Every finding on record at Artesia Healthcare & Rehabilitation Center, LLC

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 3 (R #46, R #55, and R #60) of 6 (R #1, R #7, R #9, R #46, R #55 and R #60) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: R#46A. Record review of R #46's physician's orders revealed an order dated 06/06/23 for Melatonin (a supplement), nine milligrams (mg) to be given by mouth at bedtime for insomnia (a common sleep disorder).B. Record review of R #46's medical record revealed no consent form for the use of Melatonin.C. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed staff did not obtain the required consent form for the use of Melatonin prior to R #46 using of medication. The DON confirmed that staff are expected to complete the psychotropic medication (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior) consent forms prior to the resident starting psychotropic medications.R #55D. Record review of R #55's physician's orders revealed the following:1. An order dated 07/09/25 for Melatonin, five mg to be given by mouth one time a day for insomnia.2. An order dated 12/30/25 for Alprazolam (anti-anxiety medication), one mg to be given by mouth three times a day for anxiety/restlessness.E. Record review of R #55's medical record revealed no consent forms for the use of Melatonin and Alprazolam.F. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed staff did not obtain the consent form for the use of Melatonin and Alprazolam for R #55 prior to the use of medication. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications and did not.R #60G. Record review of R #60's physician's orders revealed the following:1. An order dated 02/17/26 for Melatonin, mg to be given by mouth at bedtime for Insomnia.2. An order dated 02/17/26 for Olanzapine (anti-psychotic medication), a total of five mg to be given by mouth in the morning for schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly).3. An order dated 02/19/26 for Olanzapine (anti-psychotic medication), fifteen mg to be given by mouth at bedtime for schizophrenia.4. An order dated 07/17/26 for Gabapentin (anti-convulsant medication), 100 mg to be given by mouth three times a day for pain/bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).H. Record review of R #60's medical record revealed there were no consent forms for the use of Melatonin, Olanzapine, and Gabapentin.I. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed staff did not obtain the consent forms for the use of Melatonin, Olanzapine, and Gabapentin for R #60 prior to the use of medications. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications.

Based on observation and interviews, the facility failed to maintain a clean, safe, and comfortable environment for 11 (R #1, R #4, R #20, R #25, R #28, R #32, R #46, R #50, R #51, R #55, and R #61) of 15 (R #1, R #2, R #4, R #18, R #20, R #25, R #28, R #32, R #42, R #46, R #50, R #51, R #55, R #61, and R #63) residents reviewed when staff failed to:1) Repair broken outlet covers in resident rooms #301 and #305.2) Repair damaged drywall in resident rooms #203, #208, #209, #212, #301, #302 and #305.3) Empty trash timely room [ROOM NUMBER].4) Repair or repaint handrails throughout the building.Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. These deficient practices could likely result in residents feeling frustrated, embarrassed, and unimportant. The findings are:Broken/Missing outlet coversA. On 02/22/26 at 12:22 pm, a random observation of residents' rooms revealed:- room [ROOM NUMBER] had a missing outlet cover on the wall near the bed.- room [ROOM NUMBER] had a missing outlet cover on the wall by the air conditioning unit.- room [ROOM NUMBER] had a broken outlet cover on the wall by the bed.Damaged DrywallB. On 02/22/26 at 12:43 pm, a random observation of resident rooms revealed:- room [ROOM NUMBER] had a large crack on the wall from floor to ceiling and chipped paint and scuff marks around the bottom of the wall, bottom of closet and bottom near bathroom door.- room [ROOM NUMBER] had damage to drywall, chipped paint and scuff marks around the bottom of the wall and the bottom of closet.- room [ROOM NUMBER] had damage to drywall, chipped paint and scuff marks around the bottom of the wall and bottom of closet. -room [ROOM NUMBER] had damage to drywall, chipped paint and scuff marks around the bottom of the wall and bottom of closet.- room [ROOM NUMBER] had a visible hole approximately the size of a quarter in the wall near bed.TrashC. On 02/23/26 at 12:50 pm, a random observation of resident room [ROOM NUMBER] revealed the trash was overflowing out of the trash bin and onto the floor.HANDRAILSD. On 02/22/25 at 9:55 am during an observation of the 100 hall, 200 hall, and 300 hall revealed the handrails were scuffed and chipped with paint missing in many places on the handrail.E. On 2/22/26 at 10:00 am during an interview Licensed Practical Nurse (LPN) #2, she confirmed the handrails needed to be touched up with paint due to the peeling and chipping.F. On 02/24/26 2:37 pm during an interview with Director of Nursing (DON) she stated the facility should be safe, clean, neat and orderly at all times.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #55 and R #60) of 3 (R #3, R #55 and R #60) residents reviewed for unnecessary medications, when staff failed to ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: R #55A. Record review of R #55's admission record revealed R #55 was admitted to the facility on [DATE] with the following diagnoses:1. End stage renal disease (ESRD; chronic irreversible kidney failure),2. Adult failure to thrive (a rapid or gradual, unexplained, and severe decline in physical and/or cognitive function, typically in older adults),3. Anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life),4. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),5. Opioid dependance (state of adaptation that occurs with regular, long-term use of opioid drugs). B. Record review of R #55's physician's orders revealed an order dated 07/09/25 for Melatonin, five milligrams (mg) to be given by mouth one time a day for insomnia. C. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. R #55's indicated use of Melatonin is insomnia,2. R #55 does not have a diagnosis for insomnia,3. Medications should be documented to treat specific conditions as diagnosed and this was not. R#60 D. Record review of R #60's admission record revealed R #60 was admitted to the facility on [DATE] with the following diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Bacteremia (presence of bacteria and infectious organisms in the blood stream),4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste),6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug treatments),7. Burn of third degree (destroys both the outer epidermis and the underlying dermis) of left lower limb,8. Cannabis (marijuana) use,9. Stimulant (a class of drugs that speed up messages travelling between the brain and body) use,10. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior). E. Record review of R #60's physician's orders revealed an order dated 02/17/26 for Melatonin (a supplement), five milligrams (mg) to be given by mouth at bedtime for Insomnia (a common sleep disorder). F. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed the following:1. R #60's indicated use of Melatonin is insomnia,2. R #60 does not have a diagnosis for insomnia,3. Medications should be documented to treat specific conditions as diagnosed and this was not.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 3 (R #18, R #47, and R #60) of 6 (R #1, R #2, R #18, R #26, R #47, and R #60) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #18 A. Record review of R #18's admission record revealed R #18 was admitted into the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Cirrhosis (chronic liver damage leading to scarring and liver failure) of the liver, 3. Critical illness myopathy (diseases that cause weakness, pain, or stiffness in the muscles), 4. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm), 5. Nicotine dependence (uses tobacco). B. On 02/22/26 at 2:28 pm during an observation R #18, she removed her upper denture (removeable plate or frame holding artificial teeth), and it was observed that her lower teeth are missing, broken or have cavities (a hole or empty space in a tooth). C. Record review of R #18's baseline care plan dated 10/24/25 revealed R #18 her has own teeth and dentures were not indicated. D. On 02/26/26 at 2:48 pm, during an interview with Director of Nursing (DON), she indicated that R #18's upper denture and other dental issues should have been indicated on the baseline care plan. E. Record review of R #60's admission record revealed R #60 was admitted to the facility on [DATE] with the following diagnoses: 1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly), 2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 3. Bacteremia (presence of bacteria and infectious organisms in the blood stream), 4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste), 6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug treatments), 7. Burn of third degree (destroys both the outer epidermis and the underlying dermis) of left lower limb, 8. Cannabis (marijuana) use, 9. Stimulant (a class of drugs that speed up messages travelling between the brain and body) use, 10. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior). F. Record review of R #60's baseline care plan dated 02/17/26 revealed: 1. R #60 is partial weight bearing and requires two-person assist (assistance by two staff members). 2. R #60 had multiple scabs and burns all over his body. 3. No instructions or indications of wound/injury care were indicated in the care plan. 4. R #60's frequency of pain was constant with a pain level of 5. 5. No instructions or indications of pain or monitoring of pain were included in the care plan. 6. R #60 is a risk for falls. 7. No instructions or indications of R #60's risk for falls were included in the care plan. 8. R #60 has an infection. 9. No instructions or indications of R #60's infection were included in the care plan, 10. R #60 has orders for anti-psychotic medication. 11. No instructions or indications of R #60's use of anti-psychotic medications were included in the care plan. G. Record review of R #60's physician orders revealed an order dated 02/17/26 for Olanzapine (anti-psychotic medication), five milligrams (mg) to be given by mouth in the morning for schizophrenia. H. On 02/23/26 at 9:58 am during an interview with the Infection Control Nurse (ICN) she confirmed: 1. R #60 was admitted into the facility with Morganii (gram-negative rod bacterium) and Carbapenem-resistant Acinetobacter baumannii (CRAB; a type of bacteria that is resistant to many antibiotics), 2. R #60 has an open wound, 3. R #60 is on transmission-based precautions (used to prevent the spread of infectious agents from individuals who are suspected to be infected. Includes contact precautions, droplet precautions, and airborne precautions. Examples are wearing gloves, face masks, and gowns or using disposable equipment). I. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed the baseline care plan does not include minimum healthcare information necessary to properly care for R #60 and this does not meet her expectations.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 3 (R #4 and R #7) of 4 (R #4, R #7, R #26, and R #55) residents reviewed when staff failed to:1. Revise R #4's care plan to:-Include use of a camera in R #4's room,-Include appropriate interventions for falls,-Include the changes in R #4's diet,-Remove the use of oxygen therapy,2. Revise R #7's care plan to remove the use of insulin therapy.These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are:R #4 A. Record review of R #4's admission record revealed R #4 was admitted into the facility on [DATE]. B. Record review of R #4's physician orders revealed: 1. An order dated 02/16/26 for R #4 to be on a regular diet, pureed texture (a texture modified diet that requires no chewing), regular/thin consistency fluids. 2. An order dated 02/14/26 for oxygen at two liters per minute (L/M) via nasal cannula (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) continuously with a humidified concentrator (a medical device that filters surrounding air to deliver oxygen) and portable tank (mobile containers designed for storing gases). 3. An order dated 02/14/26 for oxygen at two liters via nasal canula continuous with approval to wean off (reduce or slowly discontinue) oxygen. C. Record review of R #4's progress notes revealed: 1. On 11/14/25 R #4 had an unwitnessed fall, 2. On 11/20/25 R #4 had a witnessed fall, 3. On 12/04/25 R #4 had an unwitnessed fall, 4. On 02/04/26 R #4 had an assisted fall. D. Record review of R #4's care plan, last revised on 01/23/26, revealed the following: 1. No goals, instructions, or indications of care for the use of camera in R #4's room, 2. There were no revisions to include interventions for falls that occurred on 11/14/25, 11/20/25, 12/04/26, and 02/04/26. 3. R #4 is on a regular diet, mechanical soft texture (a texture modified diet that requires some chewing but less than a regular diet) and regular/thin liquid consistency. 4. R #4 has oxygen therapy due to sleep apnea. E. On 02/22/26 at 2:26 pm a random observation of R #4's room, revealed: 1. A device that appeared to be a camera above R #4's bed facing towards R #4 as he lay asleep in bed. 2. R #4 was not wearing oxygen and there was not a concentrator in his room. F. On 02/26/26 at 2:54 pm during an interview with the Director of Nursing (DON) she confirmed the following: 1. R #4 has a camera in his room that is used to monitor seizure activity when R #4 is lying in bed. She stated staff are instructed to reposition the camera away or turn off the camera during care to ensure privacy. 2. The use of the camera should be included in the care plan, and it is not. 3. R #4's care plan for fall risk interventions does not include interventions for falls that occurred after 11/05/25. 4. The diet texture listed in R #4's care plan is incorrect; it should state that R #4 is on a puree diet. 5. R #4 is not on continuous oxygen; the care plan should have been revised to remove continuous oxygen, and it was not. R #7 G. Record review of R #7's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep), 2. Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 3. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Generalized anxiety disorder (an overall feeling of fear or apprehension), 5. Type 2 Diabetes mellitus with unspecified complications (DM2, a condition that results from insufficient production of insulin, causing high blood sugar). H. Record review of R #7's physician record revealed an order for Insulin Glargine (a medication used to control blood sugar levels) fifteen units subcutaneously (under the skin) every day for (DM2) that was discontinued on 10/21/25. I. Record review of R #7's care plan, revised on 05/22/25 revealed an intervention to inject Insulin Glargine.

Based on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.1. Registered nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census.The deficient practice has the potential to affect all 51 residents as identified by the census provided by the Manager on Duty (MOD) on 02/22/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 02/22/26 at 9:30 am a random observation of the facility revealed the facility's staff data posting was dated 02/21/26.B. On 02/22/26 at 9:40 am, during an interview with the MOD, she confirmed the staff data posting was for 02/21/26 and had not been updated daily.

Based on record review and interview, the facility failed to ensure each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring indication of use is based on the residents' current diagnosis for 8 (R #1, R #4, R #7, R #9, R #46, R #55, R #60, and R # 63) of 9 (R #1, R #4, R #6, R #7, R #9, R #46, R #55, R #60,and R #63) residents reviewed for unnecessary medication. This deficient practice cold likely lead to adverse drug effects and poor patient outcomes. The findings are:R #1 A. Record review of R #1's admission record revealed R #55 was admitted into the facility on [DATE] with the following diagnoses: 1. Hypertension (HTN; high blood pressure), 2. Hypoglycemia (low blood sugar), 3. Localized edema (the swelling of a specific body area), 4. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior). B. Record review of R #1's physician orders revealed an order dated 02/18/26 for Ropinirole Hydrochloride (a dopamine agonist medication) oral tablet one milligram (MG) to be given by mouth one time a day for restless leg syndrome (RLS; a common neurological disorder causing an irresistible urge to move legs). C. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #1's indicated use of Ropinirole Hydrochloride is RLS, 2. R #1 does not have a diagnosis for RLS, 3. Medications should be documented to treat specific conditions as diagnosed and this was not. R #46 D. Record review of R #46's admission record revealed R #46 was admitted into the facility on [DATE] with the following diagnoses: 1. Type 2 Diabetes Mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol), 4. Hypercholesterolemia (dangerously high levels of LDL (bad) cholesterol), 5. Insomnia (sleep disorder that can make it hard to fall asleep or stay asleep), 6. Hypertension (HTN; high blood pressure), 7. Chronic kidney disease (CKD; impaired kidney function). E. Record review of R #46's physician's orders revealed the following: 1. An order dated 06/06/23 for Allopurinol (anti-inflammatory medication) oral tablet, 200 MG to be given by mouth one time a day for GOUT. 2. An order dated 12/21/23 for Keppra (anti-convulsant medication) oral tablet, 750 MG to be given by mouth two times a day for seizures. F. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed the following: 1. R #46's indicated use of Allopurinol is gout, 2. R #46 does not have a diagnosis for gout, 3. R #46's indicated use of Keppra is seizures, 4. R #46 does not have a diagnosis for seizures, 5. Medications should be documented to treat specific conditions as diagnosed and these were not. R #55 G. Record review of R #55's admission record revealed R #55 was admitted into the facility on [DATE] with the following diagnoses: 1. End stage renal disease (ESRD; chronic irreversible kidney failure), 2. Adult failure to thrive (a rapid or gradual, unexplained, and severe decline in physical and/or cognitive function, typically in older adults), 3. Anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life), 4. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 5. Opioid dependance (state of adaptation that occurs with regular, long-term use of opioid drugs), H. Record review of R #55's physician's orders revealed the following: 1. An order dated 11/01/25 for Gabapentin capsule (anti-convulsant medication), 300 MG to be given by mouth three times a day for neuropathy pain. 2. An order dated 01/15/26 for Torsemide (diuretic; water pill) oral tablet twenty MG to be given by mouth one time a day for Diuretic therapy. Start Date-01/15/26 I. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed the following: 1. R #55's indicated use of Gabapentin is neuropathy pain, 2. R #55 does not have a diagnosis for neuropathy, 3. R #55's indicated use of Torsemide is diuretic therapy. 3 Diuretic therapy is not an appropriate indication of use for medication and does not meet her expectations. 4. Medications should be documented to treat specific conditions as diagnosed and these were not. R#60 J. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE] with the following diagnoses: 1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly), 2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 3. Bacteremia (presence of bacteria and infectious organisms in the blood stream), 4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste), 6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug treatments), 7. Burn of third degree (destroys both the outer epidermis and the underlying dermis) of left lower limb, 8. Cannabis (marijuana) use, 9. Stimulant (a class of drugs that speed up messages travelling between the brain and body) use, 10. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior). K. Record review of R #60's physician's orders revealed the following: 1. An order dated 02/17/26 for Suboxone (a dual medication [buprenorphine; pain management medication and naloxone; medication used to reverse opioid overdose] used to reduce craving and withdrawal symptoms such as pain, from opioid [pain killer medications] dependance) sublingual film (thin dissolvable strip absorbed under the tongue) 8-2 milligrams MG to be given three times a day for opioid use disorder. 2. An order dated 02/17/26 for Methocarbamol (muscle relaxer medication) oral tablet 500 MG to be given by mouth four times a day for muscle relaxer. 3. An order dated 02/17/26 for Benztropine Mesylate (anticholinergic agent; use to treat involuntary movements) oral tablet 0.5 MG to be given by mouth at bedtime for muscle stiffness/tremors. L. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed the following: 1. R #60's indicated use of suboxone is opioid disorder, 2. R #60 does not have a diagnosis for opioid disorder, 3. R #60's indicated use of Methocarbamol is muscle relaxer. 3 Muscle relaxer is not an appropriate indication of use for medication and does not meet her expectations. 4. R #60's indicated use of Benztropine Mesylate is stiffness/tremors. 5. R #60 does not have a diagnosis for stiffness/tremors. 6. Medications should be documented to treat specific conditions as diagnosed and these were not. R #7 M. Record review of R #7's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep), 2. Depression, unspecified (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 3. Bipolar disorder, unspecified (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Generalized anxiety disorder (an overall feeling of fear or apprehension). N. Record review of R #7's physician orders revealed an order dated 12/08/25 for Risperidone (anti-psychotic medication) oral tablet 0.25 MG to be given once daily for aggressive behaviors. O. On 02/26/26 at 2:54 pm, during an interview with the DON, she confirmed that R #7 does not have a diagnosis of aggressive behaviors. R #9 P. Record review of R #9's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Dementia with other behavior disturbance (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment that affect behaviors), 2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 3. Need for assistance with personal care (requirement for help with daily activities that individuals may need help with). Q. Record review of R #9's physician orders revealed the following: 1. An order dated 03/31/23 for Melatonin oral capsule three MG to be given by mouth at bedtime for agitation. 2. An order dated 11/27/24 for Risperidone tablet one MG to be given by mouth daily for unspecified dementia. R. Record review of R #9's monthly Medication Administration Record (MAR) for February 2026 revealed: 1. R #9 was administered Melatonin nightly from 02/01/26-02/25/26. 2. R #9 was administered Risperidone once daily from 02/01/26-02-05-26. 3. R #9 was not being monitored for side effects of the risperidone (antipsychotic medication). 4. R #9 was not being monitored for number of hours of sleep at night to warrant the continued use of the melatonin. S. On 02/26/26 at 3:00 pm, during an interview with the DON, she confirmed the following: 2. R #9 has an active order for risperidone and does not have an order for monitoring for side effects for this medication. 3. The indication of use for R #9's use of Melatonin is agitation but R #9 does not have a diagnosis of agitation and agitation is not an appropriate indication of use. 4. R #9 does not have a diagnosis of insomnia. R #63 T. Record review of R #63's admission record revealed he was admitted into the facility on [DATE] with the following diagnoses: 1. Gangrene (a medical emergency in which blood stops flowing to specific parts of the body, and tissues in that area die), 2. Frostbite with tissue necrosis of right fingers, left fingers, right toes, and left toes (an injury caused by freezing of the skin and underlying tissues, resulting in damage to the skin and deeper tissues), 3. Need for assistance with personal care (requirement for help with daily activities that individuals may need help with), 4. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly). U. Record review of R #63's physician orders revealed the following: 1. An order dated 02/18/26 for Sertraline (HCl) oral tablet fifty MG to be given by mouth once daily for depression. 2. An order dated 02/21/26 for Olanzapine fifteen MG oral tablet to be given by mouth once daily for schizophrenia. 3. An order dated 02/22/26 for behavior monitoring due to antidepressant use. 4. An order dated 02/22/26 for anti-psychotic medication-monitoring for side effects of medication as needed. V. Record review of R #63's MAR dated February 2026 revealed: 1. Resident #63 was administered Sertraline daily from 02/18/26-02/25/26. 2. Resident #63 was administered Olanzapine daily from 02/18/26-02/25/26. 3. Resident #63 was not monitored for side effects of an antidepressant while on Sertraline from 02/18/26-02/25/26. 4. Resident #63 was not monitored for psychotic behaviors while on Olanzapine from 02/18/26-02/25/26. W. On 02/26/26 at 3:00 pm during an interview with the DON, she confirmed R #63 does not have behavior monitoring for the antipsychotic medication olanzapine and does not have side effect monitoring for the antidepressant medication he takes.R #63's medication regimen and monitoring of psychotropic medications does not meet her expectations, because psychotropic medications should be monitored for behaviors and side effects while the residents are taking these medications.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to ensure:1. Staff wore hairnets and beard nets while in the kitchen. 2. Food items were labeled and dated.These deficient practices are likely to affect all 51 residents listed on the resident census list provided by the Administrator on 02/22/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and food stored properly. The findings are:A. On 02/22/26 at 9:46 am, an observation of the kitchen revealed Dietary Aid (DA) #1 not wearing a beard net (a type of hair net used for facial hair).B. On 02/22/26 at 9:48 am during an interview with Dietary Assistant Manager (DAM), she confirmed that DA #1 was not properly wearing a beard net. She stated her expectation is for all staff to properly wear hairnets and beard nets while in the kitchen or serving food.C. On 02/22/26 at 9:51 am, an observation of the kitchen revealed the following:1. A bag of what appeared to be Tator tots that was not labeled or dated2. A bag of what appeared to be meatballs that was not labeled or dated.3. A bag of what appeared to be French fries that was not labeled or dated.D. On 02/22/26 at 9:57 am, during an interview with the Dietary Aide (DA) #1, he confirmed the items in the freezer were not labeled and dated. He confirmed the items in the freezer should be labeled and dated.

Based on record review and interview the facility failed to ensure residents were only liable for services rendered for 1 (R #64) of 4 (R #3, R #8, R #59 and R #64) residents reviewed for discharge when the facility failed to refund the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge. The findings are:A. Record review of R #64's Electronic Health Record (EHR) revealed R #64 was discharged on 10/22/25.B. On 02/26/26 at 12:22 pm, during an interview with the Business Office Manager, she confirmed1. R #64 was owed a refund for October and November of 2025, 2. The facility received payment in November and should not have,3. The facility failed to refund October within 30 days of discharge,4. The refund was mailed to R #64 on 02/20/26, approximately 120 days after discharge.

Based on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis or need for secondary screening for 2 (R #26 and R #31) of 5 (R #18, R #26, R #31, R #45, and R #55) residents reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.The findings are:R #26A. Record review of R #26's face sheet indicated that R #26 was admitted to the facility on [DATE] with the following medical diagnoses:1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness, reduced muscle strength, or impaired motor control affecting one entire side of the body) following cerebral infarct (stroke) affecting right dominant side,2. Type II diabetes (DM2, a condition results from insufficient production of insulin, causing high blood sugar),3. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),4. Mixed anxiety (feelings of fear or apprehension) and depression.B. Record review of R #26's PASARR form dated 06/20/25 revealed a PASARR level II was required.C. On 02/26/26 at 3:29 pm, during an interview with the Director of Nursing (DON), she stated that the PASRR section E, should not have indicated the need for PASRR 2 evaluation and the form was not filled out correctly. The DON stated that this form does not meet her expectations because it is incorrect. R #31D. Record review of R #31's face sheet indicated that R #31 was admitted to the facility on [DATE] with the following medical diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Psychoactive substance abuse (non-medical use of substances that alter brain function, resulting in significant physical, social or psychological harm),3. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety).E. Record review of PASRR dated 12/29/25 section E indicated R #31 had no mental health illnesses issues.F. On 02/26/26 at 3:29 pm, during an interview with the DON, she stated that the PASRR should have indicated the schizophrenia diagnoses in this section and it does not. The DON stated this did not meet her expectations because it is incorrect.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #4) of 4 (R #1, R #2, R #4, and R #26) residents reviewed for care plans when staff failed to implement R #4's care plan for falls by utilizing the fall mat. This deficient practice could likely result in proper care not being provided to residents.The findings are: A. Record review of R #4's admission record revealed R #4 was admitted into the facility on [DATE].B. Record review of R #4's care plan, last revised on 03/31/25, revealed an intervention to offer fall mat as indicated.C. On 02/22/26 at 2:26 pm, a random observation of R #4's room, revealed R #4 was lying in bed and the fall mat was located underneath his bed.D. On 02/22/26 at 2:37 pm, during an interview with Registered Nurse (RN) #2 she confirmed R #4's fall mat was not placed correctly, and that it should be placed on the floor next to his bed.E. On 02/26/26 at 2:54 pm during an interview with the Director of Nursing (DON) she confirmed the recommended use of R #4's fall mat was to be placed on the floor next to his bed when he is lying in his bed. She confirmed the care plan is not person centered and should indicate what the specific recommendations are.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #42) of 1 (R #42) resident reviewed when the staff failed to follow physician orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:Cross Reference 760A. Record review of R #42's physician's orders revealed an order dated 10/24/25 for Losartan (angiotensin(hormone) receptor blocker to treat high blood pressure) 25 milligrams (mg), give half tablet by mouth one time a day for hypertension. Notify MD (Medical Doctor) for hold orders if SBP (systolic (top number of blood pressure) blood pressure) less than 110 or DBP (diastolic (bottom number) blood pressure) less than 60 or pulse less than 60.B. On 02/25/26 at 8:54 am, during an observation of medication administration, Licensed Practical Nurse (LPN) #2 reported a blood pressure reading of 103/61. She then administered the medication outside the prescribed parameters. C. On 02/26/26 at 3:45 pm, during an interview with the Director of Nursing (DON), she stated that staff who are passing medications should follow orders as written, this does not meet her expectations for medication administration.

Based on record review, and interview, the facility failed to provide quality of care when staff failed to implement and follow discharge orders for wound care for 1 (R #60) of 3 (R #1, R #4, and R #60) resident reviewed. These deficient practices could likely result in residents to not getting the treatment needed and/or potentially worsening conditions. The findings are:A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE] with the following diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Bacteremia (presence of bacteria and infectious organisms in the blood stream),4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste),6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug treatments),7. Burn of third degree (destroys both the outer epidermis and the underlying dermis) of left lower limb,8. Cannabis (marijuana) use,9. Stimulant (a class of drugs that speed up messages travelling between the brain and body) use,10. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior).B. Record review of R #60's hospital discharge order dated 02/16/26 revealed the following wound care instructions: 1. Change dressing to right hand and both legs every 5-7 days. Cleanse with soap and water, pat dry and apply mepilex ag dressing (a soft, conformable antimicrobial foam dressing with silver, designed to manage low-to-moderately exuding wounds-such as burns, pressure ulcers, and surgical wounds-while minimizing pain and trauma upon removal), secure with kerlix (sterile gauze) or tape.2. Apply moisturizer four times a day to face, left hand, healed areas on both legs.C. Record review of R #60's electronic health record revealed there were no physician orders for wound care or moisturizer.D. Record review of R #60's baseline care plan dated 02/17/26 revealed R #60 had multiple scabs and burns all over his body. No instructions or interventions were included in the care plan for how to care for R #60's wounds and injuries.E. On 02/23/26 at 9:58 am during an interview with the infection control nurse (ICN) she confirmed that R #60 has an open wound. She stated she applied gauze covering to the wound on his right leg because the wound was sticking to his pants.F. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed R #60 does not have orders and care plan interventions for wound care treatment and should. R #60 came to facility with wound care instructions. They were not followed and were not implemented. This practice did not meet her expectations.

Based on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #60) of 2 (R #1 and R #60) residents reviewed for pain when the facility failed to:1. Administer medications as per physician's orders.2. Monitor pain.3. Implement a care plan and interventions for pain management.This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life. The findings are: A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE] with the following diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Bacteremia (presence of bacteria and infectious organisms in the blood stream),4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste),6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug treatments),7. Burn of third degree (destroys both the outer epidermis and the underlying dermis) of left lower limb,8. Cannabis (marijuana) use,9. Stimulant (a class of drugs that speed up messages travelling between the brain and body) use,10. Psychoactive substance use (consumption of substances that alter brain function, affecting mood, perception, consciousness, and behavior).B. Record review of R #60's physician's orders revealed the following:1. An order dated 02/17/26 for Suboxone (a dual medication [buprenorphine; pain management medication and naloxone; medication used to reverse opioid overdose] used to reduce craving and withdrawal symptoms such as pain, from opioid [pain killer medications] dependance) Sublingual film (thin dissolvable strip absorbed under the tongue) 8-2 milligrams (MG). Give one sublingually three times a day for opioid use disorder.2. An order dated 02/17/26 for Oxycodone Hydrochloride (pain medication) oral tablet fifteen milligrams (MG) to be given by mouth every four hours as needed for moderate pain.3. An order dated 02/17/26 for Tylenol (pain medication) Oral Tablet 325 milligrams (MG). Give two tablets by mouth every six hours as needed for pain or fever.4. No order for monitoring of pain.C. Record review of R #60's Medication Administration Record (MAR; a tool used to document the daily administration of medications) dated February 2026 revealed:1. R #60 did not receive suboxone on 02/17/26, 02/18/26, 02/19/26, and 02/20/26; approximately four days due to medication not available.2. R #60 has not been administered Oxycodone.3. R #60 has not been administered Tylenol.4. There is no documented pain level.D. Record review of R #60's baseline care plan dated 02/17/26 revealed R #60's frequency of pain was constant with a pain level of five (moderate pain). No instructions or indications of pain was included in the care plan.E. On 02/25/26 at 2:42 pm, during an interview with R #60, he stated his pain is usually at a ten (worst pain imaginable on a pain scale of 0-10).F. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed:1. R #60 did not receive his suboxone medications as ordered due to the medication not being available in the facility.2. R #60 did not receive Oxycodone or Tylenol during the days suboxone was not available.3. R #60's pain level was not monitored during the days that the suboxone medication was not available because pain monitoring has not been done for this resident. 4. R #60 does not have pain monitoring and should.5. R #60 does not have care plan that includes instructions and interventions for pain management and he should.

Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #60) of 2 (R #46 and R #60) residents reviewed for bedrails. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are:A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE]. B. Record review of R #60's physician orders revealed no order for the use of bedrails.C. Record review of R #60's bedrail assessment dated [DATE] revealed R #60 does use bedrails to enhance mobility. D. On 02/23/26 at 8:38 am during a random observation of R #60's room revealed quarter size bedrails on the upper right and left sides of bed. E. On 02/23/26 at 8:42 pm during an interview with R #60, he confirmed he uses the bedrails for mobility and repositioning himself. F. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed the R #60 does not have physician orders for use of bed rails and should prior to installation.

Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #42) of 1 (R #42) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication. The findings are:A. Record review of R #42's Physician's orders revealed an order dated 10/24/25 for Losartan (angiotensin(hormone) receptor blocker to treat high blood pressure) 25 milligrams (mg); Give 0.5 tablet by mouth one time a day for hypertension. Notify MD (Medical Doctor) for hold orders if SBP (systolic (top number of blood pressure) blood pressure) less than 110 or DBP (diastolic (bottom number) blood pressure) less than 60 or pulse less than 60.B. Record review of R #42's Medication Administration Record (MAR) for February 2026, revealed staff administered the following:-Losartan, 0.5 (or 1/2) of 25 mg, 02/02/26, 02/07/26, 02/15/26, 02/21/26, 02/25/26 outside of the given parameters.C. Record review of R #42's blood pressures documented prior to administration of Losartan revealed:1. 02/02/26 - 108/602. 02/07/26 - 108/723. 02/15/26 - 100/654. 02/21/26 - 107/725. 02/25/26 - 103/61D. On 02/26/26 at 3:40 pm, during an interview with the Director of Nursing (DON), she stated the following: 1. R #42 received her blood pressure medication outside the prescribed parameters. 2. The medication was administered outside the prescribed parameters causing a significant medication error. 3. She stated her expectations are for the nurses to follow the orders as written, hold the medication and call the doctor to verify parameters.

Based on record review and interview, the facility failed to ensure hospice services met professional standards for 1 (R #4) of 1 (R #4) residents reviewed for hospice services by:1. Not having a qualifying diagnosis for R #4.2. Not having hospice plans of care for R #4.These deficient practices are likely to result in the resident not receiving the services that she needs. The findings are:A. Record review of R #4's admission record revealed R #4 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:1. Alzheimer's disease (a progressive brain disorder that damages and destroys nerve cells leading to a decline in abilities and behavioral changes),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Epilepsy (a seizure disorder),4. Down Syndrome (a genetic condition),B. Record review of R #4's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders), revealed:1. R #4 was admitted to hospice on 11/06/25.2. R #4 was admitted to hospice care with a diagnosis listed as Down Syndrome.C. Record review of R #4's Electronic Health Record (EHR) revealed the hospice plan of care was not available. D. On 02/26/25 at 2:54 pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. R #4 is currently receiving hospice services.2. R #4's current hospice admission order form dated 11/06/25, listed Down Syndrome diagnoses does not meet her expectations as a qualifying diagnosis for hospice care.3. The facility does not have a record of R #4's hospice plan of care.

Based on observations and interviews, the facility failed to utilize enhanced barrier precautions (an infection control intervention) when providing personal care to 1 (R #10) of 2 (R #10 and R #23) residents. Failure to utilize enhanced barrier precautions when performing personal care has the potential to spread organisms, diseases, and other health conditions among the residents. The findings are: A. On 02/22/26 at 10:02 am, during a random observation of R #10's room, the door to her room revealed a sign on the door that indicated R #10 was on enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when providing care for her.B. On 02/24/26 at 1:27 pm, during an observation and interview of R #10's tube feeding, Licensed Practical Nurse (LPN) #1 was observed accessing the feeding tube. LPN #1 wore gloves while accessing the tube but did not put on the required gown as per EBP signage on the door. LPN stated he is not required to wear a gown when accessing the feeding tube.C. On 02/24/26 at 1:35 pm during a second interview with LPN #1 he stated he reviewed the requirements on the EPB sign on the door and realized that he should have been wearing a gown.D. On 02/26/26 at 3:45 pm, during an interview with the Director of Nursing (DON), she stated that tube feedings require proper personal protective equipment and this did not meet her expectations.

Based on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:A. Record review of the facility's list of reportable incidents revealed an incident for R #1 dated 11/13/25. B. Record review of the facility's five-day report revealed the following: 1. The investigation was completed2. There was no evidence that the results of the investigation was submitted to the state Survey Agency withing 5 working days of the incident. E. On 12/11/25 at 2:02 pm, during an interview with the Administrator (ADM) she confirmed it is the facility's responsibility to submit a five day follow up report with the results of the investigation to the state survey agency. She could not confirm the results of the investigation regarding the incident with R #1 on 11/13/25 had been submitted to the State Survey Agency.

Based on observation, record review and interview, the facility failed to: 1. Complete the sign-off sheet and record the measurement of the dishwasher temperatures and sanitizing solutions daily. 2. Complete the sign-off sheet and record the food temperatures daily. 3. Ensure the sanitization logs were signed with the appropriate concentrations of sanitizer and water measured the proper dilution strength after dilution [cleaning solutions are measured in parts per million, (PPM). Greater than 50 PPM is required after diluting the concentrated sanitizing liquid] were completed daily.These failures could potentially affect all 54 residents in the facility who eat food prepared in the kitchen (residents were identified by the census provided by the Administrator on 09/23/25). If the facility fails to adhere to proper sanitization and food temperature monitoring, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:DISHWASHERA. Record review of the facility's policy, Food Wholesomeness: Procurement, Storge, Preparation and Service Sanitary Conditions Policy, dated November 11, 2023, January 2024, revealed under Keys to Meeting this Policy, point number 9 The dish machine meets temperature and/or chemical standards. Specific temperature and chemical concentrations are not given.B. Record review of the ES-2000 Ecolab Low Temperature (ELT) Dish Machine (low temperature dish washing machines utilize chemicals for sanitation) Manufacturer's Recommendations label on the front of the machine revealed the dish machine should be operated at minimum temperatures of 120 F for washing and rinsing and minimum chlorine requirement 50 parts per million (PPM; a unit used to measure very small concentrations of a substance (solute) in a mixture or solution).C. Record review of the facility's dish washing machine temperature logs dated September 2025, revealed the following: 1. On 09/01/25, staff documented wash temperatures for dinner 119 F.2. On 09/04/25, staff documented the following wash temperatures for dinner: none.3. On 09/05/25, staff documented the following wash temperatures for dinner: none.4. On 09/06/25, staff documented the following wash temperatures for dinner: none. 5. On 09/07/25, staff documented the following wash temperatures for breakfast: breakfast 115 F, dinner none.6. On 09/08/25, staff documented the following wash temperatures for dinner: none.7. On 09/09/25, staff documented the following wash temperatures for dinner: none. 8. On 09/10/25, staff documented the following wash temperatures for dinner: none.9. On 09/17/25, staff documented the following wash temperatures for breakfast and lunch: none.10. On 09/18/25, staff documented the following wash temperatures for dinner: none.11. On 09/19/25, staff documented the following wash temperatures for dinner: none.12. On 09/20/25, staff documented the following wash temperatures for dinner: none.13. On 09/21/25, staff documented the following wash temperatures for breakfast and lunch: none.14. On 09/22/25 staff documented the following wash temperatures for dinner: none.D. On 09/23/25 at 9:34 am, during an interview with the assistant dietary manager (ADM), she confirmed the daily temperature logs were just not being done daily as required and should be completed daily.E. On 09/23/25 at 10:32 AM during an observation of the dishwasher, the ADMIN (Administrator) operated the dishwasher: 1. On the first demonstration, the temperature of the water was 110 F; the PPM after the final rinse measured at 0 [sanitizing test tape is used to measure sanitizing solutions left on a surface, the indicator can range from 0-500 PPM, recommendation standards should be at least 50 PPM].2. On the second demonstration, the temperature of the water reached 125 F; PPM measured 0.3. On the third demonstration, the temperature of water reached 135 F; PPM measured 0. F. On 09/23/25 at 10:55 am during an interview, the ADMIN confirmed the concentration of sanitizer remaining after rinse cycle is not adequate for proper sanitization of any kitchenware and should be operated according to the manufacturing guidelines.Food Temperature MonitoringG. Record review of the facility's food temperature log dated September 2025, revealed the following: 1. On 09/04/25, staff did not document dinner temperatures.2. On 09/05/25, staff did not document dinner temperatures.3. On 09/06/25, staff did not document breakfast temperatures.4. On 09/07/25, staff did not document breakfast and lunch temperatures.5. On 09/14/25, staff did not document breakfast and lunch temperatures.6. On 09/17/25, staff did not document breakfast and lunch temperatures.7. On 09/18/25, staff did not document breakfast and lunch temperatures.8. On 09/19/25, staff did not document breakfast and lunch temperatures.9. On 09/20/25, staff did not document lunch and dinner temperatures.10. On 09/21/25, staff did not document breakfast and lunch temperatures.11. On 09/22/25, staff did not document breakfast and lunch temperatures.H. On 09/23/25 at 8:10 AM, during an interview with ADM, she confirmed the temperatures were not logged daily and should be filled out with every meal.I. On 09/23/25 at 8:52 am, during an observation of the breakfast food trays, the food trays were on large open-to-air mobile rack to be delivered to the residents in their rooms. The plates were only covered in plastic wrap. The temperature of the cooked scrambled eggs on the mobile rack measured 96.7 F. J. On 09/23/25 at 8:56 am, during interview with ADMIN, he confirmed the temperature of the scrambled eggs on the mobile rack, being delivered on trays to the resident rooms were too cold. He also confirmed the preferred transfer method should be food covered with heat preserving dome covers not plastic wrap. Kitchen Cleansing Solution TestingK. Record review of the facility's Food & Nutrition: Sanitizer Test Strip log [log that is used to test the concentration of chemicals in wash water to clean dishes and/or kitchen countertops and workspaces], dated August and September 2025, revealed the following:1. On 08/30/25, staff did not document that testing of the sanitizing solution had been completed. 2. On 08/31/25, staff did not document that testing of the sanitizing solution had been completed.3. On 09/17/25, staff did not document that testing of the sanitizing solution had been completed.4. On 09/18/25, staff did not document that testing of the sanitizing solution had been completed.5. On 09/19/25, staff did not document that testing of the sanitizing solution had been completed.6. On 09/20/25, staff did not document that testing of the sanitizing solution had been completed.7. On 09/21/25, staff did not document that testing of the sanitizing solution had been completed.8. On 09/22/25, staff did not document that testing of the sanitizing solution had been completed.L. On 09/23/25 at 8:17 am, during an interview with the ADM, she stated the sanitizing solution should be checked daily, and parameters are confirmed using testing tape, this number is logged in daily on the Sanitizing Strip log. She confirmed this process had not been done consistently and should be checked to make sure enough sanitizer is used to kill potential bacteria.

Based on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for 2 (R #21 and R #24) of 4 (R #21, R #24, R #40 and R #195) residents reviewed for abuse and neglect. These deificenct practices likely resulted in R #21 and R #24 experiencing psychosocial harm. The findings are: R #21 A. Record review of Facility Reportable Incident form to the state survey agency for R #21 revealed that there was an initial report filed on 11/17/22 stating that a staff member had popped up (tilting the wheelchair backwards so that the front wheels and the resident's feet did not touch the floor) the front of R #21's wheelchair and taken the resident into the dining room against her will; causing the resident undue distress and for her to scream out. B. Record review of facility face sheet for R #21 revealed admitting diagnosis which included: Dementia (memory loss), Psychotic Disturbance (mental disease), Mood Disturbance, And Anxiety (feeling of fear), Hypothyroidism (low hormone), Major Depressive Disorder (feeling of sadness), Fracture Of Right Femur (break of large leg bone), Hypokalemia (low potassium), Gastro-Esophageal Reflux Disease (acid reflux), Hypertension (high blood pressure), Muscle Weakness, Difficulty In Walking, Need For Assistance With Personal Care, and History Of Falling. C. On 03/21/23 at 2:00 pm, during an interview R #21 was unable to recall incident due to disease process of dementia. D. On 03/21/23 at 1:30 pm, during an interview, the Admissions Director (AD) stated that she and the Business Office Manager (BOM) were sitting at the reception desk when they heard R #21,crying out to leave her alone. When I looked Certified Nursing Assistant (CNA) #9 was seen popping her (R #21) wheelchair back, forcing her to go into the dining room. She stated resident was very upset and it took a while to calm her down. By upset AD stated resident was verbally yelling out and crying. AD and BOM spoke with her and used redirection to calm her down. (BOM) called the resident's daughter and had her to talk to R #21 over the phone to help calm her down. E. On 03/21/23 at 1:45 pm, during an interview BOM stated she remembered seeing CNA #9 going into the dining hall with R #21 who was crying and screaming that she didn't want to go in there. CNA #9 put her wheelchair on two wheels to get her there. BOM stated she did not know why R #21 did not want to go into the dining room but it was not uncommon for her to act this way (upset, refusing to go into dining area). BOM further stated it was meal time which she assumes was why CNA #9 was taking R #21 into the dining area. F. On 03/21/23 at 1:15 pm, during an interview, the Social Services Director (SSD) stated that she witnessed CNA #9 rolling (name of R #21) while legs were suspended in the air and not touching the floor. Resident was upset and crying. G. On 03/23/23 at 2:30 pm, CNA #9 was interviewed, CNA #9 denied abusing R #21. CNA #9 also stated she did push the wheelchair back so that it was only on the two rear wheels and R #21's feet were not touching the floor. R #24 H. Record review of Facility Reportable Incident form to the state survey agency for R #24 revealed that there was an initial report filed on 11/17/22 stating that a staff member (CNA #9) calls (R #24) ugly and a pig in Spanish. (R #24) has dementia and carries two baby dolls with her believing they are her children. CNA #9 was reported to hit and abuse the babies in front of the resident to make her cry. CNA #9 was seen popping R #24 wheelchair back in order to force her to go down the 100 hall against her will. This caused great distress to R #24. I. Record review of facility face sheet for R#24 revealed admission diagnosis which included: Hypertension(high blood pressure), Hypothyroidism (underactive thyroid), Need For Assistance With Personal Care, Depression (sadness), History Of Falling, Insomnia (trouble sleeping), Anemia (low red blood cells), Osteoarthritis (joint problems), Muscle Weakness, Lack Of Coordination, Abnormalities Of Gait (walking) And Mobility (ability to move around), Hyperlipidemia (high levels of fat), Pain, Muscle Spasm (sudden involuntary contraction), Manic Episode (mood swings), Muscle Atrophy (wasting away), Olecranon Bursitis (fluid filled sac), Difficulty Walking, Dementia (memory loss), Behavioral Disturbance (mood disorder). J. Record review of the care plan dated 01/17/2023 for R#24 revealed resident self propels in wheelchair up and down hallways saying, hello, hello. She is always carrying 2 baby dolls with her. K. On 03/21/23 at 2:20 pm, during an interview R #24 was unable to recall the incident due to disease process of dementia. L. On 03/21/23 at 1:45 pm, during an interview CNA #2 stated I witnessed [name of R #24] being verbally and physically mistreated by [name of CNA #9]. CNA #2 also stated CNA #9 would call R #24 names in Spanish. CNA #9 would bang her chair into R #24's chair during meals and hit R #24's dolls which the resident believed were her babies. CNA #2 stated this would cause R #24 to become scared, upset, and cry. M. Record review of the facility notice of disciplinary action and five day follow up to the investigation dated 11/28/22 indicated CNA #9 was place on leave and then subsequently terminated due to these allegations. N. Record review of undated Abuse and Neglect - Clinical Protocol policy revealed the following: 1. Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 47333

Based on observation, record review and interview the facility failed to adequately supervise a resident to prevent injuries for 1 (R #8) of 1 (R #8) resident's reviewed for accidents. Resident #8 was noted to: 1) have a fall with a [MEDICAL CONDITION] spine at C2 (vertebra is located in the cervical spine, which extends from the base of the skull to the bottom of the neck), and 2) continues to have repeated falls with one resulting in a head injury that required stitches. If residents are not adequately supervised residents have the potential to suffer further injuries. The findings are: [NAME] On 09/20/19 at 10:00 am, observation of R #8 revealed, R #8 was up in a wheel chair moving about the facility and had a hard neck collar in place. B. Record review of the facility face sheet for R #8 revealed an admitted [DATE]. [DIAGNOSES REDACTED]. characterized by irregular and often faster heartbeat), muscle weakness, shortness of breath, difficulty walking, and repeated falls. C. Record review of Nursing SBAR (Situation Background Assessment Request) communication revealed: 1. 02/14/19 - Fall without injury. 2. 02/23/19 - Fall laceration to forehead, bridge of nose. Resident was in the dining groom. A loud noise was heard. Resident was found on the floor face down. Obtained 2 lacerations to his forehead and one on the bridge of his nose. Send to emergency room (ER). 3. 03/07/19 - Fall 4. 05/05/19 - Fall Resident was found lying face down on the floor of his room with the bridge of his nose split open. Resident tried to transfer self to bed, Hematoma to left forehead, laceration to bridge of nose. Received from emergency medical service, had been to the hospital due to fall, patient sleepy, transferred from stretcher to bed. Vital signs taken and recorded. Patient has hematoma on his left eye. With discharge. Summary from hospital 1. Stitches placed on now bridge, 2. Knee immobilizer on right knee. 3. Dr. primary in 48 to 72 hours for revaluation of right knee, return to emergency for symptoms worsening or worsening confusion. Patient given [MEDICATION NAME] as needed as ordered with his night medications. Seen sleeping thereafter. 5. 05/23/19 - Fall Certified Nurse Aide needs further instruction/training. Attempted to transfer to shower chair without assistance. chairs were to far apart. 6. 06/9/19 -without injury. 7. 08/28/19 - Fall with [MEDICAL CONDITION]. Resident was found in floor with a [MEDICAL CONDITION]. Resident is alert and oriented. Nursing staff applied pressure to laceration and called 911. Sent to emergency room (ER). 8. 09/22/19 - Patient found in the floor in front of wheelchair. Upon finishing report with nurse leaving shift, nurse and I turned down the hall and met the 100 hall nurse who was standing above resident that was on the floor in front of wheelchair. Resident had noticeable abrasion to forehead. Assessed resident for injuries at this time. Resident oriented to self. Resident is wearing cervical collar due to previous fracture to vertebrae. Resident states that his head does hurt, asked if he knew how he got on the floor. Resident denied knowing, resident is often confused. Orders for ER to evaluate and treat. D. Record review of a nursing note dated 03/04/19 for R #8 revealed,Received radiology report this day at 11:30 pm, reviewed documentation form ER visit on 02/23/19. Final impression on X-ray of right knee performed on 02/23/19 states Fracture fibula (calf bone is a leg bone located on the lateral side of the tibia), as well as impaction [MEDICAL CONDITION] tibia plateau (is a break of the upper part of the tibia that involves the knee joint). Correlate with the possible recent trauma . E. Record review of a nursing note date 08/28/19 for R #8 revealed, ER nurse called to report that resident has a C2 fracture and he was being sent to another hospital. F. Record review of a physician order [REDACTED]. G. Record review of a statement written by Certified Nurse Aide (CNA) #3 dated 08/28/19 revealed, I was working on hall 300 alone. I needed help from a co worker form another hall. After we finished the two residents, I heard (name of resident (R #8)) screaming. I immediately ran to assist, as I walked in he was laying on the side of his bed with his head leaning against the bed frame. H. On 09/23/19 at 8:15 am, during an interview, the Director of Nursing (DON) stated that the facility does not have enough help to monitor the residents as often as needed and they keep residents at the nursing station at times for monitoring. I. On 09/24/19 at 1:20 am, during an interview, CNA #3 stated, I was assigned to the 300 hall by myself for about 12 residents on 08/28/19. Sometimes there are only 2 of us for the whole building on the 2 to 10 shift and sometimes our Assistant Director of Nursing works as a aide. If I need help for transfers I have to get someone from another hall. [NAME] On 09/25/19 at 7:55 am, during an interview, CNA #2, stated (Name of resident R #8) is confused and gets agitated. He thinks he can still do things for himself. We put him to bed and then in a few minutes he is agitated and trying to get up. My opinion is that he should have 1 on 1 care. If I lay him down, I will try to check on him at least every 10 minutes and if he is agitated I get him up. When he is up I take him to the nursing station.

Based on record review and interview the facility failed to thoroughly investigate rib fractures for 1 (R #1) of 1 (R #1) reviewed for an injury of unknown origin. R #1 c/o (complained of) abdominal pain until R #1's daughter requested, on 05/08/18, R #1 be sent to ER (emergency room ). At the time of ER evaluation R #1 was determined to have 3 broken ribs on the left side in the back. If the facility does not thoroughly investigate an incident they are unable to implement possible corrective actions to avoid further injuries. The findings are: A. Record review of face sheet for R #1 revealed she was admitted to the facility on [DATE] with most recent readmission being 05/09/18. Admission [DIAGNOSES REDACTED]. B. Record review of care plans dated 04/24/18 for R #1 include, assisted to activities MUST BE SUPERVISED (this was capitalized in the care plan), alteration in mood/behavior, impaired cognition (a subtle but measurable memory disorder), at risk for injury related to (r/t) falls, alteration in psychosocial well-being (relates to one's psychological development in, and interaction with, a social environment). C. Record review of care plan for falls dated 04/24/18 revealed, Problem: R #1 has a risk for injury r/t falls, r/t dementia, hypertension (high blood pressure) and anxiety (an emotion characterized by an unpleasant state of inner turmoil). Goals: Will have no falls times (x) 90 days. Resident will have no significant injury r/t falls x 90 days . D. Record review of Nurse's Notes for R #1's revealed no evidence of nurse's notes or other nursing documentation from 03/27/18 thru 05/08/18. E. Record review of Nurse's Note for R #1 dated 05/08/18 at 6:37 pm revealed, Late entry for 05/04/18. 3 CNA's (Certified Nursing Assistant) (CNA #1, 2, and 3) and nurse (LPN (Licensed Practical Nurse) #1) in physical therapy room readjusting another resident in wheel chair. When lifting other resident up in chair, CNA contacted this residents' abdomen . F. Record review of Nurse's Note for R #1 dated 05/08/18 at 8:08 pm revealed. Late entry 05/07/18 at 6:00 pm. Resident OOB (out of bed) to DR (dining room) for breakfast. CNA notified this nurse that resident was c/o (complaining of) stomach pain and didn't eat. Upon assessment resident noted to have upper outer RT (right) quadrant (Any one of the four areas on the front of the abdomen formed by two imaginary lines, one vertical and one horizontal intersecting at the navel) pain. Medicated with Tylenol with fair effect x 1 . G. Record review of Nurse's Note dated 05/08/18 at 8:12 pm revealed, Resident continues with RT (right) upper outer quadrant pain. Also, c/o back pain. Medicated with Tylenol . Son in and concerned Resident refused lunch . Spoke with daughter POA (power of attorney) and she request we send resident to ER for evaluation (eval) .Notified MD (Medical Doctor) and DON (Director of Nursing). Sent via EMS (Emergency Medical Services) at 2:45 pm. Received call at 5:45 PM from (name of hospital) ER Nurse that resident has rib fracture to RT side and would be admitted to hospital. Notified DON about situation. Family at ER with resident. H. On 05/24/18 at 8:35 am during an interview Licensed Practical Nurse #1 (LPN) stated, Myself and 3 CNA's were in the therapy room where we had moved another resident for more space to reposition him in his high back wheelchair. While repositioning, R #1 came up behind one of the CNA's and during the repositioning the CNA accidentally bumped into R #1's abdomen. I believe it was 2-3 days later when she began complaining of abdominal pain. She is not routinely my resident so I'm not sure if she had any falls or other incidents prior to this. I. On 05/24/18 at 9:10 am during an interview CNA #1, stated, I saw 2 other CNA's repositioning (name of resident) in his wheelchair and went to help. I then saw (R #1) and she looked like she had been crying. I asked what was the matter and (name of resident) said she had been bumped in the stomach. (name of LPN #1) was there and assessed her, so I went back to work. J. Record review of emergency room records from (name of hospital) dated 05/08/18 at 2:35 pm revealed, XXX[AGE] year-old female, .Sent from nursing home for evaluation of abdominal pain . we do not have any records from the nursing home . ED (Emergency Department) Course: CT (computed Tomography - a three-dimensional image of a body structure is constructed) chest Impression: Several mildly displaced acute posterior (towards the back) and posterior lateral (towards the back and side) aspect rib fractures involving the seventh, eighth and ninth ribs. There is a small freely layering hemothorax (a collection of blood in the space between the chest wall and the lung) with mild Atelectasis (A condition where lungs collapse partially or completely) developing within the left lower lobe (of the lung) . K. Record review of History and Physical from (name of hospital) dated 05/08/18 at 5:15 pm revealed, . patient was found to have a fracture of posterior 7,8,9 ribs on the CT scan with small hemothorax . L. Record review of Nurse's Notes for R #1 dated 05/13/18 at 3:36 am revealed, Resident is S/P (status [REDACTED]. M. On 05/23/18 at 11:05 am during an interview with the Administrator (ADM), the MDSC (Minimum Data Set Coordinator) and Interim Director of Nursing (IDON), and the Assistant Director of Nursing (ADON), the ADM stated, Our ex-DON was the one doing the investigation before and after we found out about the broken ribs. I did do some interviews with at least 2 of the CNA's and the LPN (Licensed Practical Nurse) after knowing about the fractures. I did not do any further follow-up to really determine what happened. The MDSC/IDON stated, We were not aware of what really had happened and what was being done as the ex-DON was doing all the incident report and the investigation. (Name of Resident) complained of abdominal pain. We did not know R #1 had rib fractures. The ADON stated, The incident happened on 05/05/18. We did not know R #1's ribs were broken until after she was sent to the hospital and they called us.

Based on record review, interview, and observation the facility failed to treat a skin issue for 1 (R #19) of 1 (R #19) residents reviewed for non pressure skin issues. If the facility does obtain physician orders [REDACTED]. The findings are: A. Record review of the face sheet dated 07/21/17 for R #19 revealed, R #19 was admitted on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the care plan dated 07/21/17 for R #19 revealed, Risk for impaired skin integrity related to (r/t) [MEDICAL CONDITION] and Braden scale (skin assessment) of 22 (means high risk), skin will remain intact, weekly skin checks, skin assessment quarterly and as needed (PRN), notify medical doctor, family and responsible party of changes as needed, nurse will document daily on any aspects of wound healing, including but not limited to: positioning, nutrition and hydration, pain, dressing, and lab work, . C. On 03/06/18 at 09:31 am, during an interview, R #19 stated I have a sore or rash on my right hip or lower back. Sometimes it hurts and itches. D. On 03/08/18 at 1:49 pm, during observation with Licensed Practical Nurse (LPN) #3 of R #19's right back hip area revealed 3 - 1 centimeter (cm) red raised blister/boil looking areas. LPN #3 stated I am not sure what they are. R #19 stated that sometimes they hurt and itch. E. On 03/13/18 at 1:45 am, during interview, R #19 stated that nothing had been done for the sores on the right hip/back area. F. On 03/13/18 at 2:00 pm, during interview, Licensed Practical Nurse (LPN) #2 stated that I have not called the physician because after my days off, it was reported to me that the nurse practitioner had addressed it in progress notes. LPN #2 also stated that the [MEDICATION NAME] gel (gel is used to treat joint pain) was to be used for (Name of Resident's) neck and the areas on the hip. G. Record review of nursing notes dated from 02/27/18 through 03/08/18 for R #19 revealed, no documentation about the areas on the hip/back. H. Record review of the Nurse Practitioner (NP) #1's progress note dated 02/16//18 (closest progress note to 03/01/18 when skin issue was discovered) revealed Neck radiculopathy (mechanical compression of a nerve root) causing numbness to bilateral (both sides of the body) arms, weakness, [MEDICATION NAME] gel 30 day trail. Skin was marked as intact. There was no evidence that this skin issue was addressed by the NP #1. I. Record review of the Shower Aide Skin Assessment Sheet dated 03/01/18 revealed, Two blister cluster on right side. 1. Record review of the Shower Aide Skin Assessment Sheet dated 03/05/18 revealed, Two cluster of blisters on lower back. 2. Record review of the Shower Aide Skin Assessment Sheet dated 03/12/18 revealed, nothing about the blisters noted. J. On 03/05/18 at 2:06 pm, during interview, Certified Nurse Aide (CNA) #4 stated (Name of resident) still had the area on the right hip area and I failed to put it on the skin assessment. They have been there for a while. K. On 03/13/18 at 2:47 pm, during observation with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), R #19's right hip/wound area was viewed and revealed 3 inflamed raised areas about 1 cm in diameter. The DON stated the areas are not open, We will get some keflex (antibiotic) order to treat it. When asked if this was something that needed to be reported to the physician the DON stated Yes, I did not know about these areas and I don't like that you knew about it before me. The DON stated that [MEDICATION NAME] gel would not be something to use on these areas. R #19 stated I do not know what they are, but it hurts.

Based on record review and interview the facility failed to develop a plan of care to address a urinary tract infection [MEDICAL CONDITION] for one (#7) of one (#7) residents sampled for UTIs. This failure likely caused Resident #7 to remain in pain and ineffectively treated for [REDACTED]. A. Review of the nurse's notes for Resident #7 indicated the following: 1. 11/11/14 at 5:45 am, the resident complained of pain with urination and had blood tinged urine. 2. 11/11/14 at 6:30 am, urine was collected from the resident that was cloudy, pinkish in color and had a foul odor. 3. 11/11/14 at 10:00 pm, the resident was complaining of pain in her lower back. 4. 11/15/14 at 8:00 pm, the resident was continuing to complain of burning with urination and back pain. B. Review of urine analysis laboratory test results dated 11/12/14 for Resident #7 indicated the following abnormal results: 1. Clarity of urine-cloudy. The reference range as used by (name of medical laboratory) indicated the urine should be clear. 2. Amount of protein present in urine indicates a +1 (a positive result). The reference range used by (name of medical laboratory) indicated there should be negative (no) protein in the urine. 3. Leukocytes( white blood cells) 500 (a positive result). The reference range used by (name of medical laboratory) indicated there should be zero white blood cells in the urine. 4. Blood present in urine is indicated as +3 (positive result). The reference range as used by (name of medical laboratory) indicated there should be negative (no) blood in the urine. C. Review of the urine microbiology results for Resident #7 dated 11/14/14 indicated the resident had a bacterial urinary infection of [DIAGNOSES REDACTED] Pneumoniae(a bacteria that normally lives in the intestinal tract). D. Review of Resident #7's care plan dated 10/12/14 revealed there was no documentation to indicate a comprehensive care plan with strategies to address the sign and symptoms of a UTI was developed when the resident began having pain, blood and a foul odor in the urine, and burning when urinating on 11/11/14. E. On 11/18/14 at 10:00 am, during an interview, the facility Director of Nursing (DON) stated there was not a care plan developed for the risk and treatment of [REDACTED].

Based on record review and interview, the facility failed to promptly address the active signs and symptoms of an Urinary Tract Infection [MEDICAL CONDITION] that included pain, blood, and burning with urination for one (#7) of one (#7) residents sampled for UTIs. This failure likely caused Resident #7 to remain in pain and discomfort longer than reasonably necessary. The findings are: A. Review of the nurse's notes for Resident #7 indicated the following: 1. 11/11/14 at 5:45 am, the resident complained of pain with urination and had blood tinged urine. 2. 11/11/14 at 6:30 am, urine was collected from the resident that was cloudy, pinkish in color and had a foul odor. 3. 11/11/14 at 10:00 pm, the resident was complaining of pain in her lower back. 4. 11/15/14 at 8:00 pm, the resident was continuing to complain of burning with urination and back pain. B. Review of urine analysis laboratory test results dated 11/12/14 for Resident #7 indicated the following abnormal results: 1. Clarity of urine-cloudy. The reference range as used by (name of medical laboratory) indicates the urine should be clear. 2. Amount of protein present in urine indicates a +1 (a positive result). The reference range used by (name of medical laboratory) indicates there should be negative (no) protein in the urine. 3. Leukocytes( white blood cells) 500 (a positive result). The reference range used by (name of medical laboratory) indicates there should be zero white blood cells in the urine. 4. Blood present in urine is indicated as +3 (positive result). The reference range as used by (name of medical Laboratory) indicates there should be negative (no) blood in the urine. C. Review of the urine microbiology results for Resident #7 dated 11/14/14 indicated the resident had a bacterial urinary infection of [DIAGNOSES REDACTED] Pneumoniae(a bacteria that normally lives in the intestinal tract). D. On 11/18/14 at 10:00 am, during an interview, the facility Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated there was a delay of four days between the time Resident #7 began complaining and displaying signs and symptoms of a UTI and the first dose of an antibiotic given on 11/15/14. The DON stated, There should not have been a delay and Resident #7's physician or nurse practitioner should have been notified directly.