2026-04/03/2026 and there was 1 incident, 02/05/2026, regarding Resident #2, no other concern noted. On 04/03/2026 at 11:21AM, 4:09PM, and 04/04/2026 at 3:32PM attempted interview with previous administrator but unsuccessful. During an interview on 04/04/2026 at 3:49PM the administrator stated she has been with the facility for roughly 1 week and could not speak on the actions of the previous administrator. The administrator stated the incident on 02/05/2026 would necessitate a notification to local law enforcement which was completed, and to the state survey agency was not completed for an unknown reason. The administrator stated Resident #2 had never displayed any form of aggression to any other resident and was isolated to the 02/05/2026 incident. The administrator prior to 02/05/2026 Resident #2 had never exhibited any aggression to any residents and never found any indication of aggression prior to 02/05/2026 incident. The administrator stated Resident #3 did not sustain any skin irregularity or discoloration on 02/05/2026 nor verbalized being fearful of living at the facility. The administrator stated the state survey agency should have been notified of the incident on 02/05/2026 however does not know why the previous administrator did not complete the notification. The administrator stated the previous administrator was not available for interview as they were no longer corresponding or answering any attempts for communication. The administrator stated the well-being of Resident # 3, was not compromised and there were no negative effects due to the previous administrator not notifying the state survey agency. The administrator stated that going forward, she will notify the local law enforcement and state survey agency of all allegations of abuse not only as mandated by the facility's policy and procedure but also state regulations. Record review of the facility's Area of Focus: Abuse & Neglect policy and procedure issued:01/03/2022; Reviewed:11/24/2025 documented, Reporting Allegations: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facility) in accordance with state law through established procedures.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet.Record review of a face sheet dated 3/12/2026 indicated Resident #1 was a [AGE] year-old female, re-admitted [DATE] (initial admission date 11/13/2025), with diagnoses of Acute and Chronic Respiratory failure with Hypoxia (occurs when the lungs cannot adequately oxygenate the blood), Encounter for attention Tracheostomy (routine maintenance needed for a tracheostomy), Dependence on supplemental oxygen, Hemiplegia and Hemiparesis following cerebral infarction (partial paralysis or weakness after a stroke), and Persistent Vegetative State (a disorder or consciousness following severe brain injury where a patient may be awake but have no awareness of themselves or their surroundings). Review of a quarterly MDS assessment, dated 2/24/2026, indicated Resident #1 should not be interviewed for a BIMS due to the resident was rarely/never understood. The MDS indicated Resident #1 was unable to answer questions for cognitive review. The MDS also indicated Resident #1 needed maximum assistance with all activities of daily living, all functional abilities regarding mobility were not assessed due to Resident #1's active diagnosis of Persistent Vegetative state. Record review of Resident #1's care plan, undated, revealed, Resident #1 had a focus goal of being unable to communicate with others related to persistent vegetative state with an intervention of the resident being provided a specialized call device that is easier to operate. During an observation on 3/11/2026 at 2:15 p.m., Resident #1 was in her room with no call light within reach. Resident #1's call light was clipped to itself behind the resident on the wall. (Resident #1 was not interviewed due to current diagnosis). During an interview on 3/12/2026 at 10:45 a.m., Resident #1's family member stated the facility was responsive to his requests for his family member. The family member stated the facility was good about repositioning Resident #1, she was kept clean and the facility staff ensured her vent and feeding tube are well maintained. During an interview on 3/11/2026 at 2:15 p.m., LVN B stated she was unaware Resident #1's call light was not within her reach, but that it should be within her reach. LVN B stated CNA A may have repositioned the resident and did not place it back within reach of Resident #1. LVN B stated this resident unable to respond to any stimuli and cannot use the call light. During an interview on 3/11/2026 at 2:25 p.m., CNA A stated she did care for Resident #1 today and did reposition Resident #1 in bed with LVN B. CNA A stated she was unsure why the call light was not placed within reach of the resident. CNA A stated it was expected for the call lights to always be within reach of all residents, including Resident #1. CNA A stated since Resident #1 was without her call light and does not move or respond to stimuli she does not think anything would have changed with this resident. CNA A stated she ensured Resident #1 was checked on and repositioned during her rounds which are every 2 hours. During an interview on 3/11/2026 at 2:45 p.m., the DON stated it expected that all residents should have a call light pinned on the bed, blanket, or within reach of the resident, including Resident #1. The DON stated even though Resident #1 was not aware of her surroundings the resident could go into respiratory distress. The DON stated she provided re-education to staff about call lights being in reach of all residents to include Resident #1. Record review of facility policy titled, Resident Call System reviewed 12/23/2025 and revised 01/04/2023, reflected, 1. Facility associates should always be aware of call lights and 5. The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. A. The call system must be accessible to residents while in their bed or other sleeping accommodation within the residents' room. B. The call system must be accessible to the resident at each toileting and bath or shower facility and would be accessible to a resident lying on the floor in this area.

Based on record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents, for one (Resident #1) of five residents reviewed for base line care plans for newly admitted residents. 1) The facility did not develop a baseline care plan that addressed Resident #1's diabetes mellitus when he was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increase the risk of adverse events regarding diabetes mellitus exacerbation or complications. The findings included: Record review of Resident #1's admission record dated 12/19/2025 revealed Resident #1 was initially admitted on [DATE] and readmitted [DATE]. Resident #1 discharged home with home health services on 09/22/2025. Resident #1 was admitted to the facility with multiple diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, and heart disease. Record review of Resident #1's discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 12-Moderate cognition impairment and needed partial/moderate assistance with ADLs and was coded for type 2 diabetes with diabetic peripheral angiopathy without gangrene (narrowing of arteries in the legs due to diabetes but without tissue death). Record review of Resident #1's NURSING: Baseline Care Plan assessment admission date 09/18/2025 revealed #18 was not check marked for Resident has Diabetes Mellitus. Record review of Resident #1's Care Plan Report date initiated 09/18/2025 revealed it did not include a care plan for diabetes mellitus. During an interview on 12/19/2025 at 3:37PM the MDS Coordinator stated while she reviewed the baseline care plan assessment, box number 18 was not checked marked. The MDS Coordinator stated number 18 was entitled resident has diabetes mellitus. The MDS Coordinator stated if Resident #1 had diabetes mellitus the baseline care plan would be reflective of the admitting diagnosis. The MDS Coordinator stated Resident #1 was admitted to the facility on [DATE] for respite care and discharged on 09/22/2025. The MDS Coordinator stated LVN A failed to check mark number 18 by mistake. The MDS Coordinator stated there was no negative outcome due to Resident #1's baseline care plan lacking his admitting diagnosis of diabetes mellitus. The MDS Coordinator stated while she reviewed Resident #1's baseline care line, Resident #1's diagnosis of diabetes mellitus should have been within his baseline care plan. The MDS Coordinator stated baseline care plans are important because they outline the individualized plan of care, but reiterated there was no negative outcome from the missed baseline care assessment of diabetes mellitus for Resident #1. The MDS Coordinator stated the usual procedure for admission/readmissions begins when the admitting nurse facilitates the admission baseline care plan assessment, which will then be reviewed by the RN which used to be the previous DON. The MDS Coordinator stated that going forward she will be more diligent while reviewing baseline care plans as well as comprehensive care plans. During an interview on 12/20/2025 at 10:32AM LVN A stated Resident #1 was admitted on [DATE] for a 5-day respite stay. LVN A stated she was Resident #1's admitting nurse and recalled Resident #1 had diabetes mellitus. LVN A stated while reviewing Resident #1's baseline care plan assessment, dated 09/18/2025, she had forgotten to click the resident has diabetes mellitus box, and since she did not check mark the box on the admission assessment, the baseline care plan did not populate interventions/care plan for diabetes mellitus. LVN A stated Resident #1 never suffered any negative outcomes due to the missed diabetes mellitus diagnosis on the baseline care plan. LVN A stated she recalled Resident #1 received oral antidiabetic medication. LVN A stated she followed Resident #1's physician orders, and completed glucose monitoring, and oral antidiabetic medication administration. LVN A stated the procedure for facilitating a baseline care plan commences when the admission nurse populates a care plan assessment. Once the care plan assessment was completed, an RN would review the assessment and sign off that the assessment was accurate and addresses the admitting diagnoses. Once the RN signed off, a baseline care plan would then be populated within Resident #1's electronic health record. LVN A stated lastly, the MDS Coordinator would review the baseline care plan as a third review. LVN A stated she accidentally missed clicking the resident has diabetes mellitus box. LVN A stated she should have clicked that specific box, but did not, and therefore affected the accuracy of Resident #1's baseline care plan. However, LVN A stated there were no negative outcomes for the missed check mark. LVN A stated baseline care plans are important as they reflect the individualized plan of care for Resident #1. LVN A stated going forward she will be more diligent in clicking the admission assessment boxes to ensure the baseline care plans are accurate. During an interview on 12/20/2025 at 11:34AM the Interim DON stated she became the interim DON in November 2025 and could not speak to the actions of the previous DON. The interim DON stated that going forward all admissions/readmissions would thoroughly be reviewed during the daily morning meetings, as well as being reviewed by not only herself but also the MDS Coordinator to ensure accuracy. Additionally, the facility would facilitate an impromptu in-service regarding care plan assessments, and baseline care plans. The interim DON stated while she reviewed Resident #1's electronic health care record as well as through her staff interviews, Resident #1 had no negative outcome due to the mistake of LVN A. The interim DON stated a diagnosis of diabetes mellitus would be within a baseline care plan. The interim DON stated baseline care plans were important, as they were individualized plans of care of what the facility was doing to mitigate any potential exacerbation of disease processes. Attempted to phone interview with the previous DON on 12/19/2025 at 4:58PM, 12/20/20/2025 at 10:30AM, 11:46AM but they did not return call by the exit conference. Record review of the facility's Area of focus: Care Planning-Baseline, Comprehensive , and routine updates Baseline care plan issued: 01/04/2022 and reviewed: 12/04/2025 revealed, Baseline care plan: Completion and implementation of the baseline care plan within 48 hours of the resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard again adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for accuracy and completeness of clinical records.The facility failed to accurately document oxygen use by Resident #1 nine times during the month of August 2025 in the MAR. This failure could result in residents' records not accurately reflecting the residents' status or condition.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed the focus [Resident #1] has occasional episodes of SOB [related to] COPD initiated on 03/09/25 and revised on 07/04/25. Interventions listed for the focus included .oxygen at 2 liters via nasal cannula when necessary initiated on 4/25/25 and revised on 05/09/25. Record review of Resident #1's order summary revealed Resident #1 had an order for Oxygen at 2 liters/minute via nasal cannula as needed for shortness of breath initiated on 05/09/25 and discontinued on 08/20/25. Record review of Resident #1's MAR revealed Resident #1 was never administered 2 liters/minute of oxygen via nasal cannula in the month of August 2025. Record review of Resident #1's oxygen saturation log revealed Resident #1 received oxygen via nasal cannula when her oxygen saturation was measured on 08/07/25, 08/08/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25, and 08/18/25. In an interview with the ADON at 10:21 AM on 10/01/25, the ADON stated Resident #1 would occasionally use oxygen, but Resident #1 had a habit of removing it herself. The ADON stated she was not sure about specific days that Resident #1 used oxygen, except for 08/14/25, in which she was certain Resident #1 received oxygen via nasal cannula on that day because she helped the floor nurse treat Resident #1 with oxygen. The ADON stated it was important to sign the MAR anytime medication was administered to a resident to track and trend medication usage and possibly adjust therapies. In an interview with the DON at 10:40 AM on 10/01/25, the DON stated Resident #1 would mostly use oxygen in the evenings. The DON stated she knew Resident #1 used her oxygen more after a shortness of breath incident on 08/14/25. The DON stated it was her and the ADON's responsibility to train staff on proper documentation. The DON stated it was important to sign the MAR after medication was administered to ensure medication was not given twice and to have an accurate record to look back on and make medication changes. Record review of the facility policy General Dose Preparation and Medication Administration written on 12/01/07 and revised on 11/15/24 revealed the following policy: .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following:6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms.

Based on interview and record review, the facility failed to ensure residents participated in the care planning process with the resident and the resident's representative for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans in that: The facility failed to ensure care plan meetings were held with Resident #1 and/or the resident's representative. This failure could place residents at risk of not being involved in developing the plan for the care they will receive.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed it had been developed with interventions made in the care plan throughout her stay at the facility. The care plan did not address how often a care plan meeting should be held. Record review of the most recent care plan meeting attendance sheet dated 03/06/25 revealed Resident #1's representative was in attendance via phone call. In an interview with the RP for Resident #1 at 2:18 PM on 09/30/25, the RP stated the last time she was involved in a care plan meeting with the facility was in March of 2025. The RP stated she had not been notified about any other care plan meetings after the meeting in March of 2025. In an interview with the SW at 11:22 AM on 10/01/25, the SW stated he started working at the facility on 07/16/25. The SW stated he had not had a care plan meeting with Resident #1 or her representative since he had worked at the facility. The SW stated care plan meetings should be held at least quarterly, and possibly more often depending on the needs of the residents. The SW stated he tried to sync up their quarterly care plan meetings with comprehensive assessments. The SW stated he scheduled the care plan meetings. The SW stated it was important to invite the resident and resident representative to the care plan meetings to ensure everyone was on the same page regarding the resident's care. In an interview with the ADM at 11:43 AM on 10/01/25, the ADM stated the last care plan meeting for Resident #1 the facility had evidence for was held was on 03/06/25. The ADM stated there had not been any major changes in the care of Resident #1 since the last care plan meeting. The ADM stated the SW was responsible for scheduling care plan meetings. The ADM stated it was important to involve the resident and resident representative in the care planning process so everyone could share their opinion and be on the same page regarding care. Record review of the facility policy Comprehensive Care Plans and Conferences written on 01/26/23 and revised on 08/29/25 revealed the following policy: .2. The IDT must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative, if applicable.4. The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation.7. The resident's care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified immediately when her oxygen saturation fell to 82% on 08/14/2025. This failure could place residents at risk of their representative being unaware of their change in condition.The findings included:Record review of Resident #1's face sheet dated 10/01/25 revealed a [AGE] year-old female with an admission date of 08/31/23 and a discharge date of 08/18/25. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (ongoing inflammation and narrowing of the airways, making it difficult to breathe) and Alzheimer's Disease (progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's comprehensive care plan dated 08/18/25 revealed the focus [Resident #1] has occasional episodes of SOB [related to] COPD initiated on 03/09/25 and revised on 07/04/25. Interventions listed for the focus included .oxygen at 2 liters via nasal cannula when necessary initiated on 4/25/25 and revised on 05/09/25. Record review of Resident #1's order summary revealed Resident #1 had an order for Oxygen at 2 liters/minute via nasal cannula as needed for shortness of breath initiated on 05/09/25 and discontinued on 08/20/25.Record review of Resident #1's oxygen saturation log revealed Resident #1 received oxygen via nasal cannula when her oxygen saturation was measured at 82% on 08/14/25. Record review of the change in condition evaluation completed by ADON dated 08/14/25 revealed Resident #1 experienced abnormal vital signs, decreased food and/or fluid intake, and functional decline on the morning of 08/14/25. Further review revealed Resident #1 experienced a sudden decreased level of consciousness along with a low-grade fever of 99.1 degrees Fahrenheit. Further review revealed Resident #1 had SOB, non-productive cough, abnormal lung sounds, and common cold symptoms. Further review revealed the ADON documented the physician was notified on 08/14/25 and the RP was notified on 08/21/25. In an interview with the RP at 2:18 PM on 09/30/25, the RP stated she was not notified of the change in condition for Resident #1 on 08/14/25. The RP stated she found about the change of condition when she requested Resident #1's medical records after she was discharged on 08/18/25. In an interview with the ADON at 4:04 PM on 09/30/25, the ADON stated she filled out the change in condition evaluation for Resident #1 on 08/14/25. The ADON stated she noticed Resident #1 had coughing, SOB, had not gotten out of bed, and generally did not look well. The ADON stated she was pretty sure she called the RP but could not specifically remember doing it. The ADON stated she thought she might have accidentally checked the wrong date on the evaluation for when she notified the RP. The ADON stated after a change in condition the RP should be notified right afterwards because it was important to keep them updated on the residents' status in case they had any relevant information. In an interview with the DON at 5:03 PM on 09/30/25, the DON stated she did not know why the change of condition form for Resident #1 stated the RP was notified a week after the change in condition occurred. The DON stated the date and time the RP was notified should be entered after the RP was contacted. The DON stated the RP should have been notified right away once the resident was stabilized after a change of condition so they may ask questions, come visit, or request medical treatments. Record review of the facility policy Changes in Resident's Condition or Status dated 11/26/18 and reviewed 08/29/25 revealed the following policy:.(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - .(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment);

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #1, #2, and #3), reviewed for pharmaceutical services, in that: 1. LVN A failed to administer Resident #1's Morphine at his scheduled time on 10/09/25.2. LVN A failed to administer Resident #3's Tramadol at her scheduled time on 10/09/25.3. LVN B administered Resident #2's Tramadol without an order in place.The findings included: 1. Record review of Resident #1's face sheet, dated 10/10/25, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses that included: other chronic pain (pain that last more than 3 months), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in blood vessels), secondary osteoarthritis (joint degeneration caused by another medical condition), right ankle and foot, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left dominant side. Record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #1's care plan, with an initiation date of 06/17/24 had a focus that stated Resident #1 was on pain medication therapy related to chronic pain with an initiation date of 03/08/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 03/08/25. Record review of Resident #1's active physician's orders, retrieved on 10/10/25, revealed an order for Morphine Sulfate ER Tablet Extended Release 15mg with a start date of 10/02/25 and an indefinite end date stated it was to be administered two times a day, at 9:00 am and 5:00 pm. Record review of Resident #1's narcotic sheet revealed LVN A had signed that she administered Resident #1's morphine at 7:57 pm on 10/09/25. During an interview with Resident #1 on 10/09/25 at around 8:05 pm, he stated he had just gotten his morphine not too long ago. He stated he did not have any pain between 5:00 pm and the time of interview. Resident #1 stated he had a meeting after dinner, but stated he had not asked to hold his medication. During an interview with LVN A on 10/09/25 at 8:28 pm, she stated Resident #1 had morphine scheduled at 5:00 pm, and stated she administered it at 7:57 pm. LVN A stated she did not know Resident #1 had morphine scheduled at 5:00 pm and stated it was not given on time because she was busy and stated it was her first time doing med pass and she did not know there were so many scheduled narcotics. LVN A also stated Resident #1 had a lot of family in his room and they were having a meeting and she did not want to interrupt. LVN A stated Resident #1 never complained of pain from the time his morphine was scheduled at 5:00 pm to the time it was administered at 7:57 pm. LVN A stated it was important to provide medication at the time it was scheduled so that residents' pain would not get out of control. LVN A stated she had been trained over medication administration and following physician orders when she was hired in September of 2025. LVN A stated the facility policy for medication administration stated medications were due at the time they were ordered. LVN A stated she did not follow the facility policy. LVN A stated not administering medication such as morphine on time could negatively impact residents because they could have pain. During an interview with the DON on 10/10/25 at 6:48 pm, she stated Resident #1 had orders for Morphine 2 times a day, once at 9:00am and 5:00pm. The DON stated Resident #1 received his morphine late on 10/09/25 at 7:57pm. The DON stated LVN A was responsible for administering the medication to Resident #1 at the time it was late and stated it was late because Resident #1 had stuff going on with a family member trying to get power of attorney. The DON stated Resident #1 did not have any negative outcome due to receiving his medication late and did not verbalize any pain to her. The DON stated it was important that residents got their medications for the continuity of care and stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they were comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated as per their facility policy medication had to be given in a timely manner, and stated they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, and did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw or start having behaviors and yelling out, or they could get anxiety. 2. Record review of Resident #3's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: pain in left shoulder, type 2 diabetes (high blood sugar) without complications, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left non-dominant side, vascular dementia (changes in memory, thinking and behavior caused by impaired supply of blood to the brain), severe with agitation and psychotic disturbance. Record review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #3's care plan, with an initiation date of 03/25/25 had a focus that stated Resident #3 was on as needed pain medication therapy related to limited mobility, terminal prognosis, and occasional complaint of pain with a created date of 04/02/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/02/25. Record review of Resident #3's active physician's orders, retrieved on 10/10/25, revealed an order started on 06/23/25 for tramadol 50mg to be administered 2 times a day at 9:00 am and 5:00 pm. Record review of Resident #3's narcotic sheet revealed LVN A had signed that she administered Resident #3's tramadol at 8:00 pm on 10/09/25. LVN A was attempted to be reached for interview via telephone on 10/10/25 at 4:56 pm, 4:57 pm, 5:16 pm, 5:19 pm and 5:53 pm with no calls successfully answered or returned. During an interview with Resident #3 on 10/10/25 at 5:45 pm, she required re-direction to questions and stated she had no pain yesterday and she was good. Resident #3 was unable to answer any other questions coherently. During an interview with the DON on 10/10/25 at 6:48 pm, she stated she did not know Resident #3's scheduled time to receive her tramadol, but knew it was 2 times a day. The DON stated Resident #3 received her tramadol on 10/09/25 at 8:00 pm. The DON stated she was not in front of Resident #3 from their scheduled time of 5:00 pm until she received her medication at 8:00 pm, and could not tell me if she was in any pain. The DON stated LVN A was responsible for administering the medication to Resident #3 on 10/09/25. The DON stated it was late because they did not have a med aide and LVN A was the one passing the medication. The DON stated Resident #3 did not have any negative outcome due to receiving her medication late. The DON stated it was important that residents got their medications for the continuity of care. She stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they are comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated, as per their facility policy, medication had to be given in a timely manner, and they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, but did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw, start having behaviors and yelling out, or they could get anxiety. 3. Record review of Resident #2's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: heart failure (when the heart muscle does not pump blood as well as it should), chronic kidney disease, stage 5 (when kidneys have almost completely stopped filter waste from the blood), orthostatic hypotension (sudden drop in blood pressure when going to a standing position from sitting or lying), type 1 diabetes with neuropathic arthropathy (nerve and joint damage from long term diabetes) Record review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #2's care plan, with an initiation date of 07/18/24 had a focus that stated Resident #2 was on pain medication therapy with a created date of 04/27/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/27/25. Record review of Resident #2's active physician's orders, retrieved on 10/10/25, revealed Resident #2 did not have an order for tramadol on 09/20/25. Resident #2's tramadol order was started on 09/22/25.Record review of Resident #2's narcotic sheet revealed LVN B had signed that he administered Resident #2 with tramadol on 09/20/25 at 2:00 pm. During an interview with LVN B on 10/10/25 at 3:06 pm, LVN B confirmed that he provided Resident #2 with tramadol on 09/20/25. LVN B stated Resident #2 had an order for tramadol for a long time, and she had gone to the hospital, and when she came back, the order was not put back in. LVN B stated Resident #2 asked for a tramadol and he administered it because he thought she still had the order, and after he administered it, he saw she did not have an order for tramadol. LVN B stated before administering medication, he should review the residents' charts to ensure they had orders for the medication. LVN B stated he did not review Resident #2's orders prior to providing her with tramadol. LVN B stated he should have reached out to the physician to request an order, but , he did not get a chance to. LVN B stated he should not have provided Resident #2 with the tramadol if she did not have an order. LVN B stated he had been trained over mediation administration and ensuring residents had orders in place prior to providing medication. LVN B stated he was trained about a month prior by the DON. LVN B stated the facility policy stated they could not administer a medication without an order. LVN B stated he did not follow the facility policy. LVN B stated administering medications without orders in place could cause an accidental overdose. LVN B stated Resident#2 had no negative impacts due to being administered tramadol. During an interview with Resident #2 on 10/10/25 at 4:00 pm, she stated she recalled getting tramadol on 09/20/25 after she requested it from LVN B. Resident #2 stated she did not have any negative side effects by receiving tramadol. During an interview with the DON on 10/10/25 at 5:45 pm, she stated she did not have any directly related in-services or trainings prior to the identified failures. During an interview with the DON on 10/10/25 at 6:48 pm, she stated staff should review residents charts to ensure they had orders for medication and stated the order should match the blister pack and the narcotic sheet. The DON confirmed that LVN B administered tramadol to Resident #2 on 09/20/25 at 2:00pm. The DON stated Resident #2 had gone to the hospital and when she came back the medication list they provided did not include the tramadol. The DON stated Resident #2 got orders for tramadol on 09/22/25. The DON stated she did not know if LVN B was aware the Resident #2 did not have orders for tramadol on 09/20/25 and did not know if he reviewed her orders before administering tramadol. The DON stated she was not aware of LVN B reaching out the physician to request an order for tramadol before providing it but stated LVN B should have done that. The DON stated LVN B should not have administered tramadol without an order. The DON stated when LVN B had orientation in July of 2025 he was trained over medication administration and ensuring residents had orders prior to administering medication. The DON stated, per their facility policy, medication could not be administered without an order. The DON stated LVN B did not follow this policy. The DON stated administrating medication without an order could negatively impact residents because it could be contraindicated. The DON stated Resident #3 did not have any negative outcome due to being administered tramadol on 09/20/25. Record review of an in-service completed 10/09/25 covering Administering of Medications revealed that LVN A had received the training. Record review of the facility's policy titled, Administration of Medications with a reviewed date of 09/09/25 revealed, 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication administration.e. Right Time and Frequency. Check the order for when it would be given and when was the last time it was given.3. A physician order that includes dosage, route, frequency, duration, and other required consideration including the purpose, diagnoses or indication for use is required for administration of medication.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 3 residents (Resident #1, #2 and #3) reviewed for medical records accuracy, in that: 1. Facility staff failed to document Resident #1's administered tramadol on his medication administration record in September 2025 and October 2025. 2. Facility staff failed to document Resident #2's administered tramadol on her medication administration record in September 2025 and her administered morphine in October 2025. 3. Facility staff failed to document Resident #3's administered Morphine on her medication administration record in October 2025. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care, treatment and medication administration.The findings included: 1.Record review of Resident #1's face sheet, dated 10/10/25, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses that included: other chronic pain (pain that last more than 3 months), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in blood vessels), secondary osteoarthritis (joint degeneration caused by another medical condition), right ankle and foot, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left dominant side. Record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #1's care plan, with an initiation date of 06/17/24 had a focus that stated Resident #1 was on pain medication therapy related to chronic pain with an initiation date of 03/08/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 03/08/25. Record review of Resident #1's order summary report revealed an order for tramadol oral tablet 50 MG every 12 hours as needed for pain with a start date of 06/18/25 and discontinue date of 10/01/25. Record review of Resident #1's order summary report revealed an order for tramadol oral tablet 50 MG every 6 hours as needed for pain with a start date of 10/01/25 and a current order status of active as of 10/10/25. Record review of Resident #1's narcotic sheet revealed LVN C had signed that she administered Resident #1 with his ordered tramadol on 09/24/25 at 10:10am. Record review of Resident #1's narcotic sheet revealed LVN B had signed that he administered Resident #1 with his ordered tramadol on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. Record review of Resident #1's order for tramadol on his September 2025 and October 2025 MAR revealed staff did not sign off that his medication was administered on 09/24/25 at 10:10am and 9:00pm and 10/05/25 at 8:00am and 8:00pm. During an interview with LVN C on 10/10/25 at 2:10 pm, she confirmed that she provided Resident #1 with his tramadol on 09/24/25 at 10:10 am. LVN C reviewed Residents #1's September MAR and stated it was blank, and it meant it was not signed as administered. LVN C stated she was responsible for documenting the administration of the medication. LVN C stated she did not recall why she did not document the medication was administered on Resident #1's MAR. LVN C stated the administration of Resident #1's medication should have been documented on his MAR and stated it was important to do for resident safety and because some physicians will look at the MAR and not the narcotic sheet and may discontinue a medication if they see It was not being given. LVN C stated she had been trained over medication administration and documentation and stated she was last trained on 10/09/25. LVN C stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN C stated she had not followed the facility policy. LVN C stated not documenting the administration of medication on the MAR could impact residents safety. During an interview with LVN B on 10/10/25 at 3:06pm, he confirmed that he provided Resident #1 with his tramadol on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. LVN B reviewed Residents #1's September and October MAR and stated he had not documented on the MAR. LVN B stated he was responsible for documenting the administration of the medication. LVN B stated he was planning to go back and document but he forgot. LVN B stated the administration of Resident #1's medication should have been documented on his MAR, and it was important to do so to ensure someone was not over medicated and make sure it was being monitored correctly. LVN B stated he had been trained over medication administration and documentation, and he was last trained by the DON a week or 2 prior. LVN B stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN B stated he had not followed the facility policy. LVN B stated not documenting the administration of medication on the MAR could negatively impact residents by medication accidently being given again or the physician may not know what's being administered and if something were to occur with the residents they may not respond appropriately. During an interview with the DON on 10/10/25 at 6:48pm, she stated LVN C administered Resident #1 with tramadol on 09/24/25 at 10:10am and LVN B provided it on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. The DON stated both staff members were responsible for documenting the administration of those medications. The DON stated she had already reviewed the MAR and confirmed those dates were not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet and then get distracted and would forget to sign the MAR. The DON stated staff should document on the MAR and stated it was important to ensure they were not double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics, they had to be documented in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. 1. 2.Record review of Resident #2's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: heart failure (when the heart muscle does not pump blood as well as it should), chronic kidney disease, stage 5 (when kidneys have almost completely stopped filter waste from the blood), orthostatic hypotension (sudden drop in blood pressure when going to a standing position from sitting or lying), type 1 diabetes with neuropathic arthropathy (nerve and joint damage from long term diabetes) Record review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #2's care plan, with an initiation date of 07/18/24 had a focus that stated Resident #2 was on pain medication therapy with a created date of 04/27/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/27/25. Record review of Resident #2's physician's orders, retrieved on 10/10/25, revealed Resident #2 had an order for tramadol oral tablet 50MG to be administered every 8 hours as needed for pain with a start dated of 09/22/25 and an indefinite end date.Record review of Resident #2's physician's orders, retrieved on 10/10/25, revealed Resident #2 had an order for morphine sulfate extended release tablet 15MG wit directions to administer .5 tablet every 8 hours as needed for pain with a start dated of 09/23/25 and an indefinite end date.Record review of Resident #2's narcotic sheet revealed LVN D had signed that he administered Resident #2 with tramadol on 09/22/25 at 11:15AM. Record review of Resident #2's narcotic sheet revealed LVN C had signed that she administered Resident #2 with morphine on 10/06/25 at 12:00pm. Record review of Resident #2's narcotic sheet revealed LVN D had signed that he administered Resident #2 with morphine on 10/07/25 at 11:15am. Record review of Resident #2's order for tramadol on her September 2025 MAR revealed staff did not sign off that her medication was administered on 09/22/25 at 11:15am.Record review of Resident #2's order for morphine on her October 2025 MAR revealed staff did not sign off that her medication was administered on 10/06/25 at 12:00PM and 10/07/25 at 11:15am. During an interview with LVN C on 10/10/25 at 2:10pm, she confirmed that she provided Resident #2 with her morphine on 10/06/25 at 12:00pm. LVN C reviewed Residents #2's October 2025 MAR, and stated it was blank and stated it meant it was not signed as administered. LVN C stated she was responsible for documenting the administration of the medication. LVN C stated she recalled having Resident #2's MAR open, clicking it, signing the narcotic book, and then administering the medication. LVN C stated she thought she got busy assisting Resident #2 with getting up and when she returned to click save on the MAR, it was already gone and she did not remember to sign it. LVN C stated the administration of Resident #2's medication should have been documented on her MAR, and it was important to that do for resident safety and because some physicians would look at the MAR and not the narcotic sheet and may discontinue a medication if they see it was not being given. LVN C stated she had been trained over medication administration and documentation. LVN C stated she was last trained on 10/09/25. LVN C stated the facility policy stated they were to document medication provided on both the narcotic sheet and the MAR. LVN C stated she had not followed the facility policy. LVN C stated not documenting the administration of medication on the MAR could impact residents safety. During an interview with LVN D on 10/10/25 at 1:45pm he confirmed that he provided Resident #2 with her tramadol on 09/22/25 at 11:15am and her morphing on 10/07/25 at 11:15am. LVN D reviewed Residents #2's September and October 2025 MAR and stated they were both blank and stated it meant he had not signed the MAR that the medications were administered. LVN D stated he was responsible for documenting the administration of the medication. LVN D stated he did not document on the MAR because he was just busy but did state the administration of Resident #2's medication should have been documented on her MAR and stated it was important to do so they could be accountable for the narcotics and to see how residents were doing and to do an evaluation. LVN D stated he had been trained over medication administration and documentation and stated he knew better. LVN D stated the facility policy stated they had to sign off on the MAR. LVN D stated he thought he had followed his facility policy. LVN D stated not documenting administered medication on the MAR could negatively impact residents because you couldn't prove that a resident got it and there would be no documentation when the physician reviewed the MAR and if they saw that someone's not taking the medication and they may discontinue it. During an interview with the DON on 10/10/25 at 6:48pm she stated LVN C administered Resident #1 with tramadol on 09/24/25 at 10:10am and LVN B provided it on 09/24/25 at 9:00pm and on 10/05/25 at 8:00am and 8:00pm. The DON stated both staff members was responsible for documenting the administration of those medications. The DON stated she had already reviewed the MAR and confirmed those dates were not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet and then get distracted and would forget to sign the MAR. The DON stated the MAR should be documented on and stated it was important to ensure they were double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics they had to be documented for in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. 3.Record review of Resident #3's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: pain in left shoulder, type 2 diabetes (high blood sugar) without complications, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left non-dominant side, vascular dementia (changes in memory, thinking and behavior caused by impaired supply of blood to the brain), severe with agitation and psychotic disturbance. Record review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #3's care plan, with an initiation date of 03/25/25 had a focus that stated Resident #3 was on as needed pain medication therapy related to limited mobility, terminal prognosis, and occasional complaint of pain with a created date of 04/02/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/02/25. Record review of Resident #3's physician's orders, retrieved on 10/10/25, revealed an order started on 04/15/25 for morphine sulfate oral solution 10MG/5ML for 1ML to be provide every hours for her pain and with no end date. Record review of Resident #3's narcotic sheet revealed SDC had signed that she administered Resident #3 her morphine on `10/03/25t at 8:00AM. During an interview with the SDC on 10/10/25 at 2:38pm she confirmed she provided Resident #3 with her morphine on 10/03/25 at 8:00am. SDC stated she had already reviewed Resident #3's October MAR and stated it was blank and was not signed as administered and stated it looked as if Resident #3 had not received the medication but SDC stated she did. The SDC stated she probably did not document it on the MAR because she was probably busy. The SDC stated she was responsible for documenting medication administration on the MAR and stated she should have documented on the MAR and stated it was important to document on the MAR because the physician might not see a medication being administered and could discontinue it and because the following nurse would not know the last time something was given and might end up giving it again too soon. The SDC stated she had been trained over medication administration and documentation about 2 months prior by LVN C. The SDC stated the facility policy stated the narcotic sheet needed to match their MAR and stated they had to document their medication administration on both the narcotic sheet and resident's MAR. The SDC stated she did not follow the facility policy. The SDC stated not documenting medication administration on the MAR could negatively impact residents by giving them too much medication or the physician may see that it was not being given and discontinue the medication. During an interview with the DON on 10/10/25 at 5:45pm, she stated she did not have any directly related in services or trainings prior to identified failures. During an interview with the DON on 10/10/25 at 6:48pm, she stated the SDC administered Resident #3 with morphine on 10/03/25 at 8:00am. The DON stated the SDC was responsible for documenting the administration of medication. The DON stated she had already reviewed the MAR and confirmed that date was not documented for in the MAR. The DON stated she thought the staff would sign the narcotic sheet, and then get distracted and would forget to sign the MAR. The DON stated the MAR should be documented on, and it was important to ensure they were not double dosing or giving an inaccurate dose and for the continuity of care. The DON stated staff had been trained over medication administration and documentation during their orientation and annually. The DON stated the facility policy stated when administering narcotics, they had to be documented for in 2 places, the narcotic sheet and the MAR. The DON stated staff had not followed the facility policy in this situation. The DON stated not documenting medication administration in the MAR could negatively impact residents by not controlling their pain or side effects. Record review of Inservice completed 10/09/25 covering Administering of Medications revealed that LVN C had received the training. Record review of the facility's policy titled, Administration of Medications with a reviewed date of 09/09/25 stated, 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication administration.F. Right documentation. Make sure to write the time and any remarks on the chart correctly. Medication administration should be documented timely following the administration to the resident. Controlled substances should be signed out from the descending count sheet and documented on the MAR for each routine and PRN dose of medication administered.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition room for storage, preparation, and sanitation.1.The facility failed to ensure dinnerware was cleaned and dried properly.2.The facility failed to ensure the pots, pans, and utensils used to cook and prepare food were in good working condition. 3.The facility failed to ensure items in the refrigerator and freezer were labeled, dated, and sealed properly.4.The facility failed to ensure items in the refrigerator and freezer were not expired.5.The facility failed to ensure boxes in the freezer were not stacked to the ceiling.6.The facility failed to ensure the steam table wells were clean.These failures could place residents at risk for food contamination and foodborne illness.Findings were:Observation and initial tour of the kitchen on 08/04/25 at 10:05 am revealed 24 of 31 clear plastic drinking glasses that had a thick removable whitish substance on the inside bottoms and sides and were wet inside on the clean rack. The trays had no drainage mats under the glasses. There were approximately a hundred plastic plate covers on clean racks that had a removable whitish substance on the tops where the hand holds were, the sides, and around the inner edge where the plastic cover rested on the plates. There were 2 non-stick type pans with flaking coating in the bottoms and sides and were hanging on the clean rack. One of them was badly dented. There were 2 large cooking pots that were badly pitted around the bottoms of the insides. The pits were dark brown/black. There was a dirty metal spatula, a dented and bent metal pastry scraper, and a plastic spatula with chips around the edges in a clean bin. There were multiple trays of glasses with different beverages in them and several pitchers filled with brown liquid in the refrigerator. The trays and pitchers were unlabeled and undated in the refrigerator. There were 6, 4-ounce containers of apple juice in a pan dated 06/01-06/07 in the refrigerator. There was a 20-pound box of frozen hash browns, a large box of frozen breaded yellow squash, and a large box of sweet corn on the cob that were not tightly sealed and opened to the air in the freezer. The hash browns were covered with ice crystals. There was a 1-gallon zip type bag of what appeared to be shredded cheese that was opened to the air and a 1-gallon zip type bag of what appeared to be cheese slices opened to the air in the walk-in freezer. There was a large accumulation of ice hanging from the ceiling onto a large box of an unknown product. Boxes in the walk-in freezer were stacked to the ceiling. 4 of 4 steam table wells had a flaking, yellow/white substance on the bottoms, sides, and floating in them. Observation during a return visit to the kitchen on 08/06/25 at 1:30 pm revealed the same boxes in the freezer were stacked to the ceiling.In an interview with the DM on 08/04/25 at 10:27 am, she said she did not know what the removable white substance was inside the drinking glasses, or the plastic plate covers. She said the glasses should have drying mats under them to drain properly. She said the plastic plate covers were in use. She said if the residents touched the cover to remove it from the plate, it could cause cross contamination as well as the edges of the plates where the cover rested on them. She said the non-stick type pans on the dry rack were only used for making grilled cheese sandwiches. She said kitchen staff used metal utensils in the non-stick type pans and had not been trained on using non-metal utensils in non-stick type pans. She said the flaking coating in the pans could get into the food and possibly make the residents sick. She said she guessed the large cooking pots were pitted inside. She said she did not know why there were brown/black substances in the pits. She said, If it was food in the pits, I guess it could get in the food. She said cross contamination could occur and make residents sick. She said the metal spatula was in a clean bin and did not look clean. The DM said the dented and bent metal pastry scraper did not look safe to use because the metal was sharp and could cut someone. She said it should have been thrown away. She said the plastic spatula with chips around the edges should have been thrown away because the plastic was coming off, could get in the food and make residents sick. She said she was unaware of labeling and dating food and beverages on trays in the refrigerator and freezer when the products were going to be used that day. She said they did not always use all the products on the trays the same day. She said there was a box of the containers of apple juice in the freezer and the 6, 4-ounce individual containers of apple juice were thawing in the refrigerator. She said the box use by date was 14 days after thawing (verified). She said the containers of apple juice in the refrigerator were past their use by date. She said the expired apple juice could have made residents sick. She said she was unaware bagged frozen food inside boxes had to be tightly sealed after opening. She said nothing about the open zip-type 1-gallon bags of cheese. She said the ice build-up in the walk-in freezer had been there for a year. She said repairs for the kitchen were reported in the daily morning meetings. She said repairs for the freezer were on-going. She said the freezer had been repaired multiple times addressing the ice accumulation. She said she was unaware boxes could not be stacked to the ceiling and asked the state surveyor how far they had to be. She said she did not know how often the steam table wells were being cleaned. She said she provided routine training of kitchen staff. She said she was ultimately responsible for the kitchen. She said she let the registered dietician know the state surveyor was at the facility and would let her know she was requested for an interview. The registered dietician did not come to the facility and was unavailable for interview.In an interview with the ADM on 08/04/25 at 2:00 pm, she said the freezer was assessed by the company repairmen and it needed to be replaced. She said the main problem was finding a new freezer that fit in the same place as the current one. The ADM provided invoices for the walk-in freezer repairs.Record review of kitchen in-services, dated 06/27/25, reflected cooling and storing potentially hazardous hot foods, 07/22/25-mechanically altered & puree preparation, holding and guidelines, 08/04/25-importance of dating of food, 05/12/25-updated use-by date guide, 04/09/25-proper gloves, 04/11/25-importance of watching out for likes and dislikes on tray cards, seasoning of foods, 03/13/25-Snacks. Record review of the facility's expenditure request for the walk-in freezer repairs, dated 11/05/24 reflected air ducts leaking above walk in freezer creating a cone of water inside the freezer, icicles on sprinkler head, and slippery floor. The request was approved on 11/06/24.Record review of invoices for freezer repairs dated: 08/27/24 reflected on 07/23/24 the freezer was assessed for not keeping temp and needed verification of operation for state inspection. The exterior thermometer is reading inaccurately .The door gasket is sealing but recommend replacement as soon as possible. As of now unit is operating fully. 08/27/24 Returned to location, removed and replaced the door gasket, verified proper seal.Unit is in service. 09/13/24 reflected on 09/10/24 the freezer was assessed for leaking water inside. Drain pan was frozen solid.melted the ice. The freezer has a drain heater, but drainpipe is PVC not copper. This is freezer with plates holding the ceiling together.unit is back in service. 09/11/24 assessed for not running and found blown fuses at the condenser.Removed and replaced two fuses at the condenser and evaporator switch. 09/13/24 assessed for spark coming from around the fan.removed fan and found a wire practically cut in half, needed to replace the motor.unit is back in service.05/23/25 reflected on 05/22/25 the freezer was assessed for not reaching temp. Evaporator was frozen up.noticed walk-in in very poor condition and all ceiling panels are warped. Also found ceiling has holes that constantly drip water. Ice build-up on evaporator more likely due to condition of box. 05/23/25 freezer assessed for not keeping temp again.evaporator frozen over again.failed low pressure control not releasing.which kept defrost heaters from engaging.replaced worn parts and verified operations. Unit is back in service.07/07/25 reflected the freezer was assessed for not keeping temp.failed condenser fan motor.was replaced.verified operation. Unit is cooling at full capacity.Record review of the facility's undated kitchen policy titled, Use by Date Guide reflected: The following guide can be used to determine a use by date for labeling food (opened or unopened) that should be used within a certain time frame.this information is used when there are no guidelines on the containers of food.When counting, begin with the current date and use a calendar when determining the actual use by date. For example, on Dec. 18th, a can of applesauce was opened, the use by date is 7 days, therefore the date placed on the label will be Dec. 24th.guidelines for storing leftovers are 3 days (72 hours). Item/Category-Cheese, Processed, opened-Use By 30 days-store in enclosed container after opening. Cheese, Shredded, Cheddar, opened-Use By 14 days- store in enclosed container after opening. Leftover food-meat, cooked vegetables-use by 3 days. Record review of the facility's kitchen policy, revised 04/30/25, titled Safe Food Handling, revealed under Policy: All food purchased, stored, and distributed is handled with accepted food-handling practices, and per federal, state, and local requirements. Under Definitions: Cross-contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces.or utensils which are not cleaned.Under Food Contamination-means the unintended presence of potentially harmful substances, including, but not limited to, microorganisms, chemicals, or physical objects in food. Under Procedure 7. All cooking utensils, pans, dinnerware will be stored dry. All plastic ware that cannot be sanitized, is chipped and/or has lost its glaze will be discarded. All chipped and/or cracked dinnerware and glassware will be discarded.Record review of the facility's kitchen policy reviewed 05/01/25, titled, Prevention of Cross Contamination reflected under Policy: All Food and Nutrition Services associates are trained in infection control techniques to prevent the contamination of food and the spread of infection to ensure that food is stored, prepared, distributed and served in accordance with professional standards for food safety, and per federal, state, and local requirements. Under Procedure: 1.Categories of infection control training will include a minimum of a. Biological contamination b. Chemical contamination c. Physical contamination f. Equipment. 2. The director of food and nutrition services and registered dietician provide ongoing training on infection control and the prevention of food contamination. 3. The director of food and nutrition services or designee will check food storage, food preparation, and food service areas daily to ensure proper steps are being followed h. All refrigerated foods if removed from their original container are securely covered, labeled, and dated appropriately and if opened, the label will contain the appropriate use by date i. Leftovers are covered, labeled and dated appropriately, and used within 72 hours or discarded. Under Routine Housekeeping 2. Soiled equipment should never touch food. 3. All work surfaces, utensils, and equipment should be cleaned and sanitized after each use.References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A) Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. Equipment food-contact surfaces and utensils shall be cleaned throughout the day at least every 4 hours.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of their personal and/or medical records for 7 of 10 residents reviewed for residents' rights. The facility failed to ensure LVN-D locked and/or closed the medication cart computer screen and left multiple residents' information exposed. The facility also failed to ensure LVN-D turned over or put away paperwork or report sheets with multiple residents' information on it. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings include: In an observation on 08/06/25 at 8:10 AM revealed LVN-D's medication cart laptop screen was left opened with multiple residents' information exposed. While examining the laptop and information on the screen, LVN-D walked out of a resident's room, reached past this surveyor and closed the screen. In an observation on 08/06/25 at 9:31 AM revealed a report sheet with multiple residents' information left face up on LVN-D's medication cart. While examining the paperwork and getting a photo of it, LVN-D walked out of a resident's room and grabbed the paper. In an interview on 08/06/25 at 9:32 AM, LVN-D stated she should have locked and closed her laptop screen as well as placed the paper facedown or away because they had residents' information on them, and anyone could have walked by and seen it. She stated she knew it was considered a HIPAA violation to leave resident information exposed. She stated she was really busy and had forgotten to lock the screen or turn the paper over when she walked away. In an interview on 08/06/25 at 9:33 AM, the DON stated it was considered a HIPAA violation to leave residents' information exposed where anyone could have seen it or stolen it. She stated she had just in-serviced LVN-D over this topic this morning. In an interview on 08/06/25 at 9:35 AM, the ADON stated leaving residents' information out in the open for anyone to read or take was considered a HIPAA violation, and the nurses knew they were not supposed to do this to keep the information private and accessible to only those authorized to access it. Record review of the facility document titled Nursing Facility Residents' Rights, dated November 2021, revealed in part, Dignity and Respect: You have the right to: Access personal and clinical records, which will be maintained as confidential and may not be released without your consent. Record review of the facility's policy titled Resident Rights, revealed in part The facility will ensure its associates are educated to the importance of resident's rights. Any violation or potential violation should be reported immediately to their supervisor, the Director of Nursing, Social Services, or Executive Director.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #70) of 6 residents reviewed for care plans. The facility failed to ensure Resident #70's care plan was implemented by not having the resident's call light within reach on 08/04/25 at 2:10 PM. This failure could place residents at an increased risk of needs going unmet or harm.The findings included:Record review of Resident #70's face sheet dated 08/04/25 revealed a [AGE] year-old male with an admission date of 02/10/21. Resident #70's Pertinent diagnoses included hemiplegia and hemiparesis affecting the right dominant side (complete paralysis to right side of body), aphasia (unable to speak), and dementia (decline in mental ability that interferes with daily life). Record review of Resident #70's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Record review of Resident #70's comprehensive care plan revealed the focus [Resident #70] is at risk for falls r/t right-sided hemiplegia and hemiparesis, impaired condition initiated on 02/10/21 and revised on 07/15/25. An Intervention for this focus included Call light within reach initiated on 02/10/21. During an observation on 08/04/25 at 2:10 PM, Resident #70's call light cord and button were coiled up on the floor approximately 3 feet away from the head of the bed on Resident #70's right side. In an interview with Resident #70 on 08/04/25 at 2:10 PM, Resident #70 was unable to answer questions due to his inability to speak. Resident #70 was able to nod his head up and down or side to side to indicate yes or no answers. Resident #70 was asked if he knew how long his call light had been on the floor out of reach and he shrugged his shoulders. Resident #70 was asked if his call light was on the floor out of reach very often and he shook his head side to side. Resident #70 was asked if he was able to communicate with nursing staff in the halls with any means other than the call light and he shook his head side to side. In an interview with CNA B on 08/04/25 at 2:15 PM, CNA B stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. CNA B stated he did not know how Resident #70's call light fell on the floor out of reach. CNA B stated it was important for residents to be able to access their call lights so they could notify the nursing staff if they had any problems. In an interview with LVN A on 08/04/25 at 2:20 PM, LVN A stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. LVN A stated he was in Resident #70's room sometime after lunch and thought the call light was on Resident #70's bed. LVN A stated it was important for any resident to be able to access their call light so they could contact the nursing staff if they had any problems. LVN A stated it was especially important for Resident #70 to have his call light because he was unable to speak or yell to get attention. LVN A stated if a resident could not access their call light, they could accidentally injure themselves and not be able to get the nurses attention for help. In an interview with the DON on 08/06/25 at 2:50 PM, the DON stated it was important for all residents to have access to their call lights so all their needs could be met by the nursing staff. The DON stated if residents could not reach their call light, then they could have trouble informing the CNA's and nurses on the floor of any problems they had. The DON stated this issue could lead to a resident experiencing harm and then receiving a delayed response by the staff. Record review of the facility's policy Person Centered Care Planning last reviewed 09/05/2024 revealed the following: . The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on, interview, and record review the facility failed ensure, in accordance with accepted professional standards and practices, to maintain medical records on each resident that was complete and accurately documented for one resident 1 of 7(Resident #00) residents reviewed for medical records. The facility failed to ensure Resident #00's MARS was revised to reflect the accuracy of times the resident took hydrocodone-Acetaminophen Tablet 10-325 milligrams taken as needed for pain control on 04/09/2025.This failure could place residents at risk for not receiving appropriate and timely pain care relief to meet their current needs.The findings included:Record review on 08/06/25 of Resident #00's facesheet documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 00 had diagnoses which included diabetes(a group of diseases that result in too much sugar in the blood), necrotizing fasciitis (a serious bacterial infection that destroys the tissue under your skin called fascia) , pressure ulcers(injury to skin and underlying tissue resulting from prolonged pressure on the skin) of heel unstageable, pressure ulcer of sacral region(the anatomical area located at the base of the spine, where the lower back meet the pelvis) stage 4 cutaneous(skin) of limb, skin transplant, encounter of sepsis aftercare.Record review of Resident #00's Minimum Data Set, dated )03/03/25 documented Resident #00 had a BIMS of 14, which indicated the resident's cognitive function was intact. Resident #00 required assist with one-person physical assist for transfers, dressing, toileting, and personal hygiene. Resident #00 had 2 stage 4 pressure ulcers and 2 unstageable pressure ulcers due to coverage of wound bed by slough (dead tissue that accumulates on the surface of a wound, often appearing as a moist, yellow, tan or white layer)or eschar(dead tissue that eventually sloughs off healthy skin after an injury). Resident #00 was receiving insulin injections and IV medications. Record review of resident #00's Care Plan dated 03/22/25 revealed Resident expresses chronic pain related to immobility, limited range of motion to joints, wounds and neuropathy. The Resident is on pain Medication therapy related to wounds and neuropathy. Administer ANALGESIC medications as ordered by physician. Observe for side effects and effectiveness every shift. Record review of Resident's #00's March 2025 Physician's Orders revealed Resident's #00 was prescribed hydrocodone-Acetaminophen tablet 10-325 MG give1 tablet by mouth every 4 hours as needed for pain. The MARS and the Narc Sheet did not match as the Narc sheet showed dates the medication was removed from blister pack. The blister pack did have medication missing and matched the Narc sheet. Record review of the MARs is did not have dates documented on the days the Narc sheet documented medication administered. Record review of the of the narcotic sheet reveal that on 04/09/25 the time of 7:20 pm a pill was documented to be administered to Resident #00 and was signed out by the [NAME] LVN at 7:20 shift ended at 7:00pm.In an interview on 08/06/2025 at 1:30 pm, the Administrator stated the MARs and Narcotic sheet were to match up when compared. The Administrator said the nurse or med aid were to document in these days areas when a narcotic was dispensed to the resident in order to keep accurate account of the amount and the time the resident received their narcotic medication. The Admin stated if the two forms of documentation did not match it could cause an error in dispensing the medication that could put the resident at risk of overdosing and possibly death. In an interview on 08/06/2025 at 2:47 PM with the ADON she stated keeping the narcotic sheet and the resident's MAR accurate kept the resident safe and free of medication mistakes. The ADON stated the nurses were to document in both records as the medication was given to the resident. The ADON stated correctly documented dates and times of resident receiving medication help track drug diversion.The ADON stated she would recheck and match the both records themselves randomly this incident occurred between the time she checked them twice a month In an interview on 08/07/25 the DON stated it was of great importance to maintain accuracy in all aspects of the resident's records but more with the correct documentation of the Narcotic sheet and MAR. The DON stated inconsistencies in the documentation of date and times could keep the resident from getting their medications or getting their medication too early that could cause the resident to have an overdose which could result in hospitalization or death. The DON stated surprise audits of residents records with narcotics were done to prevent such errors from occurring. Record review of the facility policy stated It is the policy of this facility that reports allegations of drug diversion are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment. Complaints and grievances will be investigated and will be reported as required by law if the investigation reveals any alleged violations and /or misappropriation of resident property.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture. The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began. The failure could affect residents, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included: Record review of Resident #1's face sheet dated 03/04/25 revealed an [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included acquired absence of left leg above knee, unspecified dementia, and depression. Record review of Resident #1's discharge MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 2 (severe impairment). Record review of Resident #1's care plan dated 11/05/24 revealed the focus Resident is at risk for falls r/t impaired mobility, weakness, impaired cognition, and pain initiated on 09/17/24 and revised on 11/06/24. Interventions listed for the focus included: Anticipate and meet the resident's needs initiated on 05/29/24 and revised on 11/06/24. Assist with ADL's as needed initiated on 03/02/24 and revised on 11/06/24. Call light within reach initiated on 03/02/24 and revised ono 11/06/24. Complete fall risk assessment initiated on 03/02/24 and revised on 11/06/24. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs initiated on 06/04/24 and revised on 11/06/24. May have [non-slip mats] to wheelchair initiated on 08/07/24 and revised on 11/06/24. May have floor mats next to bed initiated on 06/04/24 and revised on 11/06/24. Orient resident to room initiated on 03/02/24 and revised on 11/06/24. Therapy evaluate and treat as ordered or PRN fall 05/28/24 resident currently on PT, therapy informed of fall resident DC'd off OT due to refusals initiated on 05/29/24 and revised on 11/06/24. Will review medications for adverse reactions initiated on 06/04/24 and revised on 11/06/24. Record review of the provider investigation report dated 09/05/24 revealed the following witness timeline: Timeline - 8.29.24 [Resident#1] Approximately 5:50 AM: [CNA A], rounding on 400 hall and she hears resident saying help me help me. [CNA A] attempts to get resident up. Resident states she cannot stand. [CNA A] leaves room to go get help. [CNA A] gets other [CNA B] and asks her to help get [Resident #1] up off floor. [CNA A] and [CNA B] enter [Resident #1's] room. Both get resident up from floor and assist her into wheelchair. Both aides then transfer her into bed and tuck her back into bed. Both aides leave room and continue with final rounds. Neither report fall to nurse or other aides on their shift or oncoming shift. Approximately 7:00 AM: [CNA C] is rounding on 400 hall and goes to check [Resident #1]. [Resident #1] reports pain in her leg and wanting to see the Dr. [CNA C] reports this to her nurse [RN D]. [RN D] calls doctor and Dr. order Xrays. Xray results come in and [Resident #1] is transferred to hospital with acute left femur fracture. Incident is reported to HHSC All staff interviewed from night before, no one reports [Resident #1] having a fall. [CNA B] and [CNA A] state they rounded on [Resident #1] was having increased weakness, however, was a self transfer and only required assistance to transfer into bed. Staff inserviced on: Abuse/Neglect/Exploitation, Falls, and Transfers Tuesday, September 2nd, 2024 Interview with aides [CNA A] and [CNA B] reveals that resident sometimes needed more assistance with transferring and toileting at night. [CNA B] states she asked [Resident #1] to pivot on transfer into bed but that there was no sign of pain [or] grimacing. [CNA A] agreed with interview. Wednesday, September 3rd, 2024 Aides [CNA A] and [CNA B] interview along with Nurses [RN E] and [RN D] [Resident #1] readmits to facility. Interview of resident by [ADM] and DON. Resident revealed that she fell in door way when ambulating back to bed after having gone to restroom. She states she does not remember who came to help her but a nurse came to help her. When the resident stated she could not stand the nurse went to get another nurse and they both picked her up off the floor and transferred her to bed. Resident stated at the time she felt nothing and went back to sleep. Later, around 7a she felt pain and requested from a different nurse to see the doctor. Aides interviewed again and statement of [CNA A] changes. Aides [CNA A] and [CNA B] suspended pending investigation. [CNA A] and [CNA B] terminated based off of investigation findings. Record review of the provider investigation revealed the following interviews: Resident #1 on 09/04/24 Around 7a I got up from bed to go to the restroom. I was going back to bed when I heard a pop and my leg gave out. I fell in my doorway. A nurse came right away and tried to help me off the floor but I could not stand. She left and came back with a second nurse. Both nurses helped get me off the floor and sat me in my wheelchair. They then wheeled me closer to my bed and transferred me into bed. I do not remember their names. I didn't feel any pain then. Later, another nurse came to check on me and I told her my leg was turned the wrong way and hurt and I needed to see the doctor. She said okay that she would tell someone. Another Nurse called the doctor and they did xrays on my leg and it was broken. CNA A on 09/04/24 I was walking down 400 hall when I heard a resident saying help me help me. I entered [Resident #1's] room and found her on the floor in the doorway of the bathroom. I went to get the other [CNA B]. [CNA B] and I got her up. We put her in her wheelchair and then put her in bed. I asked [Resident #1] if she was okay and she said she was. We then kept rounding. We never told the nurse. Record review of x-ray of Resident #1 dated 08/29/24 revealed a fracture through the left distal femoral shaft at the level tip of the intramedullary femoral stem, minimally comminuted (fracture that extends into the knee and up through the femur). Further review revealed a fracture of the right tibia and fibula. Record review of a local hospital's patient records for Resident #1 dated 08/30/24 revealed the following plan: Regarding patient's left distal femur fracture, this fracture is not fixable and unfortunately is not convertible either. At this time [Doctor] has recommended a left above-knee amputation. Interview was attempted with CNA A at 10:58 AM on 03/05/25, but CNA A could not be reached so a message was left. Interview was attempted with CNA B at 11:00 AM on 03/05/25, but CNA B could not be reached so a message was left. In an interview with the ADM at 11:22 AM on 03/05/25, the ADM stated they did not know Resident #1 had fallen from the incident on 08/29/24 until they interviewed her on 09/04/24. The ADM stated before they were able to interview Resident #1 they thought the breaks were from brittle bones. The ADM stated they originally thought the fractures caused the fall, and not the fall caused the fractures. The ADM stated Resident #1 had problems with her left knee, and she had several surgeries on it in the past few years. The ADM stated she believe the ultimate outcome of left leg above knee amputation of Resident #1 would not have changed even if the CNA's A and B had acted appropriately. The ADM stated CNA A and CNA B should have found a nurse to evaluate the resident on the floor before moving her at all. The ADM stated no employee had ever come to her to report another employee for possible abuse of a resident. The ADM stated the two CNA's involved in this incident had always been good CNA's. The ADM stated they conducted safe surveys after the incident and all residents reported they felt safe. The ADM stated they inserviced all employees on abuse, neglect, falls, and alerting staff if there was a fall. The ADM stated they made cards that all employees carried on their badges to inform them of the proper steps in case a resident fell . In an interview with Witness #1 at 1:40 PM on 03/05/25, Witness #1 stated she was a good friend of Resident #1. Witness #1 stated she visited Resident #1 when she was in the hospital after her fall on 08/29/24. Witness #1 stated Resident #1 told her she went to the bathroom and fell . Witness #1 stated Resident #1 told her the CNA's tried to move her several times while she was in the bathroom, but her legs kept hurting more and more. Witness #1 stated the two CNA's had a tough time picking up Resident #1, but one of them bear hugged her and threw her in bed. Witness #1 stated Resident #1 told her she asked for the nurses to come back and check on her legs, but they left the room. In an interview with the NP at 2:49 PM on 3/5/25, the NP stated Resident #1 had infective hardware with multiple revision surgeries (surgery to correct or modify the results of a previous surgery) on her left knee. The NP stated Resident #1 was on IV antibiotics for an extended period of time before the fall on 08/29/24. The NP stated she initially sent the resident out to the hospital for swelling and the fractures in her legs. The NP stated there was potential the CNA's could have caused more damage when they moved her. The NP stated in this condition Resident #1's leg was in, any fall or twist could have injured it. The NP stated she still had Resident #1 as her patient, and Resident #1 was doing much better with pain control after the amputation. In an interview with Resident #1 at 10:48 AM on 03/06/25, Resident #1 stated she remembered the facility she was at when she had her fall at the end of August. Resident #1 stated she was leaving her bathroom when her feet came out from under her. Resident #1 stated she did not remember hearing a pop before falling. Resident #1 stated he hips faced one way while her legs faced the other. Resident #1 stated it was very painful. Resident #1 stated when she told the nurses about her pain they did not believe her. Resident #1 stated one of the nurses told her bite the bullet for a bit while she moved her back into bed. Resident #1 stated she told the first two nurses that she wanted to see the doctor but they laughed at her. Resident #1 stated once she was back in bed she positioned her legs so they did not hurt as bad. Resident #1 stated it was not until a 3rd nurse came in 30 minutes later that started helping her for the pain. In an interview with CNA C at 1:59 PM on 03/06/25, CNA C stated when she entered Resident #1's room around 7:00 AM on 08/29/24 it looked like Resident #1 was in severe pain and very uncomfortable. CNA C stated Resident #1 told her she was in pain. CNA C stated she went and got the nurse as soon as she realized the condition Resident #1 was in. Record review of the facility policy titled Incident and Reportable Event Management issues 07/19/21, revised 08/15/23 and reviewed 09/25/24 revealed the following: Incident/Injury 1. The licensed nurse should evaluate the resident and render first aide if needed a. The nurses evaluation should be completed prior to moving a resident who has fallen, to determine presence of injury. 2. The licensed nurse should create an event note and include the following details; a. The assessment details of the resident (including location details of the resident) b. Presence or absence of injury, and any treatments rendered c. If resident is able to report what occurred, this should be included in the notes d. Notification of family or responsible party e. Notification of physician and any orders received 3. The licensed nurse should create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system. 4. The licensed nurse should also notify the following in accordance with state and federal requirements a. Supervisor on duty and/or DON In interviews beginning at 2:12 PM on 03/04/25 with staff from multiple shifts, the DON, ADM, CNA C, CNA F, LVN G, CNA H, CNA I, CNA J, LVN K, LVN L, MA M, CNA N, CNA O, CNA P, and RN Q were able to identify the proper procedures to follow when responding to a witnesses or unwitnessed fall. All staff knew not to move the resident before getting the nurse and referenced the card attached to their name badges to demonstrate the proper protocol. All staff were familiar with different types of abuse and neglect. Record review and verification of the corrective action implemented by the facility beginning on 08/29/25: The facility terminated the employment of CNA A and CNA B effective 09/05/24 verified by record review of the provider investigation, staff roster, and interview with the ADM. Resident #1 was discharged to another nursing facility on 11/05/24 verified through record review of Resident #1's face sheet and interview with the ADM. teams Re-educated and in-services staff beginning on 08/29/25 verified through interviews with carious staff members and record review of in-services. Abuse and Neglect Exploitation Falls Transfers Ad-Hoc QAPI conducted on 09/05/24 regarding incidents/accidents verified by interview with the ADM. Reviewed all policies regarding falls on 09/05/24 verified by interview with the ADM. Badge cards created on 09/05/24 for all staff to be worn at all times detailing proper step-by-step procedures for what to do if a resident fell or was found on the ground verified by interviews with various staff. The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.

Based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R #1) of 4 residents reviewed for falls and accident hazards. R #1 had an unwitnessed fall and sustained a fractured left leg (tibia), and displaced fractured right leg (femur) which led to hospitalization . The facility did not provide the amount of supervision necessary to prevent R #1 from falling and sustaining multiple fractures which lead to hospitalization . This failure could place residents with high risk for falls at risk for additional falls and injuries. The findings included: Review of R #1's Face sheet dated 09/26/22 documented age [AGE] year-old female admitted [DATE], with the diagnosis of multiple system degeneration of the nervous system, muscle spasms, urinary tract infection, polyneuropathy (malfunction of many peripheral nerves throughout the body), tremor, [CONDITION(S)] (inability to understand or express speech), dysphagia (problems with swallowing), seizures, and [CONDITION(S)] (weak bones). Review of R #1's Minimum Data Set (MDS) dated [DATE] documented she: - had resident was unable to complete interview for BIMS, had ok memory -required extensive assistance for all activities of daily living, bed mobility, toilet use, personal hygiene, and transfers. -was frequently incontinent of urine and bowel. Review of R #1's Care Plan dated 08/08/2022 documented The resident has an ADL self-care performance deficit related to physical limitations related to disease process paraneoplastic neuromyopathy and [CONDITION(S)] Goal The resident will maintain current level of function through the review date. Interventions documented . -BED MOBILITY: The resident required 2 assist by staff to turn and reposition in bed. -TOILET USE: The resident required 2 assist by staff for toileting. -Transfer: The resident required 2 assist by staff to move between surfaces. Review of R #1's Care Plan dated 08/08/2022 documented Resident is at risk for falls related to impaired mobility, balance problems Goal The resident will not sustain serious injury requiring hospitalization through the review date Interventions documented -anticipate and meet the resident's needs. -assist with ADLs as needed. Record review of nurses note dated 09/19/22 at 4:38 PM documented resident's emergency light was on so this nurse went into bathroom to find Resident #1 sitting on her bottom on the floor, CNA A stated that she placed her on the toilet and left room and came back to find her on the floor, during assessment resident complained of pain to left wrist, left knee, has reddened area to forehead, Resident #1 was helped into bed by CNA A, 911 was called due to resident hitting head, Resident #1 refused to go to emergency room , paramedics did not take due to resident being Alert and Oriented x 4, RP was notified and would like us to get orders for x-ray of the left wrist and left knee, DON notified, Hospice notified, gave orders for x-ray of the left wrist, left knee, orders given by Nurse Practitioner. Nurses noted dated 09/20/22 at 3:12 AM documented Resident had X-rays taken of Chest, left wrist, left knee & right knee on 09/19/22. Results were received around 10:30 PM Chest Xray: No acute cardiopulmonary disease. Left wrist: No acute osseous abnormality noted. Left knee: Mildly displaced acute fracture in the proximal metaphysis of the left tibia. Right knee: Acute appearing displaced fracture in the distal metaphysis of the right femur. DON was notified immediately. This writer went to ask resident if she wanted to go to the ER & indicated no. This writer called daughter & daughter stated that she wanted her mother to go & then stated, give me about 5 minutes & I will call you back. Called me back & she stated that she wanted her mother to go. This writer went back down to resident's room & asked her if she were willing to go to the ER & she indicated yes. Called [medical transport] & they stated that it would be about 1.5-2hr wait. Called 911. One of the paramedics that arrived stated that they had been here earlier & that she didn't want to go & I stated that she had changed her mind. Asked resident if she was willing to go to the ER [emergency room ] in their presence & she gave a thumbs up This writer just called [hospital ER] & they stated that resident was going to be admitted for her fractures. Also called [hospice angency] to inform them of the admission, as well. During an interview with DON on 09/28/22 at 10:29AM revealed Resident #1 had limited use of her hands and the CNA A should have stayed with Resident #1 while on the toilet in the restroom. The DON stated, CNA A was an agency (shift key) worker, and the facility has since stopped using that CNA due to the incident. CNA A was reported by the facility to the staffing agency. DON revealed she contacted the agency because of the incident and was given information that the facility would no longer allow CNA A to work at the facility. DON revealed the facility had agency workers (CNA or Nurse staff) agree to pick up a shift, a manager will set them up with a user name and password for the computers for documentation purposes and gives them access to the kardex and care plan to see how to care for the resident. DON stated, the managers will go over which residents the agency staff will work with and reports were given from previous shift staff about the residents to the agency staff. Usually, the unit manager or any nurses who set up the agency staff before their working shifts will go over how to find and locate how to care for the residents in the care plan or kardex. DON stated when agency staff are working, there was always another facility nurse working as a resource to help agency staff with any questions or concerns. DON stated all staff document on the computer all care provided for all residents and every morning she pulled the report to make sure all residents are receiving the care they need. After the incident the facility in-serviced all staff including agency staff on fall management and following the plan of care. She revealed it was important to provide care as documented in the care plan, to ensure the resident received the care required. During an interview with LPN C (contracted nurse) on 09/28/22 at 10:40 AM it was revealed she was an agency work but had been working and picked up shifts with the facility for a couple months. She stated, as an agency worker the facility didn't educate or in-service the agency nurses before starting their jobs. She stated as a nurse she has knowledge to follow the residents care plans, orders, and reports give from the previous nurse on duty. She revealed the facility had a book with policies and information about how to do things for the agency nurses, but the facility does not require the agency nurses to read it or look over it, it's just there to help when needed. She revealed if she was working at the facility during a facility in-service, the facility would educate her on new things in the facility, or as problems arise. During an interview with CNA A on 09/28/22 at 11:29 AM, she revealed she had been an CNA for over [AGE] years. She stated she was an agency worker but had worked for the facility years prior. She recalled the incident stating, Resident #1 told her she needed to go to the restroom. She transferred the resident to her wheelchair and to the toilet. She stated, she was with Resident #1 in the restroom for a while, when she heard another resident was yelling so she got worried and asked Resident #1 if she was okay and if she could go check on the other resident. She stated she told Resident #1, Don't move, use the emergency light, and I would be right back. Resident #1 gave a thumbs up because she is non-verbal but alert. CNA A left the resident to check on the resident that was yelling. She stated right after she checked on the other resident and helped CNA B, she heard the emergency alarm on for Resident #1. She went back to Resident #1's room and found her lying face down in front of the toilet in sitting position, as if Resident #1 had fallen forward from the toilet. CNA A revealed she was an agency worker and she had been working at the facility for 3 months on different floors with different residents and was never educated by facility staff to stay with the resident at all times while toileting. She stated, when you start working for the facility, the facility just tells her what hall she would be working but not how to look into how to care for the resident. During an interview with CNA B at 11:50 AM on 09/28/22 she revealed she had worked at the facility the night of the incident with Resident #1. She stated, she was two doors down from Resident #1's room working with a resident that yells and talks loud, when CNA A went into the room with CNA B to help with care because the resident was yelling. She stated, as soon as they were done, they heard Resident #1's emergency bathroom light went on, they went to check on the resident and found her sitting on the floor leaning forward. She revealed the nurses was alerted right away and the nurse came into the restroom to check on the resident. During an interview with LVN D on 09/29/22 at 10:42PM revealed she was the nurse in charge for Resident #1. She revealed on 09/19/22 she saw Resident #1's emergency bathroom light on, she entered the room to assess Resident #1, who was sitting on the floor in front of her toilet. She revealed Resident #1 was alert and denied pain during the assessment, but she noted swelling to Resident #1's right knee. She stated, she immediately called 911, the DON, and hospice. Resident #1 refused to go to the hospital and wanted to be picked up from the floor. Staff assisted the resident into her bed and received order for x rays for the residents lower extremities. She stated, CNA A should not have left Resident #1 alone on the toilet because Resident #1 has poor trunk and arm control and is at risk for falls. She stated it is the facility's job to ensure that staff are caring for the residents as ordered. She stated when the CNA's are on the floor, she is under the impression that they are trained by the facility before working with residents. LVN D revealed it was important to stay with Resident #1 during toileting because she was total care and at risk for falls due to weakness to upper body and lower body, with no control. Staying with the resident and not leaving her alone could have prevented any accidents or falls. An interview on 09/28/22 at 2:24PM, DON revealed there was no policy for agency staff. She stated before agency staff start working at the facility there is a packet of policies that they have to look over and sign before working. She stated CNA A had worked at the facility prior to going to work for the agency and knows the policies and procedures of the facility. DON was unable to provide packet. Record review of the facility's On-the-spot-Inservice dated 9/20/22 documented It was for facility staff provided by DON. Subject: Fall management, reporting incidents/accidents, resident rights, put interventions in place, and abuse/ neglect/misappropriation. CNA A was not in-serviced. Record review of the facility's fall management policy dated 04/07/2022 documented the facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. the facility must ensure that reach resident receives adequate supervision and assistance devices to prevent accidents.