Every finding on record at Ararat Post Acute

Based on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's policy and procedure by failing to: 1.Ensure a humidifier bottle (a small bottle attached to the oxygen tubing that holds water to keep oxygen from drying out a person's nose and lungs) was changed for one of six sampled residents (Resident 26) reviewed for infection control that required oxygen therapy in accordance with the facility's policy and procedure (P&P) titled Oxygen administration. 2. Ensure the staff were using a gown while assisting the resident that was on enhanced barrier precaution (EBP- an infection control measures that involve wearing gowns and gloves for all high-contact activities with residents in nursing homes to stop the spread of multidrug-resistant organism [MDRO- is a type of bacteria that has developed resistance to multiple antibiotics, making infections difficult to treat and requiring enhanced infection prevention measures to reduce transmission]) for 1 of 6 sampled residents (Resident 6) reviewed for infection control. These failures had the potential for the residents to be at increased risk of infection and transmission of infection to other residents, staff and visitors that could result in a wide spread of infection in the facility.Findings: 1.During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted Resident 26 on [DATE] with diagnoses that included but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) following cerebral infarction (part of the brain didn't get enough blood and oxygen, so brain cells were damaged or died) affecting left non-dominant side, muscle weakness, and atrial fibrillation (an irregular heartbeat where the heart beats fast and unevenly instead of steady and strong). During a review of Resident 26's physician's order, dated [DATE], the order indicated Resident 26 to receive continuous oxygen at two liters per minute (LPM), keep oxygen saturation (how much oxygen the blood is carrying) above 92 percent. During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 26 had severely impaired cognition (ability to think, reason, and function). The MDS indicated Resident 26 was dependent on helpers for toileting and personal hygiene. During an observation on [DATE] at 9:49 AM in Resident 26's room, Resident 26 observed in bed on oxygen at 2 LPM connected to a humidifier bottle labeled [DATE]. During a concurrent observation and interview on [DATE] at 10:52 AM with Treatment Nurse (TX) 1 inside Resident 26's room, TX 1 stated the humidifier bottle was dated [DATE] and should have been changed when the oxygen tubing was changed which was labeled [DATE]. TX 1 stated, oxygen tubing and humidifier bottles were changed every Sunday mainly for infection control by preventing harboring of bacteria. During an interview on [DATE] at 10:46 with the Director of Nursing (DON), the DON stated, humidifier bottles and oxygen tubing should be changed every Sunday by the night shift licensed nurses and should be labeled by writing the date it was changed on the humidifier bottle. The DON stated humidifier bottles should be changed every Sunday for infection control, to prevent growth of bacteria in the water that can make residents sick. During a review of the facility's P&P titled, Oxygen administration, revised 8/2014, the P&P indicated, All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled. 2. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to neuromuscular dysfunction of bladder ( a condition in which impaired nerve and muscle coordination affects the bladder's ability to store or empty urine appropriately), benign prostatic hyperplasia with lower urinary tract symptoms (an overgrowth of the prostate tissue that pushes against the urethra and the bladder, blocking the flow of urine), and retention of urine. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 6 had moderately impaired cognition (ability to think, reason, and function). The MDS indicated Resident 6 required moderate assistance with toileting hygiene, showering and personal hygiene. During a review of Resident 6's physician's order, dated [DATE], the order indicated Resident 6 had an order for indwelling urinary catheter (a thin, flexible, sterile tube inserted into the bladder to drain urine into a bag outside the body) to gravity drain every shift. During a review of Resident 6's physician order dated [DATE], the order indicated Resident 6 had an order for EBP precaution due to indwelling urinary catheter use. During a review of Resident 6's Care Plan (CP), initiated on [DATE], the CP indicated Resident 26 was on EBP due to indwelling urinary catheter use. The CP goals indicated Resident 26's risk of developing and or transmitting infection would be minimized or reduced. The CP intervention indicated for staff to wear gowns and gloves while performing any care activity where close contact with the resident was expected to occur such as assisting with toileting. During an observation on [DATE] at 9:22 AM in Resident 6's room, EBP precaution signage observed posted outside the door indicated providers and staff must wear gloves and gowns for high-contact resident care activities that included assisting with toileting of residents. Certified Nursing Assistant (CNA) 2 put on gloves but did not wear a gown when CNA 2 assisted Resident 6 to the bathroom who had an indwelling urinary catheter. During an interview on [DATE] at 11:37 AM with CNA 2, CNA 2 stated, I forgot to wear a gown. CNA 2 stated gowns and gloves must be worn when in direct contact with residents on EBP precautions to prevent infection, spread of bacteria to the residents and to the staff. During an interview on [DATE] at 9:02 AM with Registered Nurse (RN) 1, RN 1 stated, proper Personal Protective Equipment (PPE- the gear healthcare workers wear to protect themselves and the patient, like gloves, gowns, masks or face shields to stop germs from spreading) must be used for residents on EBP precautions during direct contact care to prevent spread of any infections and protect high risk residents like those with indwelling urinary catheters from MDROs. During an interview on [DATE] at 10:46 with the Director of Nursing (DON), the DON stated staff, visitors and anybody must wear gowns and gloves when in close contact with residents on EBP precautions to prevent spread of infection to other residents, the staff and the community. During a review of the facility's policy and procedure (P&P) titled, Standard and enhanced precautions dated 4/2024, the P&P indicated, EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter.). For residents whom EBP are indicated, EBP should be used when performing high-contact resident care activities such as changing briefs or assisting with toileting.

Based on observation, interview, and record review, the facility failed to ensure to store, prepare, distribute and serve food for all the 24 residents in the facility receiving food from the kitchen in accordance with professional standards for food service safety, and the facility's policy and procedure titled, Food Storage, dated 11/1/2014. This deficient practice had the potential for the residents to acquire food-borne illnesses (a life threatening infection due to consuming contaminated food) from ingesting expired food. Findings: During an initial tour of the facility's kitchen on 1/20/2026 at 8:35 AM with the Dietary Manager (DM) there were undated and expired food items stored in the refrigerator: Undated uncooked celery stored in a box. Expired cabbage stored in a refrigerator with a label to use by 1/16/2026. During a concurrent observation and interview on 1/20/2026 at 8: 35 with the Dietary Manager (DM) stated that all kitchen stored food is labeled and someone must have forgotten to label the celery. DM stated that the cabbage was not going to be used and that someone must have forgotten to throw it away. During an interview on 1/21/2026 with Dietary Supervisor (DS) stated that all food that is expired gets thrown away immediately and the cabbage must have been left behind by accident. During a review of the facility's policy and procedure titled, Food Storage, dated 11/1/2014, indicated, that all food items will be stored, thawed and prepare in accordance with good sanitary practice.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 32) reviewed for pressure ulcer ( a skin breakdown due to prolonged unrelieved pressure and skin friction) receives care, consistent with professional standards of practice, to prevent pressure ulcers had recommended inflation/adjustment setting for the low air loss mattress (LAL - therapeutic mattress that uses blower and airflow to relieve pressure and keep the skin dry and prevent moisture build up). This deficient practice had the potential to result in the resident to be at risk of developing pressure ulcers. Findings: During a review of Resident 32's admission Record (AR) the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis (no movement) of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities), left knee and hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 32's Minimum Data Set (MDS - a resident assessment and care screening tool) dated 11/20/2025, indicated, Resident 32 has severe impaired cognitive skills (ability to think and reason). The MDS indicated that Resident 32 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene and turning and repositioning in bed. During a review of Resident 32's Initial History and Physical dated 2/11/2025, the initial History and Physical assessment indicated that Resident 32 does not have the capacity to understand and make decisions. During a review of Resident 32's Order Summary Report dated 1/5/2026, the summary report indicated a physician's order to apply a low air loss mattress for skin integrity. During a review of Resident 32's Braden Scale for Predicting Pressure Sore Risk dated 8/21/2025, indicated the resident was at high risk of developing pressure ulcer. During a review of Resident 32's Risk for Pressure Ulcers Care Plan dated 1/4/2024. Indicated Resident 32 was at risk for developing pressure ulcers and skin breakdown due to impaired mobility with intervention to apply pressure relieving/reducing device when in bed low air loss mattress. During an observation on 1/20/2026, at 9:51 AM in Resident 32's room was observed Resident 32 lying on a low air loss mattress with a setting for a person that weights 350 pounds (lb.) the maximum possible setting on the mattress. During an interview on 1/20/2026 at 10:25 AM with the Treatment Nurse (TX1) stated, Resident 32 weighs 140 pounds and the low air loss mattress setting was at set at the maximum setting of 350 lbs. stated that nursing did not monitor the bed setting every shift of the resident every shift. The TX 1 stated not be sure why the low air loss mattress was set at the maximum setting of 350 lbs. During an interview on 1/23/2026 at 1: 42 PM with the Director of Nurses (DON) stated that Resident 32's low air loss mattress setting should not have been left at maximum of 350 lbs. and should have been adjusted by nursing. DON stated the low air loss mattress constantly circulates air to keep the skin cool and dry to prevent moisture and the mattress should not have kept rigid. DON stated Resident 32 was at risk for pressure ulcers, falls or injury since the low air loss mattress maximum setting is to be used when transferring out of the bed.

Based on interview and record review, the facility failed to implement its policy and procedure to provide the Medicare change status form: Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of three sampled residents (Residents 45) within two (2) days of the last Medicare part A covered day. This deficient practice had the potential for Resident 45 not to exercise the right to appeal and not be aware of possible charges for services rendered that were not covered after her last Medicare part A coverage day. Findings: During a concurrent interview and record review on 1/23/2026 at 11:41 AM with the social service coordinator (SSC), the facility document notices provided to Resident 45: SNF-ABN date of notice 6/19/2025 and NOMNC dated 6/18/2025 was reviewed. The documents SNF-ABN and NOMNC was signed by Resident 45 on 6/18/2025. SSC stated, he was responsible in providing the notices to resident or responsible party. SSC stated, it is facility's policy to provide the notices to Resident 45 a minimum of 2 days prior to the last day of Medicare part A coverage, and Resident 45 last Medicare Part A covered day was 6/18/2025, which made the notices late. SSC stated providing the notices late, did not give Resident 45 time to appeal the change in medical coverage, and had the potential to incur charges that was no longer covered by Medicare part A. During an interview on 1/23/2026 at 11:50 AM with the Director of Nurses (DON), DON stated, facility document notices SNF-ABN and NOMNC should be provided to the resident a minimum of 2 days prior to the last day of Medicare part A as per policy, to ensure the resident had ample time to make medical coverage decisions, as well as appeal the change of medical coverage. DON stated, Resident 45's SNF-ABN and NOMNC notices was late which did not give Resident 45 time to exercise the right to appeal the change of coverage and potentially can incur charges no longer covered by Medicare part A. A review of the facility's policy and procedure titled, Medicare Denial Process, dated 10/24/2022 indicated: a) Medicare Status Change form maybe completed by designee a minimum of 2 days prior to the last Medicare Part A covered day, and b) the designee prepares and issues the Medicare Status Change which includes SNF-ABN and NOMNC to the beneficiary or representative.

Based on observation, interview and record review, the facility failed to provide privacy and a homelike environment for two of two sampled residents (Resident 29 and Resident 39) by failing to report the missing to the maintenance supervisor to replace the missing horizontal window blind slats in Resident 29 and Resident 39's room. This deficient practice resulted in having a non-homelike environment and a violation of the residents' rights for privacy when the residents were exposed to the other people outside in the walkway and neighboring building near the facility. In addition, the loss of privacy had the potential to affect their psychosocial wellbeing of the residents. Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility originally admitted Resident 29 on 4/30/2024 and readmitted on [DATE] with diagnoses that included heart failure (the heart is unable to pump blood around the body properly), diabetes mellitus (a disease that affects how the body uses blood sugar) and osteoarthritis (chronic joint disease, often called wear-and-tear arthritis) of both knees. During a review of Resident 29's Minimum Data Set (MDS, a Resident assessment tool), dated 11/13/2025, indicated Resident 29's cognition (ability to think and reason) was intact. During a concurrent observation and interview on 1/20/2026 at 9:46 AM with Resident 29 in Resident 29's room, Resident 29's bed was near by the window with opened vertical blinds that had two pieces of slats missing exposing the room from outside walkway and neighboring building. Resident 29 stated, she was not sure who she who she reported the missing slats on the blinds to which has been missing for at least two days. Resident 29 stated, the blinds help with the sun for shade and provides her privacy. 2. During a review of Resident 39's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] , with diagnoses that included congestive heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should), and diabetes mellitus. During a review of Resident 39's History and Physical (H&P) dated 1/11/2026, the H&P indicated Resident 39 was alert and oriented to place and time. During a review of Resident 39's MDS dated [DATE], indicated the resident's cognitive status was moderately impaired. During a concurrent observation and interview on 1/20/2026 at 9:55 AM with Resident 39 in Resident 39's room, Resident 39's bed was near by the window, with opened vertical blinds that had two pieces of slates missing exposing the room from outside walkway. Resident 29 stated, she was not sure who she reported the missing blinds to which has been missing for at least two days. Resident 29 stated, the blinds help with the sun for shade and provides her privacy. from outside walkway. Resident 39 pointing at the missing vertical blinds, nodded yes when asked if the missing vertical blinds bothers her. During a concurrent observation and interview on 1/20/2026 at 10 AM with Registered Nurse (RN) 3 in Resident 29's room and then Resident 39's room. RN 3 stated both rooms for Residents 29 and 39 were missing window slates on the vertical blinds which exposes the residents from outside walkway, and neighboring building. RN 3 stated, the rooms with missing window vertical blinds slate was not homelike, it could affect residents' comfort and privacy. During an interview on 1/21/2026 at 2:27 PM with the Maintenance Director (MTD), MTD stated, he was not aware of Resident 29 and Resident 39's missing slats on the window blinds. MTD stated, it was probably missed when they check the rooms. MTD stated, it was important to replace the missing blinds right away for Residents comfort (shade from the sun) and privacy. During an interview on 1/21/2026 at 3:10 PM with the Director of Nurses (DON), DON stated, it was not homelike for Resident 29 and Resident 39 to have missing window blinds in their room, it should have been replaced right away. DON stated the missing slats on the window blinds in Resident 29 and 39's room could potentially affect Resident 29 and Resident privacy that may negatively affect their psychosocial wellbeing. A review of the facility's policy and procedure (P&P) titled Resident Rooms and Environment, dated 11/1/2017, the P&P indicated, facility provides residents with safe, comfortable and homelike environment. A review of the facility's policy and procedure (P&P) titled Privacy and Dignity, dated 7/1/2016 indicated, facility promote and/or enhance privacy, dignity and overall quality of life, and facility respect's the resident's private space.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 41's) with intravenous (IV- a catheter inserted with a needle into the vein) peripheral catheter (a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) on the left arm had dried up blood on the site covered with transparent dressing and was not changed in accordance to the facility's policy and procedure titled Peripheral Venous Catheter Insertion. This deficient practice can potentially cause infection on the on the IV site that can lead to severe infection. Findings: During a record review of Resident 41's admission Record (AR) dated 1/17/2026 indicated Resident 41 was admitted on [DATE], with the diagnoses of pneumonia (an infection/inflammation in the lungs), dysphagia (difficulty swallowing), History of malignant neoplasm of the prostate (cancerous tumor that can spread (metastasize) to other parts of the body). During a review of Resident 41's Progress Notes dated 1/18/2026 at 7:42 AM indicated that Resident 41 was to continue with intravenous medication (IV -fluids given directly into the blood stream), Ceftriaxone (Antibiotic Medication) for three days from the admission date of 1/17/2026. During a record review of Resident 41's Initial History & Physical dated 1/20/2026, indicated that Resident 41 has fluctuating capacity to understand and make decisions. During an observation on 1/20/2026 at 10 AM in Resident 41's room, Resident 41 was lying in bed with a peripheral catheter inserted to the left forearm between the elbow and the wrist area transparent clear dressing covered with dried up blood around the peripheral catheter site. A review of the Physician's order, dated 1/17/2026 timed at 4:47 PM, indicated Resident 41 was to receive Ceftriaxone1 gram (medication used to treat infection) intravenously (into the vein) on 1/18/2026, 1/19/2026, and 1/20/2026. During an interview on 1/20/2026 at 10:42 AM with Registered Nurse (RN3) stated, that Resident 41 had the peripheral catheter upon admission. RN3 stated to have noticed the red dry fluid around the peripheral catheter site but due to the risk of dislodgement and believing Resident 41 was a difficult stick (difficult to insert a peripheral catheter into the vein) RN3 felt comfortable leaving the dressing on until discontinuation of the intravenous catheter. During an interview on 1/23/2026 at 1:42 PM with the Director of Nurses (DON) stated, that nursing should have change the peripheral catheter dressing to prevent infection and to be able to assess new findings such as redness. During a review of the facility's policy and procedure titled, Peripheral Venous Catheter Insertion dated 3/2023, indicated that peripheral intravenous catheter sites will be changed when clinically indicated.

Based on observation, interview, and record review, the facility failed to ensure the resident evaluations including a written report of a physical examination was completed within 72 hours following admission and the initial comprehensive visit was not done by the Nurse Practitioner, Physician Assistant, and the Clinical Nurse Specialist for one of six sampled residents (Resident 17). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: During a review of Resident 17's admission Record (AR) indicated Resident 17 was admitted on [DATE] and readmitted on [DATE] with admitting diagnoses of acute embolism and thrombosis of left femoral vein (sudden blood clots that block blood flow), pneumonia (an infection/inflammation in the lungs). During a review of Resident 17's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/28/2025, the MDS indicated Resident 17 had a cognition (ability to think and reason) was intact. The MDS indicated that Resident 17 was partial/moderately dependent on staff for personal hygiene, putting on and taking off footwear, lower body dressing, upper body dressing, toileting hygiene, and supervision or touching assistance with oral hygiene, and eating. During a review of Resident 17's History and Physical assessment report, dated 1/19/2026 after being readmitted from the hospital on 1/16/2026 was performed, documented and signed on 1/20/2026 by the Physician Assistant PA). During an interview on 1/22/2026 at 10:25 AM with Director of Nurses (DON), stated, the PA came in today (1/22/2026) and not the primary physician to assess the resident (Resident 17). The DON stated the initial comprehensive assessment needs to be performed, documented, completed and signed by the attending physician. During a review of the facility's policy and procedure (P&P) titled, Physician Services & Visits, dated 10/24/2022, indicated, resident evaluations including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission. The P&P indicated that the initial comprehensive visit cannot be done by the Nurse Practitioner, Physician Assistant, and the Clinical Nurse Specialist.

Based on observation, interview and record review, the facility failed to remove a lidocaine patch (a medicated sticky patch placed on the skin to numb an area and relieve pain) at 9 PM and place a new patch at 9 AM to ensure the patch was on for 12 hours and off for 12 hours as ordered by the physician order for one of two sampled residents (Resident 10) reviewed for pharmacy services. This failure resulted in Resident 10 receiving lidocaine in excess duration as prescribed which had the potential to cause adverse effects (undesired effect) of medication that include increased systemic absorption (process by which medication moves from its site of administration into the bloodstream, allowing it to travel throughout the entire body), skin irritation, or medication toxicity (the medicine becomes harmful because there is too much of it in the body), that could lead to a decline in Resident 10's condition, harm or hospitalization. Findings: During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 12/4/2025 with diagnoses that included but not limited to spinal stenosis (the spaces in the spine have narrowed, which puts pressure on the spinal cord or nerves), lumbar (refers to the lower part of the back) region with neurogenic claudication (means leg pain, weakness or numbness caused by pressure on the nerves), fracture of second to fifth lumbar vertebrae (small bones that stack on top of each other to make up the spine), low back pain, and chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should). During a review of Resident 10's untitled Care Plan (CP), initiated on 12/05/2025, the CP indicated Resident 10 was at risk for pain due to spinal stenosis, lumbar fracture and low back pain. The CP goals indicated Resident 10 would not have an interruption in normal activities due to pain and Resident 10 would verbalize adequate relief of pain. The CP intervention indicated for licensed nursing staff to administer lidocaine patch every 12 hours as ordered. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 10 had intact cognition (ability to think, reason, and function). The MDS indicated Resident 10 required moderate assistance with toileting, showering and personal hygiene. During a review of Resident 10's physician's order dated 12/12/2025, the order indicated Resident 10 had an order for a lidocaine external patch four percent, apply to left lower back topically (applying a medicine, cream, or treatment directly onto a specific, localized part of the body) one time a day for pain management. Apply one (1) patch at 9 AM and remove at 9 PM, per schedule. During a concurrent observation and interview on 1/21/2025 at 8:52 AM with LVN 1 inside Resident 10's room, LVN 1 removed the lidocaine patch from Resident 10's left lower back and then placed a new patch on the same area. LVN 1 stated the patch should have been removed last night at 9 PM and a new patch to be placed at 9 AM as scheduled. LVN 1 stated the physician's order was to put the patch on for 12 hours and off for 12 hours. LVN 1 stated the doctor's order should be followed because the patch can cause skin irritations after prolonged use. During an interview on 1/23/2026 at 10:46 with the Director of Nursing (DON), the DON stated the lidocaine patch should be placed by the licensed nurse at 9 AM and removed at 9 PM. The DON stated the lidocaine patch should be removed after 12 hours to prevent absorption of the drug that the resident does not need. The DON stated excessive absorption of lidocaine in the body can be harmful to the residents. During a review of the facility's policy and procedure (P&P) titled, Medication administration, dated 7/2016, the P&P indicated, Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. During a review of the facility's P&P titled, Transdermal patches, dated 7/2016, the P&P indicated, At a minimum every shift, the licensed nurse will verify that the patch is present, intact and the skin around patch is free of skin irritation or other reactions.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 4), reviewed for use of unnecessary medications, was monitored for complications of Apixaban (a blood thinner medication) such as bruising and bleeding as indicated in the resident's care plan and the physician's order. This deficient practice had the potential for the resident not to receive immediate care or no care that can lead to a resident decline in well-being. for complication of Apixaban such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds. Findings: During a review of the admission Record (AR) indicated Resident 4 was admitted on [DATE] and readmitted on [DATE] with admitting diagnoses of atrial fibrillation (heart dysrhythmia), dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/31/2025, indicated Resident 4 cognitive (ability to think and reason) level was intact. During a review of Medication Administration Record (MAR), indicated that Resident 4 received Apixaban 5 milligrams (mg - a unit of measurement) twice a day from 1/1/2026 through 1/20/2026. During a review of the Order Summary Report dated 1/1/2026, indicated anticoagulant medication monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds every shift. During an observation on 1/20/2025 at 9:39 AM in Resident 4's room, Resident 4 was observed with purplish skin discoloration of irregular shape to left anterior hand. In an interview Resident 4 stated he does not know how he obtained the bruise and that might have accidentally bumped hand onto the furniture. During an interview with the Treatment Nurse (TXN 1) on 1/21/2025 at 3:45 PM stated that on 1/20/2026 she did not receive a report regarding bruising and skin abnormalities from the certified nurse assistants (CNA's). TX Nurse1 stated that the attending CNA should have reported the bruise for continuous monitoring and investigation. During an interview on 1/23/2026 at 2:20 PM with the Director of Nursing (DON), stated, that the CNA's who provide daily care should have reported to the license nurse the bruise that was on Resident 4's left hand. DON stated monitoring of anticoagulant side effects helps prevent serious complications such as uncontrollable bleeding. During a review of Resident 4's care plan titled Anticoagulant Therapy dated 1/30/2025, indicated that Resident 4's skin will be inspected daily and will report any abnormalities to the nurse. The care plan also indicated that all adverse reactions will be monitored, documented and reported. During a review of the facility's policy and procedure titled, Pressure Ulcer Prevention dated 2/1/2015, indicated that CNAs are required to inspect the resident's skin during ADL care and will report unusual findings to the License Nurse.

Based on interview, and record review, the facility failed to ensure the documentation in the Licensed Nursing Weekly Summary (LNWS) accurately documented one of six sampled residents (Resident 5) reviewed for identifyable residents records, the actual status of having unplanned weight loss and behavior of yelling requiring the use of psychotropic medications (a medication that affects mood and behavior) in the weekly assessment from 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026. This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to the resident. Findings: During a review of Resident 5's admission Record (AR), indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dementia (a progressive state of decline in mental abilities) with agitation, chronic kidney disease stage 4 (severe kidney function loss). During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/10/2025, the MDS indicated Resident 5 had severely impaired cognitive skills (ability to reason) and never/rarely made decisions. that was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking footwear, and personal hygiene. The MDS dated [DATE], indicated Resident 5 receives hospice services. During a review of Resident 5's Nutritional Risk Care Plan Report, dated 5/30/2024, indicated hospice care and services was discontinued on 12/2/2025. During a review of Resident 5's Order Summary Report (Physician Orders), dated 12/12/2025 indicated, Resident 5 was placed on weekly weight x 4 weeks for poor oral intake and weight loss. On 12/22/2025, a physician order indicated Resident 5 was started on Depakote (medication use to treat and manage symptoms for psychiatric disorders) 125 milligrams (mg - Metric unit of measurement, used for medication dosage and/or amount) twice a day for mood disorder for constant yelling. During a review of Resident 5's Licensed Nursing Weekly Summary (LNWS) dated 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026, the LNWS indicated Resident 5 had no weight loss issues, and no antipsychotic medications administered for mood manifestation and its side effects, and no documentation of the weekly episodes of mood or behavioral changes. During a review of Resident 5's Unplanned/Unexpected weight loss Care Plan Report dated 12/11/2025, indicated monitor and evaluate any weight loss. During a review of Resident 5's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/1/2026 - 1/23/2026, indicated Resident 5 received Depakote twice a day from 1/1/2026 - 1/23/2026 and had a total of 8 episodes of yelling in the day shift (7 - 3:30 PM), 25 episodes in the evening shift (3 - 11:30 PM) , and 11 episodes in the night shift (11 - 7:30 AM). During an interview on 1/22/2026 at 2:21 PM with Director of Nurses (DON) stated that the weight loss and the medication administered Depakote with the episodes of yelling which were being monitored should have been reflected in the LNWS the The documentation in the LNSW about Resident 5's behavior of yelling requiring administration of psychotropic medication and current un planned weight loss did not reflect the actual status of the resident. DON stated that not reflecting accurate residents' information in the documentation it is an opportunity to missed important information as well as communication to the physician and other interdisciplinary members. During a review of the facility's policy and procedure (P&P) titled, Licensed Nurse Weekly Progress Notes, dated 1/1/2016, indicated, the Licensed Nurse will document the resident's response and progress toward the goal and will identify possible skin, weight, medication, hydration and behavioral risk factors.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 39 and Resident 41) and their representatives, reviewed for resident's rights were offered an information regarding Advance Directives (AD a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in accordance with facility policy titled Advance Directives and regulatory requirements. This deficient practice has the potential for care and services to not be performed during medical emergencies according to the residents and/or family wishes. 1. During a record review of Resident 41's admission Record (AR) dated 1/17/2026 indicated Resident 41 was admitted on [DATE], with the diagnoses of pneumonia (an infection/inflammation in the lungs), dysphagia (difficulty swallowing), history of malignant neoplasm of the prostate (cancerous tumor that can spread (metastasize) to other parts of the body). During a record review of Resident 41's Initial History & Physical dated 1/20/2026, indicated that Resident 41 has fluctuating capacity to understand and make decisions. During a concurrent interview and record review on 1/21/2026 at 9:50 AM with Social Services Coordinator (SSC), indicated Resident 41's Advance Directive Acknowledgement dated 1/17/2026, was not signed by the responsible party. SSC stated that he understands that AD should had been done when the resident was admitted to the facility to honor residents wishes and preferences, but SSC stated the AD was not completed. During an interview on 1/23/2026 at 1:42 PM with Director of Nurses (DON) stated that the AD was supposed to be initiated upon admission to ensure residents wishes and preferences are followed and to ensure that during medical emergencies residents and Responsible Party (RP) wishes and preferences are followed. 2. During a review of Resident 39's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] , with diagnoses that included congestive heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should), and diabetes (chronic condition where blood sugar (glucose) levels are too high because the body does not make enough insulin or cannot use it proper). During a review of Resident 39's History and Physical (H&P) dated 1/11/2026, the H&P indicated Resident 39 was alert and oriented to place and time and able to make decisions. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 1/12/2026, indicated the resident cognitive status (level of mental functioning) was moderately impaired. During a concurrent interview and record review on 1/20/2026 at 2:56 PM with Registered Nurse (RN) 3, Director of Nurses (DON), and Social Service Coordinator (SSC), Resident 39's physical chart was reviewed. There was no documented evidence in Resident 39'clinical record to indicate that an Advance Directive or acknowledgement of Advance Directive was offered and/or if the resident was informed. DON stated, Advance directive acknowledgement should have been done upon admission, and it should be in Resident 39's physical chart. SSC stated, he was responsible ensuring Resident 39 had an advance directive or an acknowledgement of an advance directive, he stated he must have missed informing the RP about the advance Directive acknowledgement. SSC stated, not having an Advance Directive was important to ensure residents' healthcare wishes and preferred care during medical emergencies were clearly identified, documented, and honored. During an interview on 1/21/2026 at 3:01 PM with the DON, DON stated, Resident 39's Advance Directive should have been initiated upon admission to ensure Resident 39 and/ or family wishes are followed. DON stated, not having an advance directive had the potential for care and services to not be performed during medical emergencies according to the residents and/or family wishes. During a review of the facility's policy and procedure (P&P) titled Advance Directives, dated 6/1/2021, the P&P indicated: a) the facility will honor resident's advance directive and will provide the resident information related to advance directive upon admission, b) upon admission designee will inform the resident their right to execute an advance directive, if one does not already exist. and c) a copy of the advance directive is maintained as part of Resident's medical record.

Based on interview and record review, the facility failed to post an accurate nurse staffing information worked by License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting, when posted document on 1/20/2026 at 11:34 AM titled Posted Nurse Staffing Information indicated 11 to 7 shift actual staff are one LVN and two CNA's during morning facility rounds. (actual staff for 11 to 7 shift was posted in advance, during the day not at the beginning of the 11 to 7 shift). This deficient practice of posting inaccurate nurse staffing information in advance mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. Findings: During a concurrent interview and record review of Posted Nurse Staffing Information on 1/20/2026 at 11:34 AM with Registered Nurse (RN) 1 at the nurses' station, the posting indicated there were one LVN and two CNAs assigned to work during the 11PM to 7AM shift. RN 1 stated, she works as a Director of Staff Development (DSD), and she was responsible as well as charge nurses in posting actual nursing staff per shift. RN 1 stated actual nursing staff for 11 to 7 shifts should have been blank until the beginning of 11 to 7 shift as per policy and should not be filled out in advance to ensure accurate nursing staff working that shift. RN 1 stated, the nursing posting was an error and a misleading information for to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. During an interview on 1/21/2026 at 3:30 PM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type and hours of nursing care provided in the facility. DON stated, it is not acceptable to write ahead of time the actual nursing staff per shift, it needs to be done at the beginning of each shift as per policy. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Posting. revised 10/24/2022, indicated: a) the facility will post the total number and the actual hours worked by licensed nursing and unlicensed nursing staff directly responsible for resident care per shift (RNs, LVNs, and CNAs), and b) the facility will post the nursing staffing data on a daily basis at the beginning of the each shift.

Based on observation, interview, and record review, the facility failed to provide a safe and secured environment for Resident 1, who was identified as being at high risk for elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of potential dangers) and wandering (when a person roams and becomes lost or confused about their location) for one of two sampled residents (Resident 1). The facility failed to: Ensure that facility staff supervise Resident 1 and did not leave the resident unattended in the Activity/Dining Room, which was located adjacent to an exit door. Ensure that Activity Staff (AS) 1 was informed of Resident 1's high risk for elopement and need for monitoring, when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room and left the resident with AS 1 in the Activity Room. 3. Ensure that Resident 1 was continuously monitored and supervised by a facility staff in the Activity Room when AS 1 left the facility at the end of her shift on 10/28/2025 at around 5 PM. As a result of these deficient practices, on 10/28/2025 between the hours of 5 PM to 6 PM, Resident 1 wandered out of the facility unsupervised. Resident 1 was later found the same day, on 10/28/2025, at approximately 6:07 PM, sitting at a bus stop on a busy street 0.4 miles from the facility. Resident 1 was located and returned to the facility by a family member (Responsible Party [RP] 1). Resident 1 was placed at significant risk and exposure from falls, injury from motor vehicular accidents, and extreme weather conditions due to the facility's failure to provide Resident 1 with a safe and secure environment, in accordance with the resident's care plan. Findings: During a review of the facility's Policy and Procedures (P&P) titled Wandering and Elopement revised 8/1/2014, the P&P indicated that resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change of condition according to the RAI (Resident Assessment Instrument- a standardized process that nursing homes use to evaluate a resident's needs and develop an individualized care plan) guidelines. The P&P further indicated that the IDT may consider interventions listed in the Elopement Risk Reduction Approaches for residents identified to be at risk for elopement. During a review of the facility's P&P titled Elopement Risk Reduction Approaches, the P&P indicated As necessary, provide new residents (to the facility, wing, unit, etc.) with additional staff assistance until they are comfortable in their new environment. The P&P further indicated that for residents identified at risk for wandering, facility staff needs to know the following information: i. How to identify and understand the resident's needs. ii. The resident's propensity to wander and the triggering conditions. iii. Recognition of the consequences of limited mobility. iv. The consequences of unsafe wandering, the protocols to follow to minimize successful exiting During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included multiple fracture (a broken bone) of left side ribs, repeated falls, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Elopement- Wandering Risk Scale assessment dated [DATE], the Assessment indicated Resident 1 was identified at high risk for wandering/elopement due to forgetful/short attention span, diagnosis of dementia with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and a known wanderer, including history of wandering. The Assessment did not indicate any recommendations from the facility's licensed nurse who completed the Elopement- Wandering Risk Scale Assessment. During a review of Resident 1's Care Plan titled At risk for wandering/elopement dated 10/22/2025, the Care Plan indicated the goal was to ensure Resident 1 would remain safe within the facility and free from injury and interventions included the following interventions: 1. Keep environment free from clutter; 2. Monitor resident whereabouts every 1 hour; 3. Redirect resident calmly when attempts to ambulate unassisted occurs. The Care Plan did not include to have all interdisciplinary care team made aware of Resident 1's high risk for elopement and the type of supervision required for Resident 1 to remain safe and secured between hours when no staff was monitoring the resident's whereabouts. During a review of Resident 1's Care Plan titled At risk for falls dated 10/22/2025, the care plan indicated that Resident 1 had cognitive impairment and history of recent falls resulting in rib fracture. The care plan interventions indicated that Resident 1 needs a safe environment including even floor, free from spills and clutters, adequate lighting, an accessible call light, and handrails on walls. During a review of the facility Minimum Data Set (MDS - a resident assessment tool) dated 10/25/2025, the MDS indicated Resident 1 had severely impaired (significantly limits one person's physical or mental ability to do basic work activities) cognition (thought process). The MDS also indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) during sit-to-stand, and partial/moderate assistance (helper does less than half the effort) on walking 50 feet. During a review of Resident 1's Monitoring Log dated 10/28/2025, the log timed 4 PM marked R indicated that Resident 1 was in the resident's room, and another one timed at 5 PM marked D indicated that Resident 1 was in the Dining Room (Activity Room). During a telephone interview conducted on 11/05/2025 at 11:30 AM, Certified Nurse Assistant (CNA) 1 stated that she was assigned to care for Resident 1 on 10/28/2025. CNA 1 stated that Resident 1 was identified as being at risk for elopement and required hourly monitoring. CNA 1 recalled that at approximately 5:00 PM on 10/28/2025, Licensed Vocational Nurse (LVN 1) escorted Resident 1 to the Activity Room. CNA 1 stated she was attending to another resident at that time and was not asked by LVN 1 to supervise or monitor Resident 1 while the resident was in the Activity Room. CNA 1 further stated that she became aware that Resident 1 was missing from the facility at approximately 5:30 PM on 10/28/2025 and immediately reported the incident to the charge nurse. During a telephone interview conducted on 11/05/2025 at 11:44 AM, LVN 1 stated that on 10/28/2025, between the hours of 4:00 PM and 5:00 PM, LVN 1 observed Resident 1 walking out of his room. LVN 1 noted that Resident 1 was dressed and appeared to be wandering. LVN 1 stated that she redirected and accompanied Resident 1 to the Activity Room, where she handed off the resident to AS 1. LVN 1 stated that she was not certain whether AS 1 was aware of Resident 1's high risk for elopement and the need for close monitoring. LVN 1 further stated that she assumed AS 1 would supervise Resident 1, as it is the facility's expectation that no resident should be left unsupervised. During an interview conducted on 11/05/2025 at 12:20 PM, AS 1 stated that she was not informed by LVN 1 that Resident 1 was at risk for elopement and was not familiar with the resident's medical history. AS 1 stated that she does not typically know most residents' diagnoses but acknowledged that no resident should be left unsupervised. AS 1 stated that on 10/28/2025 at around 5:00 PM, as she was preparing to leave for the day, she went to the Nursing Station to inform Registered Nurse (RN) 1 that someone needed to get Resident 1 from the Activity Room. AS 1 stated that there were two dietary staff members present in the Activity/Dining Room when she stepped out to look for the nurse. AS 1 stated that it was not appropriate to expect dietary staff to supervise Resident 1 and stated that she should not have left Resident 1 unsupervised in the Activity Room on 10/28/2025. During an interview on 11/05/2025 at 2:45 PM, RN 1 stated that she completed an elopement risk assessment for Resident 1 upon admission. RN 1 stated that all staff, including nurses and activity staff, were informed about Resident 1's high risk for elopement. RN 1 stated that on 10/28/2025, at around 5:00 PM, while making resident rounds prior to her 30-minute meal break, she observed Resident 1 with AS 1 in the Activity Room. RN 1 stated that she was on her meal break and was not aware of the time AS 1 ended her shift. RN 1 stated AS 1 did not inform her that Resident 1 needed someone to supervise Resident 1 in the Activity Room prior to leaving the facility at end of her (AS 1) shift, on 10/28/2025. RN 1 stated that upon returning from her break at approximately 5:35 PM, RN 1 stated she was notified by LVN 1 that Resident 1 was missing. During a telephone interview on 11/06/2025 at 2:10 PM, RP 1 stated that she received a call from the facility on 10/28/2025 at around 5:30 PM, informing her that Resident 1 was missing from the facility. RP 1 stated that she and other family members immediately took their car out to search for Resident 1. RP 1 stated that they found Resident 1 while driving toward the facility. Resident 1 was sitting at a bus stop near a busy street intersection, 0.4 miles away from the facility. RP 1 stated Resident 1 appeared to be sweating heavily from walking. RP 1 stated that Resident 1 looked lost and was surprised to see her and the other family members. Resident 1 did not respond when asked why he was there. During an interview on 11/05/2025 at 3:50 PM with the Administrator (ADM) and Director of Nursing (DON), the DON stated that the supervision and safety of residents is very important, and that staff communication should be thorough at all times. The ADM stated that AS 1 should not have assumed that any dietary or non-clinical staff present would be responsible for monitoring or supervising a resident. The ADM further stated that AS 1 should have remained with Resident 1 until relieved by a clinical staff member.

Based on interview and record review for two of three sampled residents, the facility failed to ensure: 1. Resident 20 ' s Physician Orders for Life Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatment that can or cannot be done at the end-of-life) and Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) Acknowledgment Form reflected resident's wishes. 2.Resident 15 ' s POLST and Advance Directive Acknowledgment Form reflected Resident 15 Advance Directive. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 20 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included pulmonary aspergillosis (fungal lung infection caused by inhaling certain mold spores), acute embolism (a clot that moves through the bloodstream) and thrombosis (a clot in a blood vessel) of left femoral vein (a large blood vessel in the thigh), left tibial vein (deep veins in the lower extremities [legs]), and left peroneal vein (fibular vein that runs on the lateral side of lower extremity), and malignant neoplasm (cancer) of lower lobe, left bronchus or lung. During a review of Resident 20 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident had the capacity to understand and make decisions. During a review of Resident 20 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition. During a review of Resident 20 ' s POLST dated 12/11/2024 did not indicate if resident received information about an Advance Directive or if resident had an advance directive on file. During a review of Resident 20 ' s Advance Directive Acknowledgement form dated 12/3/2024 indicated Resident 20 had an Advance Directive. During a review of Resident 20 ' s medical chart on 12/13/2024 at 12:24 PM, indicated no evidence that Advance Directive was formulated. During a concurrent interview and record review of Resident 20 ' s POLST and Advance Directive Acknowledgment form on 12/14/2024 at 3:15 PM, the Social Services Director (SSD) stated he was aware that Resident ' s 20 ' s POLST and Advance Directive Acknowledgment form did not match. SSD stated the POLST should be filled out to its entirety, to know what the resident ' s healthcare decisions and wishes are. SSD stated the POLST should not be left blank. SSD stated he clarified with family on 12/13/2024 regarding Resident 20 ' s Advance Directive and was told resident did not have an advance directive and would like more information to obtain an AD. SSD stated it was important for all documentation like the POLST and Advance Directive to be the same, in the case of an emergency to know what the resident ' s wishes are. During an interview on 12/14/2024 at 5:01 PM, the Director of Nursing (DON) stated resident ' s POLST and Advance Directive Acknowledgment form should indicate resident ' s wishes. The DON stated if the information is not the same, staff should verify and clarify with the family and resident. The DON stated it was important to make sure all documents indicate the same thing so that resident ' s wishes can be followed. 42878 2. During a review of Resident 15 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone),hyperlipidemia(a condition in which there are high levels of fat particles in the blood). During a review of Resident 15 ' s History and Physical Assessment [HPA] dated 7/02/2024, the HPA indicated Resident 15 has the capacity to understand and make medical decisions. During a review of Resident 15 ' s MDS, dated [DATE] indicated Resident 15 ' s cognition was intact. During a review of Resident 15 ' s POLST dated 7/4/2024, the POLST did not indicate if Resident 15 had an Advance directive. During an interview and concurrent record review on 12/13/2024 at 11:58 AM with the Social Services Director (SSD), the SSD stated there was no advance directives or evidence that indicated an Advance Directive acknowledgment form was offered to Resident 15 or the responsible party [RP]. The SSD stated advance directives is completed on admission as part of the resident ' s admission paperwork and it should be in the paper chart to indicate Resident 15 ' s wishes. The SSD stated it was important to get this information, so the facility know what the resident ' s or the RP ' s wishes are in case of an emergency. During a review of the facility ' s policy and procedure titled Advanced Directives with a revision date of 06/01/2021, indicated to provide residents with the opportunity to make decisions regarding their health care .The admission staff will inform and provide written information to all adult residents concerning the right to accept or refuse medical treatment.

Based on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling in accordance with the facilities policy and procedure by failing to ensure: 1. Rotten plums were not kept in the food supply for residents and stored in the plastic container in kitchen walk in refrigerator. 2. A half full box of Kale vegetable was discarded as indicated in the label to with discard date 12/9/2024. 3. A plastic bag with five Danishes were kept sealed in the freezer with used by date 12/11/24. 4. A sliced can of apple was discard as indicated in the label to be discarded on [DATE] These deficient practices had the potential to place residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: On 12/12/2024 at 9:30 AM, during an initial observation of the kitchen refrigerator with Dietary Supervisor a plastic container containing plums was observed in the walk-in refrigerator with 2 rotten plums and a carton box with kale half full labeled with discard date of 12/9/2024. On 12/12/2024 at 9:35 AM, there was an observation of the facilities walk in freezer of an opened clear plastic bag half full the bag was labeled as Danishes with a use by date of 12/11/2024. During a subsequent observation and interview on 12/12/2024 at of the kitchen dry storage area rack where canned food is stored there was an observation of a metal can containing sliced apples with a label On 12/12/2024 at 9:50 AM during a subsequent interview with Dietary Supervisor, DS stated all staff should be checking the refrigerator every morning for spoiled food and produce. DS stated spoiled plums, kale and Danishes found in freezer should have been discarded by the discard date or once they were observed to be spoiled in the morning when the refrigerator is checked. DS stated cans such as the sliced apple can with discard date of September should be removed from can storage on the discard date to prevent them from being served and possibly making the residents sick and prevent any food borne illness to the residents.

Based on observation, interview, and record review, the facility failed implement the policy and procedure for infection control by ensuring resident care equipment utilized for residents was sanitary, labeled and properly stored for eight of 8 sampled residents: For Residents 20 and 70 cloth gait belts (safety device used to help people move around safely, especially when they are at risk of falling) were inside the restroom. For Residents 2,3,5,9,11 and 15.the cloth gait belts were inside the restroom that any resident could readily access. This deficient practice had the potential for the residents to share resident care equipment, which can spread infection and cross contamination (transfer disease causing organism) to other residents. Findings: 1a. During a review of Resident 70 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (a broken bone that occurs near or around a hip or knee replacement) around internal prosthetic (an artificial device that replaces a missing body part) left knee joint, repeated falls, and muscle weakness. During a review of Resident 70 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident did not have the capacity to understand and make decisions. During a concurrent observation and interview in Resident 70 ' s room on 12/12/2024 at 11:50 AM, a soiled cloth gait belt with no resident name was observed in the resident restroom. Resident 70 ' s Family Member (FM) 1 stated Resident 70 had a roommate when she was admitted to facility but does not share a room with anyone at the moment. FM 1 stated Resident 70 does not use the restroom. FM 1 stated she was not sure who the belt belonged to. During a concurrent observation and interview in Resident 70 ' s room on 12/12/2024 at 12:15 PM, Registered Nurse (RN) 1 confirmed soiled cloth gait belt was in Resident 70 ' s restroom with no resident name. RN 1 stated the cloth gait belt did not belong to Resident 70 and must have been for someone else. 1b. During a review of Resident 20 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included pulmonary aspergillosis (fungal lung infection caused by inhaling certain mold spores), acute embolism (a clot that moves through the bloodstream) and thrombosis (a clot in a blood vessel) of left femoral vein (a large blood vessel in the thigh), left tibial vein (deep veins in the lower extremities [legs]), and left peroneal vein (fibular vein that runs on the lateral side of lower extremity), and malignant neoplasm (cancer) of lower lobe, left bronchus or lung. During a review of Resident 20 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident had the capacity to understand and make decisions. During a review of Resident 20 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition. During an observation in Resident 20 ' s room on 12/12/2024 at 11:53 AM, a cloth gait belt labeled Rehab was observed in the resident restroom. During a concurrent observation and interview in Resident 20 ' s room on 12/12/2024 at 12:18 PM, Infection Prevention Nurse (IPN) confirmed cloth gait belt labeled Rehab was in Resident 20 ' s restroom. IPN stated the cloth gait belt belonged to the Rehab department. IPN stated the gait belt was being sanitized. 2a. During a review of Resident 15 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 15 ' s History and Physical Assessment, dated 7/2/2024, indicated Resident 15 has the capacity to understand and make medical decisions. During a review of Resident 15 ' s Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/16/2024 indicated Resident 15 ' s cognition (ability to think and reason) was intact. During a review of Resident 3 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (high levels of sugar in the blood) with diabetic neuropathy (a complication of diabetes that damages nerves in the body),Hypertensive heart disease (a group of heart conditions that occurs when high blood pressure is left unmanaged over a long period of time). During a review of Resident 3 ' s History and Physical Assessment, dated 3/23/2024, the HPA indicated Resident 3 has the capacity to understand and make medical decisions. During a review of Resident 3 MDS, dated [DATE], indicated Resident 15 ' s cognition was intact. During an observation on 12/12/24 at 11:47 AM of Resident 15 ' s and 3 ' s shared restroom there was a cloth gait belt with no resident name was observed inside the resident restroom hanging from a metal hook attached to the door. During a concurrent observation and interview in Resident 15 ' s and 3 ' s restroom on 12/12/2024 at 11:55 AM, Registered Nurse (RN) 1 confirmed soiled cloth gait belt was in Resident 15 ' s and 3 ' s shared restroom with no resident name. RN 1 stated she believed the cloth gait belt belonged to Resident 3 but was unsure as there was no name on the gait belt. 2b. During a review of Resident 2 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a long term condition where the kidneys are damaged) and Type 2 Diabetes mellitus (high levels of sugar in the blood). During a review of Resident 2 ' s History and Physical Assessment [HPA] dated 1/12/2024, the HPA indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition. During a review of Resident 9 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (a disease affecting the nerves outside the brain and spinal cord), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet) During a review of Resident 9 ' s History and Physical Assessment [HPA] dated 2/15/2024, the HPA indicated Resident 9 does not have the capacity to understand and make decisions. During a review of Resident 9 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, indicated the resident had moderately impaired cognition. During a review of Resident 11 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), unspecified dementia (loss of memory, language, problem solving and other thinking abilities). During a review of Resident 11 ' s History and Physical [H&P] dated 3/15/2024, the H&P indicated the resident was not able to make her own decisions. During a review of Resident 5 ' s Face Sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), chronic kidney disease stage 3 (a moderate level of kidney damage that results in reduced kidney function). During a review of Resident 5 ' s History and Physical [H&P] dated 2/21/2024, the H&P indicated the resident does not have the capacity to understand and make her own decisions. During an observation on 12/12/24 at 12:00 PM of Resident 2,9,11 and 5 ' s shared restroom there was a cloth gait belt with no resident name was observed inside the resident restroom hanging from a metal hook attached to the door. . During a concurrent observation and interview in Resident ' s 2, 9,11 and 5 ' s room on 12/12/2024 at 12:05 PM with Certified Nursing Assistant (CNA 1), CNA 1 stated she will use the cloth gait belt for Resident ' s 2 and 11. CNA 1 stated she was not instructed how to clean the gait belt sometimes she would wipe it down with a wipe in between resident uses but the cloth gait belt was shared for the resident ' s in that room. During a concurrent interview and observation of Resident 2, 9, 11 and 5 shared restroom on 12/12/2024 at 12:08 PM with Infection Prevention Nurse (IPN) , IPN stated there was no identifier in the cloth gait belt in the restroom and gait cloth gait belts should not be shared among different residents as there was no way to properly clean them in between residents use. IPN stated each Resident should have their won personal cloth gait belt labeled with their name and be kept next to residents' bedside. During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:59 PM, the DON stated there was no way to sanitize cloth gait belts. The DON stated all cloth gait belts were removed from resident restrooms and plastic gait belts were ordered to sanitize the gait belts when used between patients. The DON stated it was important to disinfect the gait belts after each use for infection control. During a review of the facility ' s policy and procedure (P&P) titled Cleaning & Disinfection of Resident Care Equipment, dated 5/1/2017 indicated resident- care equipment, including reusable items and durable medical equipment is cleaned and disinfected per current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.

Based on interview and record review, the facility failed to develop a care plan that included for one of one sampled resident (Resident 18), that indicated alternative interventions were implemented for refusal receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions. As a result, Resident 18 ' s blood sugar remained high which can result in complications such as high blood sugar levels such as ketoacidosis (a life-threatening condition that occurs when the body produces too many ketones), kidney failure (failure of the kidney to get rid of toxins and extra fluids, and blindness. Cross Reference to F580 Findings: During a review of Resident 18 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (bone fracture) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with unspecified diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision). During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition. During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders: On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 = 0 UNIT; 151 - 200 = 1 UNIT; 201 - 250 = 2 UNIT; 251 - 300 = 3 UNIT; 301 - 350 = 4 UNIT; 351 - 400 = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, subcutaneously before meals for DM On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS) During a review of Resident 18 ' s Medication Administration Record (MAR) from 11/2024 to 12/2024 indicated Resident 18 refused Insulin Lispro on the following occasions: On 11/30/2024 at 5:00 PM, Resident 18 had a BS of 202 mg/dL On 12/3/2024 at 7:00 AM, Resident 18 had a BS of 217 mg/dL On 12/4/2024 at 5:00 PM, Resident 18 had a BS of 234 mg/dL On 12/7/2024 at 7:00 AM, Resident 18 had a BS of 209 mg/dL On 12/7/2024 at 11:30 AM, Resident 18 had a BS of 248 mg/dL On 12/7/2024 at 5:00 PM, Resident 18 had a BS of 171 mg/dL On 12/8/2024 at 11:30 AM, Resident 18 had a BS of 180 mg/dL On 12/9/2024 at 5:00 PM, Resident 18 had a BS of 178 mg/dL On 12/11/2024 at 5:00 PM, Resident 18 had a BS of 180 mg/dL During a review of Resident 18 ' s Progress Notes from 11/2024 to 12/2024 indicated the following: On 11/30/2024 at 5:37 PM, Resident family member (FM) 1 at bedside and resident declined medication three times, risks and benefits explained and FM 1 said, I know, but I don ' t want her to have any insulin this evening. Her BS was low in the afternoon, and I don ' t want her BS to go down again. No insulin, please. Rights honored. On 12/1/2024 at 5:55 PM, Only 1 unit was administered, FM 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down. On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes. On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware. On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident. On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 mg/dL and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response. On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes. On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware. On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident. On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response. On 12/6/2024 at 4:02 PM, FM 1 was made aware that MD has not given any order per the requested Insulin Glargine. FM 1 said okay that means resident wouldn ' t be having it again today. never mind again. The note indicated no response was received from MD and was endorsed to the next shift. On 12/7/2024 at 5:28 PM, FM 1 was at Resident ' s bedside and decline medication 3 times, risks and benefits explained, verbalized understanding, but declined medication. On 12/9/2024 at 4:40 PM, Resident refused three times, explained risks and benefit but continued to refuse. On 12/11/2024 at 4:56 PM, Resident refused three times, explained risk and benefit, but continued to refuse. During a concurrent interview and record review of Resident 18 ' s MAR from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the Minimum Data Set Registered Nurse (MDS RN), verified Resident 18 refused Insulin Lispro on: 11/30/2024 at 5:00 PM, 12/3/2024 at 7:00 AM, 12/4/2024 at 5:00 PM, 12/7/2024 at 7:00 AM, 11:30 AM, and 5:00 PM, 12/8/2024 at 11:30 AM, 12/9/2024 at 5:00 PM, and 12/11/2024 at 5:00 PM. During a concurrent interview and record review of Resident 18 ' s Progress notes from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the MDS RN could not find documented evidence of a plan of care that addressed Resident 18 ' s refusal to take Insulin Lispro. MDS RN stated staff should inform the physician that Resident 18 was refusing Insulin, to better plan resident ' s care and communicate with the interdisciplinary team. During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated she expects her staff to notify the physician if a resident refuses medication like Insulin. The DON stated it was important to notify the physician so that the physician can give new orders or add something else in Resident 18 ' s care plan. The DON stated a care plan should have been initiated for Resident 18 ' s refusal to take Insulin. During a review of the facility ' s policy and procedure (P&P) titled Refusal of Treatment, dated 10/1/2017 indicated the Interdisciplinary Team will assess the resident ' s needs, and offer the resident alternative treatments while continuing to provide other services in the Care Plan. The P&P indicated when the resident ' s refusal or discontinuance brings about a significant change in the resident ' s condition, a reassessment is made, and new information is incorporated into the resident ' s Care Plan.

Based on interview and record review, the facility failed to ensure the physician was notified for one of one sampled residents (Resident 18), who refused to receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions. This deficient practice had the potential for Resident 18 to not receive appropriate care, treatment and/or services and increased the risk for Resident 18 to be hyperglycemic (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: urinating large amounts of urine, excessive thirst, feeling tired, blurred vision) and suffer from complications of high blood sugar levels such as ketoacidosis (a life-threatening condition that occurs when the body produces too many ketones), kidney failure (failure of the kidney to get rid of toxins and extra fluids, and blindness. Findings: During a review of Resident 18 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (a broken bone that occurs near or around an orthopedic implant, such as a hip or knee replacement) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision). During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition. During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders: On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 mg/dL (milligrams per deciliter) = 0 UNIT; 151 - 200 mg/dL = 1 UNIT; 201 - 250 mg/dL = 2 UNIT; 251 - 300 mg/dL = 3 UNIT; 301 - 350 mg/dL = 4 UNIT; 351 - 400 mg/dL = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, mg/dL subcutaneously before meals for DM On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS) During a review of Resident 18 ' s Medication Administration Record (MAR) from 11/2024 to 12/2024 indicated Resident 18 refused Insulin Lispro on the following occasions: On 11/30/2024 at 5:00 PM, Resident 18 had a BS of 202 mg/dL On 12/3/2024 at 7:00 AM, Resident 18 had a BS of 217 mg/dL On 12/4/2024 at 5:00 PM, Resident 18 had a BS of 234 mg/dL On 12/7/2024 at 7:00 AM, Resident 18 had a BS of 209 mg/dL On 12/7/2024 at 11:30 AM, Resident 18 had a BS of 248 mg/dL On 12/7/2024 at 5:00 PM, Resident 18 had a BS of 171 mg/dL On 12/8/2024 at 11:30 AM, Resident 18 had a BS of 180 mg/dL On 12/9/2024 at 5:00 PM, Resident 18 had a BS of 178 mg/dL On 12/11/2024 at 5:00 PM, Resident 18 had a BS of 180 mg/dL During a review of Resident 18 ' s Progress Notes from 11/2024 to 12/2024 indicated the following: On 11/30/2024 at 5:37 PM, Resident family member (FM) 1 at bedside and resident declined medication three times, risks and benefits explained and FM 1 said, I know, but I don ' t want her to have any insulin this evening. Her BS was low in the afternoon, and I don ' t want her BS to go down again. No insulin, please. Rights honored. On 12/1/2024 at 5:55 PM, Only 1 unit was administered, FM 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down. On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes. On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware. On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident. On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 mg/dL and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response. On 12/6/2024 at 4:02 PM, FM 1 was made aware that MD has not given any order per the requested Insulin Glargine. FM 1 said okay that means resident wouldn ' t be having it again today. never mind again. The note indicated no response was received from MD and was endorsed to the next shift. On 12/7/2024 at 5:28 PM, FM 1 was at Resident ' s bedside and decline medication 3 times, risks and benefits explained, verbalized understanding, but declined medication. On 12/9/2024 at 4:40 PM, Resident refused three times, explained risks and benefit but continued to refuse. On 12/11/2024 at 4:56 PM, Resident refused three times, explained risk and benefit, but continued to refuse. During a concurrent interview and record review of Resident 18 ' s MAR from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the Minimum Data Set Registered Nurse (MDS RN), verified Resident 18 refused Insulin Lispro on: 11/30/2024 at 5 PM, 12/3/2024 at 7AM, 12/4/2024 at 5PM, 12/7/2024 at 7AM, 11:30 AM, and 5PM, 12/8/2024 at 11:30 AM, 12/9/2024 at 5:00 PM, and 12/11/2024 at 5:00 PM. During a concurrent interview and record review of Resident 18 ' s Progress notes from 11/2024 to 12/2024 on 12/14/2024 at 2:32 PM, the MDS RN stated she could not find documented evidence of notification to Resident 18 ' s physician regarding resident ' s refusal to take Insulin Lispro. MDS RN stated staff should inform the physician that Resident 18 was refusing Insulin, to better plan resident ' s care and communicate with the interdisciplinary team. During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated the staff was supposed to notify the physician if a resident refuses medication like Insulin. The DON stated it was important to notify the physician so that the physician can give new orders or add something else in Resident 18 ' s care plan. The DON stated resident refusal to receive insulin was considered a significant change in condition and should be documented in progress notes to include the physician notification. The DON stated a care plan should have been initiated for Resident 18 ' s refusal to take Insulin. During a review of the facility ' s policy and procedure (P&P) titled Refusal of Treatment, dated 10/1/2017 indicated the charge nurse or DON will document information relating to the refusal/discontinuance in the resident ' s medical record that will include at least the date and time the Attending Physician was notified and his or her response. The P&P indicated the Attending Physician will be notified of refusal or discontinuance of treatment in a time frame determined by the resident ' s condition and potential serious consequences of the refusal or discontinuance.

Based on interview and record review the facility failed to follow physician ' s orders for one of one sampled resident (Resident 18) who was receiving Insulin (medication that helps keep blood sugar under control and prevents diabetes [a group of diseases that result in too much sugar in the blood] complications). This deficient practice increased the risk of Resident 18 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as hyperglycemia (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: urinating large amounts of urine, excessive thirst, feeling tired, blurred vision) Findings: During a review of Resident 18 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (bone fracture) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with unspecified diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision). During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition. During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders: On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 = 0 UNIT; 151 - 200 = 1 UNIT; 201 - 250 = 2 UNIT; 251 - 300 = 3 UNIT; 301 - 350 = 4 UNIT; 351 - 400 = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, subcutaneously before meals for DM On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS) During a review of Resident 18 ' s Progress Notes on 12/1/2024 timed at 5:55 PM indicated only 1 unit was administered, Resident 18 ' s Family Member (FM) 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down. During a concurrent interview and record review of Resident 18 ' s Progress notes on 12/14/2024 at 2:28 PM, the MDS RN stated the progress note dated 12/1/2024 timed at 5:55 PM indicated the nurse did not give Insulin as ordered by the physician. The MDS RN stated the nurse should have not given the medication. During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated she expects her staff to always follow the physician orders. The DON stated it was important for staff to follow physician orders to ensure there would not be any negative reaction. During a review of the facility ' s policy and procedure (P&P) titled Medication Administration, dated 7/1/2016 indicated medication will be administered by a licensed nurse per the order of an Attending Physician or licensed independent practitioner. The P&P indicated the Rule of 3 the licensed nurse administering medications will perform 3 checks comparing the physician ' s order, pharmacy label, and medication administration record (MAR).

Based on observation, interview and record review the facility failed to ensure medically related social services were provided to one of two (Resident 11) sampled residents, in accordance with the facility ' s policy and procedure titled Social Services Program, when the Social Services Director [SSD] by failing to follow-up or assist when Resident 11's representative requested for additional information about the Advance Directive (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions). These deficient practices led to a delay in receiving AD information as requested by Resident 11 and the Responsible Party from the facility that could result in the resident not to receive the healthcare needed in an event of an emergency where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: During a review of Resident 11 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), unspecified dementia (loss of memory, language, problem solving and other thinking abilities). During a review of Resident 11 ' s History and Physical [H&P] dated 3/15/2024, the H&P indicated the resident was not able to make her own decisions. During a review of Resident 11 ' s Physicians Order of Life Sustaining Treatment(POLST) dated 12/04/2020, the POLST indicated the resident did not have an Advance Directive. During a review of Resident 11 ' s Advance Healthcare Directive Acknowledgement form dated 3/1/2023, was signed by Resident 11 ' s Responsible Party (RP1) and indicated Resident 11 did not have an Advance Directive and would like to receive more information. During a review of facility provided list titled Advanced Directives Request for Ombudsman, Resident 11 ' s name was not observed in the list. During a concurrent interview and record review of Resident 11 ' s medical chart with the Social Services Director (SSD) on 12/13/2024 at 11:52 AM, the SSD stated his responsible to assists with resident admissions with the Admission Coordinator and licensed nurses. The SSD stated he explains the forms to all the Residents and their representatives on admission. SSD stated when a Resident or Resident Representative marks that they would like more information on Advance Directives on the Advance Directive Acknowledgement form, he calls the Ombudsman to coordinate a visit between Ombudsman and the family to ensure their questions of how to create and Advance Directive were addressed by the Ombudsman. SSD stated he had not referred Resident 11 ' s RP to the Ombudsman as he was unaware, they had requested more information with the previous SSD. During a telephone interview on 12/14/2024 at 4:34 PM with Resident 11 ' s Representative (RP 1), RP 1 stated she had requested more information regarding Advance directive over a year ago from SSD, but no one had followed up. RP 1 stated the facility has had a few different SSD since her initial request and she had followed up this year with the previous SSD but never got a response. During a review of facility ' s P&P titled Social Services Program revised on June 01, 2021, the P&P indicated Medically related social services are provided to residents in order to maintain and improve the resident ' s wellbeing.

Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing), and call 911 (emergency services and/or emergency transfer to the general acute care hospital) for one (1) of three (3) sampled residents (Resident 34), who had a full code status (when resident's heart stopped beating and/or the resident stopped breathing, the resident or his/her representative wished for all lifesaving procedures to be provided to keep the resident alive) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 started CPR on [DATE] at around 11 AM when LVN 1 found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment (POLST, a written medical order that indicated a patient/resident lifesaving treatment wishes), Medical Emergencies- Code Blue (an announcement used to indicate a patient/resident requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a cardiac arrest [the heart stopped beathing/pumping blood) or respiratory arrest [the lungs stopped working/breathing]), and Emergency Care - General. 2. Ensure Registered Nurse (RN) 1 started CPR immediately, provided full CPR with rescue breathing (inhaling into the patient's/resident's airway and lungs using mouth-to-mouth breathing or mechanical breathing), and sent LVN 1 to call 911 after RN 1 entered Resident 34's room on [DATE] at 11:02 AM, and found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment, Medical Emergencies- Code Blue, and Emergency Care - General. As a result, on [DATE], Resident 1 did not receive immediate and full CPR with rescue breathing as indicated in Resident 34's POLST that Resident 34 wished to be resuscitated (to revive [restore to life] from apparent death or from unconsciousness or provided with CPR, to prolong life by all medically effective means). RN 1 pronounced Resident 34 expired on [DATE] at 11:02 AM and informed Resident 34's Attending Physician (Physician 1) on [DATE] at 11:06 AM that Resident 34 had expired. On [DATE] at 8:47 PM, while onsite at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) and the Director of Nursing (DON), regarding the facility's failure to provide basic life support (BLS, the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway), including immediate, full CPR with rescue breathing, and call 911 for Resident 34, who had a full code status on [DATE] at 11:02 AM, and the risk for 20 other residents who were residing in the facility with full code status not receiving immediate and full CPR when those residents' hearts stopped beating and or when they stopped breathing. The IJ was called in the presence of the facility's ADM and DON. On [DATE], at 11:45 AM, the facility submitted an acceptable IJ Removal Plan ([Plan of Action] a list of steps taken to correct the deficient practices). The IJ was removed on [DATE] at 5:12 PM, in the presence of the facility's ADM and DON, while onsite at the facility, after the surveyor verified and confirmed the facility's approved IJ Removal Plan (a detailed plan to address the IJ findings) was fully implemented through observations, interviews, and record reviews, in a manner that eliminated the likelihood of serious injury, serious harm, serious impairment, or death with 20 other residents residing in the facility with full code status. The acceptable IJ Removal Plan, dated [DATE] included the following: a. On [DATE], the Director of Staff Developer (DSD) created the BLS (Basic Life Support) Skills Competency Checklist about Code Blue situation. The DSD would provide the in-service about the BLS and Cod Blue situation to LVN 1 by [DATE] after LVN 1 returned from vacation. b. On [DATE], the DON initiated the in-service education for all Licensed Nurses (LVNs and RNs) from three shifts (morning [7 AM to 3 PM,] evening [3 PM to 11 PM,] and night shifts [11 PM to 7 AM,] on Emergency Care Policy, CPR and calling 911. c. On [DATE], the DSD and the DON initiated the BLS Skills Competency checklist for 15 Licensed Nurses and 16 Certified Nurses Assistants (CNAs) with a target completion date of [DATE]. The BLS Skills Competency Checklist would be completed once a week for four (4) weeks, once a month for three (3) months, then quarterly for one year. d. On [DATE], the DON initiated in-service education for all licensed nurses (in general) who worked on [DATE] for the morning, evening, and night shifts on the facility's policy and procedure [NAME], Change of Condition Notification, for residents who have no pulse, unresponsive, and have undetected vital signs (clinical measurements, specifically pulse rate [number of heart beat per minute], temperature [a measurement of the body making and releasing heat], respiration rate [number of breaths per minute], and blood pressure [the force of the blood pushing against the walls of the arteries/blood vessels]). Any nursing staff (RNs, LVNs and CNAs in general) who did not complete the BLS Skills Competency checklist by [DATE] would not be scheduled to work until they completed the in-service education for the BLS Skills Competency Checklist. e. On [DATE], the DSD initiated weekly mock (simulation/pretend) code blue medical emergency drills for 4 weeks to monitor nursing staff's (in general) compliance with the facility's Emergency Care policy. f. On [DATE], the DON completed the BLS Skills Competency Checklist about Code Blue situation that was created by the DSD for RN 1. g. On [DATE], Medical Record Staff (MRS) 1 completed the audit of all Active Resident POLST forms and uploaded the forms into the online documentation software for electronic medical records for quick reference. h. On [DATE], outside BLS Trainer with BLS instructor credentials from the American Heart Association initiated First Aid CPR training for RNs, LVNs, and CNAs (in general). The BLS trainer would be completed the CPR training for all nursing staff from 3 shifts (morning, evening, and night shifts) by [DATE]. Findings: A review of Resident 34's Face Sheet (admission record) indicated the facility admitted Resident 34 on [DATE], with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke, when something blocked blood supply to part of the brain or when a blood vessel in the brain busted) affected the left non-dominant side. A review of a document titled, Family Medicine Office/Clinic Note, dated [DATE], indicated Resident 34 was alert and oriented to self, time, place, and situation. The note indicated Resident 34 was able to make daily decisions. The Note indicated Resident 34 was doing well. A review of Resident 34's Physician Orders for Life Sustaining Treatment (POLST) dated [DATE], and signed by Resident 34, indicated under Cardiopulmonary Resuscitation (If patient has no pulse and not breathing, showed a handwritten check mark on Attempt/Resuscitation/CPR. The POLST indicated under Medical Interventions showed a check mark on Full Treatment (primary goal of prolonging life by all medically effective means. A review of Resident 34's Progress Notes dated [DATE] timed at 12:53 PM, authored by RN 1 indicated the following events: - At 7 AM, Resident 34 was alert and able to make needs known. The progress note indicated The resident's RR (respiratory rate) was even and unlabored (produced without difficulty or exertion). No SOB (shortness of breath) noted at this time. The resident denied pain. There is no distress noted at this time. The resident is resting comfortably in bed. The resident's VS (vital signs): ,d+[DATE] (blood pressure), 61 (pulse rate), 97.8 (temperature), 19 (respiratory rate), PS (pain status): ,d+[DATE] (0 equal no pain, 10 equal the worst pain). The resident's oxygen saturation (oxygen level in the blood; 95% to 100% are generally considered normal) was 96%. - At 9 AM, Resident 34 was alert and able to make needs known. The note indicated There is no distress noted at this time. - At 10 AM, Resident (34) was alert and able to make needs known. The resident's RR was even and unlabored. No SOB noted at this time. The note indicated the resident is resting comfortably on the bed at this time. - At 11:02 AM, Resident 34 was noted to look pale. The RN could not detect the resident's pulse and blood pressure. The RN pronounced the resident expired at 11:02 AM. - At 11:06 AM, RN 1 notified the resident's primary doctor. The note indicated RN 1 received new order to endorse the resident's body to the mortuary service (as) requested by the family. During an interview with RN 1 and a concurrent review of Resident 34's Progress Notes dated [DATE] timed at 11:02 AM, on [DATE], at 2:49 PM, RN 1 stated on [DATE], when RN 1 entered Resident 34's room, RN 1 checked Resident 34's pulse and blood pressure. RN 1 stated Resident 34 had no vital signs on [DATE]. RN 1 stated Resident 34 looked pale, not responsive, but Resident 34's body was warm to touch. RN 1 stated RN 1 attempted CPR but RN 1 did not call 911 because Resident 34 had expired. RN 1 stated when the vital signs were not detected in a resident (in general), RN 1 would not call 911. RN 1 stated RN 1 attempted to perform CPR on Resident 34, but he did not document that he attempted the CPR on Resident 34 in Resident 34's Nurses Notes. During a continued interview with RN 1 on [DATE] at 3:03 PM, RN 1 stated that on [DATE], RN 1 was alone when RN 1 went into Resident 34's room. RN 1 stated RN 1 did not see Resident 34's chest rose, and Resident 34 looked pale, on [DATE]. RN 1 stated RN 1 tried to get Resident 34's vital signs, on [DATE] but RN 1 could not get any vital signs. RN 1 stated RN 1 left Resident 34's room to check on Resident 34's POLST and immediately went back to Resident 34's room and started to perform CPR by himself. RN 1 stated at the time, Resident 34's skin color looked gray. RN 1 stated, RN 1 performed chest compressions for five minutes. RN 1 stated There was no pulse or vitals, the patient's (Resident 34's) vital signs were gone. During a telephone interview with LVN 1 on [DATE] at 3:05 PM, LVN 1 stated on [DATE] (did not remember exact time) about 30 minutes prior to finding Resident 34 unresponsive, Resident 34 was alert and awake. LVN 1 stated LVN 1 found Resident 34 unresponsive and LVN 1 notified RN 1. LVN 1 stated they (RN 1 and LVN 1) assessed Resident 34 and the resident had no pulse, no blood pressure, nothing. LVN 1 stated Resident 34 was a full code, and they (RN 1 and LVN 1) did not perform CPR on Resident 34. LVN 1 stated LVN 1 did not see RN 1 performed CPR on Resident 34 and they (LVN 1 and RN 1) did not call 911. LVN 1 did not respond when asked why LVN 1 did not perform CPR for Resident 34 knowing Resident 34 was a full code. During an interview with the DON on [DATE], at 3:07 PM, the DON stated when a resident had a full code status, facility staff (in general) needed to attempt CPR, and call 911. The DON stated it was important to call 911 due to the paramedics (medical professionals who specializes in emergency treatment) might be able to revive Resident 34. The DON stated, Full code means you call 911 and at least you try to save the patient (resident). During another interview with RN 1 on [DATE] at 3:28 PM, RN 1 stated on [DATE] (did not state the time) before RN 1 attempted CPR on Resident 34, RN 1 called a code blue but there was nobody (no staff available). RN 1 stated LVN 1 was in Resident 34's room helped RN 1 with putting the papers. RN 1 stated LVN 1 helped immediately, but RN 1 could not recall exactly what LVN 1 did during that time. RN 1 stated after 5 minutes of performing CPR on Resident 34, RN 1 notified Physician 1 that Resident 34 had expired. During an interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 3:28 PM, CNA 1 stated she was assigned to Resident 34 and was on lunch break on [DATE] (did not remember the time), when RN 1 found Resident 34 unresponsive. CNA 1 stated when she returned from lunch break, Resident 34 had already expired. CNA 1 stated she did not recall any code blue being called on [DATE]. During a telephone interview with CNA 2 on [DATE] at 4:22 PM, CNA 2 stated she worked on [DATE] (with CNA 1) during the 7 AM to 3 PM shift. CNA 2 recalled that on [DATE] (did not remember exact time), during the morning shift, Resident 34 was alert and awake. CNA 2 stated on [DATE], none of the facility's staff called a Code Blue. During a telephone interview with Resident 34's family member (Family) 1 on [DATE] at 4:25 PM, Family 1 stated Resident 34 changed Resident 34's POLST around a month before Resident 34 passed away to full code status. Family 1 stated Resident 34 wished to receive full medical treatment including CPR. During a concurrent review of Resident 34's Progress Notes, dated [DATE], timed 11:02 AM, and interview with the DON on [DATE] at 5:03 PM, the DON stated a physician (in general) needed to pronounce Resident 34 expired and not RN 1. The DON stated RN 1 should have called 911 and 911's staff (paramedics) would pronounce when Resident 34 expired. The DON stated the paramedics needed to check if there was no more life or if they (the paramedics) can provide Advance Life Support (ALS, referred to as Advanced Cardiac Life Support [ACLS], was a set of life-saving protocols and skills that extend beyond BLS) to revive Resident 34, especially Resident 34 had a full code status. During another interview with RN 1 on [DATE] at 5:12 PM, RN 1 stated he needed to call 911 and performed CPR until the physician (in general) pronounced the resident's death. RN 1 stated he could not recall how many chest compressions he performed and RN 1 stated he did not use a bag valve mask (BVM, a type of device known as a bag valve mask, used to provide respiratory support to patients/residents) to provide rescue breathing, RN 1 stated I just try to pump her heart. During a telephone interview on [DATE] at 5:24 PM with Physician 1, who was also the facility's Medical Director, stated that the expectation for the licensed nurses during emergency situations was to perform CPR for full code residents and someone is delegated to call the attending physician or 911. Physician 1 stated it was acceptable for licensed nurses to call 911 first before calling the physician if the resident was not breathing. Physician 1 stated they (licensed nurses) do have the ability to call 911 . for a full code resident. During a concurrent interview and record review on [DATE] at 6:01 PM. The facility's policy and procedure titled, Emergency Care, dated [DATE] (the current policy and procedure provided by the facility), indicated for staff to immediately call 911 for medical emergency assistance during an emergency. The DON stated during emergency situations, facility's staff (in general) needed follow the facility's policy. The DON stated 911 emergency services needed to be called when Resident 34 was not breathing, pulseless, and/or unresponsive, to get help from the paramedics and preserve Resident 34's life. A review of the facility's policy and procedure titled, Emergency Care - General, revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to give emergency treatment to residents .to prevent further harm, and promote recovery. The policy indicated for facility's staff to determine the nature of the injury/illness .and to summon help and immediately call 911 for medical emergency assistance. The policy indicated these emergency situations would include but are not limited to Cessation of breathing (stop breathing), blockage of airway, pulseless victim .new onset of unconsciousness or unresponsiveness to verbal or physical stimuli. The policy indicated the licensed nurse's role during a code blue included to lead the code blue in the absence of a physician and coordinate the resuscitation efforts until paramedics arrive. The policy indicated that the licensed nurse would assure that . CPR has been initiated, 911 had been called, code blue had been paged overhead, and emergency cart was on the scene. A review of the facility's policy and procedures titled, Medical Emergencies- Code Blue, revised on [DATE] (the current policy and procedure provided by the facility), indicated the following information: 1. The first of facility personnel to arrive and find a resident with any of the above condition . that included Respiratory or Cardiac arrest, should call for help. 2. Send available staff to call a Code Blue and retrieve emergency medical equipment: 3. Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to current practice. A review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST), revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to help ensure that Facility honors residents' treatment wishes concerning resuscitation and life sustaining treatment. The policy indicated The POLST is a voluntary form used statewide as a physician order form that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders. The policy further indicated A valid POLST form is to be honored across treatment settings. A review of the facility's policy and procedure titled Change of Condition Notification, revised on [DATE] (the current policy and procedure provided by the facility), indicated the definition of an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The policy indicated If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. A review of the American Heart Association CRP & First Aid Emergency Cardiovascular Care website titled, Algorithms, for the year of 2023, the website indicated for adults, look for no breathing or only gasping and check pulse (simultaneously) and if pulse is felt within 10 seconds with no normal breathing, then to provide rescue breathing, one (1) breath every six (6) seconds or 10 breaths per minute, check pulse every two (2) minutes and if no pulse, start CPR. The website indicated, when CPR is started, perform cycles of 30 chest compressions and two (2) breaths and resume CPR cycles until an ALS provider arrived over or the victim started to move. [https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms#adult]