Every finding on record at Asbury Park Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to monitor the weight of one of seven sampled residents (Resident 1) as per physician order, when Resident 1's weight was not checked daily as ordered by the physician for a total of five days. This failure decreased the facility's potential to monitor Resident 1's weight gain or loss.Findings:A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF, a chronic condition where the heart muscle cannot pump blood effectively enough to meet the body's needs for oxygen and nutrients).A review of Resident 1's General Acute Care Hospital (GACH) Discharge Summary, dated 7/31/26, indicated an order for daily weight.A review of Resident 1's Weights and Vitals Summary, dated 8/19/26, indicated Resident 1's weight was 195.4 pounds (lbs., a unit of measurement) on 8/1/26 and 189.6 lbs. on 8/7/26. The summary indicated no weight measurements for Resident 1 on 8/2/26, 8/3/26, 8/4/26, 8/5/26, and 8/6/26.A review of Resident 1's Care Plan Report, dated 8/3/26, indicated to maintain Resident 1's weight monitoring as per physician orders.During a concurrent interview and record review on 8/19/26 at 12:43 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. ADON confirmed Resident 1's weight was checked upon admission and one week later with five days missing the weight check. ADON stated the daily weight order from the hospital should have been carried through upon admission on [DATE]. During a concurrent interview and record review on 8/19/26 at 12:37 p.m. with the Administrator (ADM), Resident 1's hospital discharge summary record, dated 7/31/26, was reviewed. ADM stated the daily weight order should have been transcribed upon admission and confirmed the facility did not do daily weight for five days after Resident 1's admission.A review of the facility's undated policy titled, Administering Medications, indicated, [Weight order] . administered in accordance with prescriber orders .A review of the facility's policy and procedures (P&P) titled, Weighing and Measuring the Resident, dated 3/2011, indicated, . To provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident . The P&P further indicated, Report significant weight loss/weight gain to the nurse supervisor.

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled residents (Resident 1) when:Resident 1's PET/CT (Positron Imaging Tomography/Computed Tomography - an imaging test that combines metabolic data with detailed structural images) scan preparation was not followed as ordered by the physician; and,Resident 1 was transferred to a different hospital contrary to the physician-ordered hospital.These failures had the potential to result in complications during Resident 1's procedure, and had the potential to result in confusion regarding Resident 1's location for continuity of care.Findings:1.During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in April 2026 with diagnoses that included ST elevation myocardial infarction (STEMI - heart attack caused by a total blockage of a heart artery) and diplopia (the perception of two images of a single object). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/28/26, indicated Resident 1 had intact cognition. During a review of Resident 1's Appointment Details, dated 5/27/26, the details indicated, .Pet/Ct Skull to Mid Thigh.5/29/26.Arrive by 9:40 AM.Starts at 10:00 AM.Visit Instructions.1. Nothing to eat 6 hours before appointment, this includes gum, candy mints etc. During a review of Resident 1's physician order, dated 5/28/29, the order indicated, 5/29/2026 Check in @ [at] 9:45am PET Scan 10am [Name of Hospital]. During a review of Resident 1's NUTRITION - Amount Eaten task, dated 5/19/26 to 6/1/26, the task indicated 26-50% of Resident's meal was eaten on 5/29/26 at 9 a.m. The task further indicated alternative meal was offered to Resident 1 and Resident 1 ate 26-50% of the alternative meal on 5/29/26 at 9 a.m. During a review of Resident 1's NURSE PROGRESS NOTE, dated 5/29/26, the note indicated, .[Resident 1] returned from appt [appointment] today. Appt. was not able to be complplete [sic] d/t [due to] [Resident 1] having multiple BM [bowel movement] at appt. will need to reschedule.there are specific instructions attached to.binder.[Resident 1] is to be NPO [nothing by mouth] 6 hours ahead. During an interview on 6/17/26 at 12:23 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated the facility has a binder for appointments and all instructions are there. LN 1 further stated that if instructions or preparations for an appointment were followed, the procedure would be smooth and will be followed on time, but if these instructions were not followed, there could be complications during the appointment. During a concurrent interview and record review on 6/17/26 at 1:25 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 had an appointment for PET/CT of Skull to Mid Thigh on 5/29/26 at 10 a.m. The DON also confirmed that preparations before the procedure included Resident 1 not eating six hours prior to the procedure. The DON further confirmed Resident 1's Nutrition - Amount Eaten task indicated Resident 1 ate 26-50% of meals on 5/29/26 at 9 a.m. The DON stated Resident 1 did not complete appointment and the procedure was cancelled because Resident 1 had bowel movement during the procedure. The DON also stated that the expectation was for Resident 1 not to receive food prior to the procedure to see what the doctor wanted to rule out, and that the instructions from the doctor were followed. The DON added that if Resident 1 received meals at 9 a.m. on 5/29/26, then the order was not followed. During a review of the facility's policy and procedure (P&P) titled Medication and Treatment Orders, revised 7/2016, the P&P indicated, .13. Orders for withholding food prior to a test or treatment ( NPO) shall be made by the attending physician as necessary. During a review of the facility's P&P titled PHYSICIANS ORDERS, undated, the P&P indicated, .It is the policy of this facility to ensure that: - Medications and treatments are administered according to standards of clinical practice upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state. 2. During a review of Resident 1's physician order, dated 5/30/26, the order indicated, .Per [name of physician] from [Hospital A] send [Resident 1] to [Hospital A]. During a review of Resident 1's Hospital Transfer Form, dated 5/30/26, the form indicated, .Reason(s) for transfer.new onset vision change.Is the primary reason for transfer for diagnostic testing, not admission? .Yes.Tests: per [name of physician] send pt [patient] out to [Hospital A]. The form further indicated, .Sent To.[Hospital B]. During a telephone interview on 6/17/26 at 8:54 a.m. with the Inpatient Social Worker (ISW), the ISW stated that the outpatient physician ordered to send Resident 1 to Hospital A Emergency Department (ED), however, the family member called and asked Hospital A's ED and Resident 1 was not there, and the facility sent Resident 1 to Hospital B instead of Hospital A, and none of the staff were able to tell where Resident 1 was transported. During a concurrent interview and record review with Licensed Nurse 2 (LN 2), LN 2 stated nurses fill out the transfer form and if the physician had a specific hospital ordered, the order should be followed. LN 2 confirmed Resident 1 had an order to be transferred to Hospital A on 5/30/26. LN 2 also confirmed that Resident 1's hospital transfer form indicated Resident 1 was sent to Hospital B contrary to the physician order to send Resident 1 to Hospital A. LN 2 stated there was no progress notes regarding the transfer and stated, .I'm not sure where she was taken. During a concurrent interview and record review on 6/17/26 at 1:25 p.m. with the DON, the DON confirmed Resident 1 was transferred out of the facility on 5/30/26 and stated it was a planned transfer to the hospital. The DON also confirmed that the order was for Resident 1 to be sent to Hospital A but the hospital transfer form indicated Resident 1 was sent to Hospital B. The DON further confirmed that there were no progress notes indicating Resident 1 went to Hospital A instead of Hospital B and stated that the best practice was for staff to document the transfer and stated, .but I don't see it. The DON stated the expectation was for staff to document what was being done and to document accurately. During a review of the facility's P&P titled Transfer or Discharge, Facility-initiated, revised 10/2022, the P&P indicated, .Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.Notice of Transfer or Discharge (Planned).2. The resident and representative are notified in writing of the following information:.c. The specific location (such as the name of the new provider.to which the resident is being transferred or discharged .Documentation of Facility-Initiated Transfer or Discharge.1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record:.d. The new location of the resident.

Based on interviews and record reviews, the facility failed to administer medication for one of four sampled residents (Resident 1) when Resident 1's ordered medication, Propranolol hydrochloride (Propranolol HCl, a medication that helps slow down the heart and reduce the effects of stress hormones on the body), was not available during medication administration.This failure had the potential to cause Resident 1 to experience worsening tremors.Findings:A review of Resident 1's admission Record indicated that the resident was admitted on 4/26 with diagnoses of multiple fractures and autistic disorder (a developmental condition that affects communication, social skills, and behavior).A review of Resident 1's Order Summary Record (OSR) dated 4/14/26 indicated that Resident 1 had the capacity to understand choices and make health care decisions. The OSR also indicated that Resident 1 was ordered Propranolol HCl 10 mg (milligram, unit of measurement) by mouth twice a day for tremors.A review of Resident 1's Medication Administration Record (MAR) for May 2026 indicated that on 5/15/26 at 1600 (4 pm) and 5/16/26 at 1600, the Propranolol HCl was not given by Licensed Nurse (LN) 1 because the medication was not available.During a concurrent interview and record review on 6/1/26 at 11:36 a.m., LN 1 reviewed the MAR entries for 5/15/26 and 5/16/26. LN 1 stated that the 4 p.m. Propranolol HCl doses scheduled for 5/15/26 and 5/16/26 were not given because the medication was not available. LN 1 stated that she remembered calling the pharmacy to follow up on the delivery of the Propranolol HCl. LN 1 explained that the progress note she wrote on 5/15/26 at 7:02 p.m. indicated that the Propranolol HCl was still pending from the pharmacy. LN 1 also reviewed the progress note she wrote on 5/16/26 at 3:25 p.m., and verified that they called the pharmacy to ask why the Propranolol HCl had not been delivered and the pharmacy staff told LN 1 that they received the request on Tuesday but were only processing it that day. LN 1 also confirmed a note written on 5/16/26 at 7:13 p.m., indicating that the Propranolol HCl did not arrive in the first delivery as promised and that she called the pharmacy again. During an interview on 6/1/26 at 12:52 p.m., the Director of Nursing (DON) stated their expectation for nursing staff to order medications when there were seven tablets left in the medication bubble pack as a sign that refills were needed. The DON stated that they expected the pharmacy to deliver medications on time so they would be available during medication pass.A review of the facility's P&P titled, Pharmacy Services, dated 3/2018 indidcated, Policy: Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies.Procedures.D. The pharmacy provider agrees to perform the following pharmaceutical services, including: 6) Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019 indidcated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered within one (1) hour of their prescribed time.

Based on observation, interview, and record review, the facility failed to ensure medications and diagnostic agents were properly labeled according to manufacturer guidelines when:Several opened and undated medications, and one opened and undated container of glucose test strips, were observed stored in 2 of 3 medication carts sampled.One opened and undated Forteo pen (pre filled injection device used to deliver specialty medication to treat osteoporosis, a condition of weakened bones), was observed stored in 1 medication room refrigerator of two medication rooms sampled.This failure had the potential for residents to receive ineffective, expired, or unstable medications, and for staff to use expired or inaccurate glucose test strips when monitoring residents' blood glucose levels.Findings: 1a. During an inspection of the 1 C medication cart and concurrent interview on [DATE] at 11:14 a.m. with Licensed Nurse (LN 5) the following medications were observed:One opened, undated vial of Insulin Glargine (long-acting insulin to control blood sugars) for Resident 110. LN 5 read the manufacture label that indicated, Use within 28 days after initial use. LN 5 confirmed the opened vial was not dated.One opened Breo Ellipta inhaler (medication inhaled into the lungs used for breathing problems) for Resident 161 without an open date. A review of the manufacturer's labeling with LN 5 indicated, Discard the inhaler 6 weeks after opening the .foil tray or when the counter reads 0 .whichever comes first. LN 5 confirmed no open date on the inhaler.One opened Trelegy Ellpta Inhaler (medication inhaled into the lungs used for breathing problems) for Resident 148. A review of the manufacturer's labeling with LN 5 indicated, Discard 6 weeks [after tray opened]. LN 5 confirmed the inhaler had no open date.1b. During an interview and record review on [DATE] at 10:34 a.m. at the 1 A medication cart with LN 4, Resident 156's Epidiolex (oral solution to treat rare seizure disorders) bottle was observed open without an open date. The manufacturer labeling indicated, Discard unused portion 12 weeks after first opening. LN 4 confirmed the opened bottle was not dated.1c. During an inspection of the 1 B medication cart on [DATE] at 4:44 p.m. with LN 8, one multi-dose container of EvenCare, G3 Blood Glucose Test Strips (diagnostic strips used to test blood sugar) was observed open and without open date. A review of the manufacturer's label with LN 8 indicated, Use within 6 months after first opening. LN 8 confirmed there was no open date on the container.2. During an inspection of the medication room [ROOM NUMBER] refrigerator on [DATE] at 3:42 p.m. with the Assistant Director of Nursing (ADON 2), one opened and undated Forteo pen for Resident 162 was observed. The manufacturer labeling indicated, Throw away 28 days after first use. ADON 2 acknowledged the medication was opened and undated.During an interview and record review on [DATE] at 9:11 a.m. with the Director of Nursing (DON), the DON stated medications are to be dated when opened in accordance with manufacturer guidelines. After reviewing photographs of the undated medications observed, the DON acknowledged the findings and stated that undated, opened medications could expose residents to medications that may be expired or unstable.During a review of the facility's policy and procedure titled, Administering Medications, revised date [DATE], indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for two of 30 sampled residents (Resident 18 and Resident 62) when:1. Resident 18's call light was not within reach and was not appropriate; and,2. Resident 62's call light system was not appropriate.This failure placed Resident 18 and Resident 62's safety at risk and had the potential for the residents' needs to be not met.Findings:1. A review of Resident 18's clinical record indicated Resident 18 was admitted June of 2013 and had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), dementia (memory loss that interferes with daily functions), and muscle weakness.A review of Resident 18's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/12/26, indicated Resident 18 was rarely/never understood. A review of Resident 18's MDS Functional Abilities, dated 3/12/26, indicated Resident 18 was dependent with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene, and needed substantial/maximal assistance with eating and showering/bathing herself. A further review of Resident 18's MDS Functional Abilities indicated Resident 18 was dependent with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfer, and toilet/shower transfers.A review of Resident 18's care plan, dated 3/26/24, indicated, The resident [Resident 18] has a communication problem r/t [related to] Dementia, non-verbal .Ensure/provide a safe environment: Call light in reach .During an observation on 3/23/26 at 9:43 a.m. in Resident 18's room, Resident 18 was observed sitting on her bed, awake. There was no observed call system provided to Resident 18. During a concurrent observation and interview on 3/23/26 at 10:45 a.m. with Certified Nurse Assistant (CNA) 4, in Resident 18's room, Resident 18 was observed lying on bed, awake, and there was no call system provided to resident 18. CNA 4 searched Resident 18's room and found Resident 18's call light button on the bottom of her bedside drawer which was 4-5 feet away from Resident 18. CNA 4 confirmed that Resident 18's call system was not within her reach. CNA 4 stated Resident 18 was not able to use and press the call light button and she needed total care. CNA 4 also stated Resident 18 needed the soft touch call system instead of the call light button. CNA 4 further stated that all call systems should be within the residents' reach so they could call for help whenever they need it.During a concurrent observation and interview on 3/24/26 at 2:50 p.m. with Licensed Nurse (LN) 3, in Resident 18's room, Resident 18 was observed lying on bed, awake, and was provided with a call light button. LN 3 confirmed the observation. LN 3 stated Resident 18 was non-verbal and was not able to hold and use her hands to press on the call light button. LN 3 further stated the call light button was not appropriate for Resident 18 and that Resident 18 needed a soft touch call system so she could call for assistance whenever she needed help.2. A review of Resident 62's clinical record indicated Resident 62 was admitted December of 2025 and had diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), and muscle weakness.A review of Resident 62's Minimum Data Set Cognitive Patterns, dated 3/13/26, indicated Resident 62 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 which indicated Resident 62 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 18's MDS Functional Abilities, dated 3/13/26, indicated Resident 62 was dependent with toileting hygiene, showering/bathing herself, lower body dressing, and putting on/taking off footwear, and needed partial/moderate assistance with personal hygiene. A further review of Resident 62's MDS Functional Abilities indicated Resident 62 was dependent with rolling left and right, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfer, and toilet/shower transfers.During a concurrent observation and interview on 3/23/26 at 10:23 a.m. with resident 62, in Resident 62's room, Resident 62 was observed lying on her bed, awake, and was provided with a call light button. Resident 62's hands were observed to be shaking repeatedly. Resident 62 stated she could not hold and press her light button because her hands were very shaky.During a concurrent observation and interview on 3/23/26 at 1:43 a.m. with CNA 3, in Resident 62's room, Resident 62 was observed lying on her bed, awake, and her hands were shaking. CNA 3 confirmed Resident 62 was provided with call light button. CNA 3 stated the call light button was not appropriate for Resident 62 because her hands were shaky and she would not be able to hold and press the call light button. During a concurrent observation and interview on 3/24/26 at 2:52 p.m. with LN 3, in Resident 62's room, Resident 62 was observed lying on bed, awake, and was provided with a call light button. LN 3 confirmed the observation. LN 3 stated Resident 62 has tremors and would not be able to hold and use the call light button. LN 3 further stated a soft touch call system would be better so Resident 62 could call for help when she needed assistance. During an interview on 3/25/26 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated she would expect staff to place residents' call system within their reach so they could use it whenever they need it. The DSD also stated that for residents who could not use the call light button, a soft touch call system should have been provided. The DSD further stated that the resident would be at risk for accident or her needs would not be met if the call button was not within her reach or if she would not be able to use the call system provided.During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that she would expect that resident's call system to be appropriate for them and are placed within the residents reach so they could call for help whenever they need something.A review of the facility's policy and procedures titled, Call System, Resident, revised 9/2022, indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan .

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program when;1. A facility staff did not wear required personal protective equipment (PPE) when providing high contact care and handling the indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time) for one out of 30 sampled residents (Resident 130) who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. Money was stored in a medication cart, creating a risk for cross contamination of medications, and3. The facility failed to perform PICC line (PICC, peripherally inserted central catheter. Long, thin tube inserted through a vein in the arm, and is passed through to the larger veins near the heart) dressing changes, as ordered for one of 30 sampled residents (Resident 132).These failures resulted in an increased risk for cross contamination, and potential exposure of residents to germs and infection.Findings: 1. A review of Resident 130's clinical record indicated Resident 130 was admitted December of 2024 and had diagnoses that included Urinary tract infection (UTI- an infection in the bladder/urinary tract), hydronephrosis (swelling of one or both kidneys caused by a buildup of urine, usually due to an obstruction or blockage), kidney stones, and neuromuscular dysfunction of bladder (the nerves and muscles in the urinary bladder don't work together properly). A review of Resident 130's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/3/26, indicated Resident 130 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 130 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 130's MDS Bladder and Bowel Status, dated 3/3/26, indicated Resident 130 uses an indwelling catheter. A review of Resident 130's care plan, undated, indicated, [Resident 130] requires Enhanced Barrier Precautions r/t [related to] indwelling catheter .Implement enhanced standard precautions (gown, gloves) when providing direct patient care and when cleaning the room. A review of Resident 130's active physician's order, dated 1/13/25, indicated, Indwelling .catheter .due to Dx [diagnosis] ofNeurogenic bladder [also known as neuromuscular dysfunction of bladder] /urinary retention [caused by a blockage or a failure of the bladder to squeeze hard enough to expel all of the urine]. A review of Resident 130's active physician's order, dated 1/19/25, indicated, Enhanced Barrier Precautions r/t Indwelling Catheter. A review of the list of residents on EBP, provided by the Infection Preventionist (IP), on 3/23/26 at 10:28 a.m. indicated Resident 130 was on EBP due to his indwelling catheter. During an observation on 3/23/26 at 3:12 p.m. in Resident 130's room, a facility staff was observed changing Resident 130's hospital gown, providing hygiene care, changing his briefs, and handling Resident 130's indwelling catheter while only wearing gloves and not wearing a gown. There was an EBP signage posted on the board on top of Resident 130's bed which indicated, STOP .ENHANCE BARRIER PRECAUTIONS .PROVIDERS AND STAFF MUST .Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing .Providing Hygiene .Changing briefs .Device care or use: .urinary catheter . During a subsequent interview on 3/23/26 at 3:18 p.m. with Certified Nurse Assistant (CNA) 5, CNA 5 confirmed that she was only wearing gloves when she changed Resident 130's hospital gown, provided hygiene care, changed his briefs, and handled Resident 130's indwelling catheter. CNA 3 stated she does not know if she should have worn a gown when doing high contact care to Resident 130. CNA 3 further stated she does not know if Resident 130 was on EBP and that there was an EBP signage posted on Resident 130's board. During a phone interview on 3/25/26 at 10:25 a.m. with the IP, the IP stated that staff should be aware and should be wearing both gloves and gown when providing high-contact care to a resident who was on EBP to prevent spreading germs and prevent the risk of the resident getting infection. During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that staff should follow EBP and wear both gloves and gown when providing high contact care to a resident who was on EBP to prevent the risk of possible infection of the resident. A review of the facility's policies and procedures (P&P) titled, Enhanced Barrier Precautions, revised 6/2024, indicated, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing .d. providing hygiene .f. changing briefs .g. device care or use ( .urinary catheter .). 9. Staff are trained prior to caring for residents on EBPs. 2.During an inspection and concurrent interview on 3/23/26 at 4:44 p.m. at the 1B medication cart with Licensed Nurse (LN 8), money was observed stored inside the secondary locked section of the medication cart. The bills were wrapped in a small blue piece of paper and stored within the compartment containing controlled substance medications (medications that the use and possession of are controlledby the federal government) and antibiotics. LN 8 confirmed the finding and stated her understanding was that money should not be stored in the medication cart. During an interview on 3/25/26 at 9:06 a.m. with the Director of Nursing (DON), the DON acknowledged that money should not be stored in the medication cart. During a review of the facility's policy and procedure, titled, Medication Labeling and Storage, revised date, indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 3.During a review of Resident 132's admission Record, (AR), the AR indicated that Resident 132 was admitted to the facility in February 2026 with diagnoses that included Bacteremia (bacteria in the blood), and infection following a procedure. During a review of Resident 132's Minimum Data Set (MDS a federally mandated resident assessment tool) dated 3/2/26, Section C, Cognitive Patterns (mental process of acquiring knowledge and understanding) showed a score of 15 which indicated intact cognition. During a review of Resident 132's Order Summary Report (OSR), dated 3/7/26, the OSR indicated, CHANGE PICC LINE/MIDLINE(Specify) DRESSING QWEEK [every week] AND PRN [as needed] FOR SOILED OR DISPLACED. During an observation of Resident 132's PICC Line dressing on 3/23/26 at 8:48 a.m., the PICC Line dressing was dated 3/7/26 and the white tape used to secure the dressing had started to peel off. During a concurrent observation and interview with LN 11 inside the room of Resident 132 on 3/23/26 at 9 a.m., LN 11 confirmed that Resident 132's PICC Line dressing to his right upper arm was dated 3/7/26, the dressing edge appeared brownish in color and started to peel off. LN 11 stated the dressing should have been changed every week as ordered by the physician to prevent potential infection. LN 11 stated further that Resident 132 was receiving antibiotics daily to treat infection. During an interview with the DON, on 3/23/26 at 11:02 a.m. the DON stated her expectations from the nurses were to change the PICC Line dressing of Resident 132 every week, and as needed if the dressing got soiled or displaced. The DON further stated, it should be labeled and dated to verify who changed the dressing and to ensure it was replaced per physician's order to prevent infections. During a review of Resident 132's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, cefTRIAXone Sodium [antibiotics] Intravenous Solution . Use 2 gram [unit measurement] intravenously [through the veins] at bedtime for Streptococcus Bacteremia [a serious condition often leading to high morbidity, sepsis, or mortality. Commonly originated from infections such as skin infections]. During a review of Resident 132's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, DAPTOmycin Intravenous Solution. Use 500 mg intravenously at bedtime for Streptococcus Bacteremia. During a review of Resident 132's Care Plan (CP), undated, the CP indicated, Resident has PICC line to RUE [right upper extremity] .Change PICC line dressing every week and as needed for soiling or displacement. During a review of the facility's policy and procedure, titled INTRAVENOUS THERAPY (IT), undated, the IT indicated, .To provide standards for the safe maintenance of the P.I.C.C. catheter in order to reduce the risk of infection or dislodging.TSM [transparent semi permeable membrane, adhesive dressing that covers the catheter insertion site] dressing will then be changed at least weekly .

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when:Three dietary staff did not wear hair and beard restraints; andOne dietary staff did not practice hand hygiene between soiled and clean dishes during the dishwashing process.These failures had the potential to result in food contamination which could cause illness for 132 residents who received food prepared from the facility kitchen. During an observation on 3/24/26 at 8:30 and 11:00 a.m., Dietary Aide (DA) 2 wore a beanie in the kitchen without a hair restraint and hair was exposed in the back and sides of the head. DA 1 and [NAME] (CK) 1 had beards without beard restraints during food preparation.During an interview on 3/24/26 at 8:45 and 11 a.m. with the Dietary Supervisor (DS), the DS confirmed DA 2 was wearing a beanie with exposed hair and was not wearing a hair net and DA 1 and CK 1 had exposed beard hair and were not wearing beard restraints. The DS stated they should be wearing a hair net and beard restraints to prevent hair from contaminating food or getting on food prep surfaces.A review of the facility policy and procedure (P&P) titled, Dress Code, dated 2023, indicated, .PROPER DRESS: .6. Hat for hair, if hair is short which completely covers the hair, 7. Hair net for hair, if hair is long (over the ears or longer), 8. beards and mustaches (any facial hair) must wear beard restraint.According to the FDA Food Code 2022, Section 2-402.11, Hair Restraints, A. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.During an concurrent observation and interview on 3/25/26 at 10:30 a.m., DA 3 touched the dirty dishes on the dirty side of the dishwashing machine and then touched the clean dishes without washing hands. The DS confirmed it was not the correct process and stated there should be two dishwashers and the person on the dirty side should not touch the dishes on the clean side without washing their hands to prevent cross contamination and spreading bacteria. During a review of the facility P&P titled, Sanitation, dated 2023, indicated, . 18. A minimum of two employees will be used when dishes are machine washed. One will handle soiled area, and one will handle the clean side. If an employee does need to go from soiled to dirty end, a strict hand-washing routine must be followed.

Based on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for one out of 30 sampled residents (Resident 13) when Resident 13's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed.This failure had the potential for Resident 13 to experience a decline in range of motion or impairment in mobility.Findings:A review of Resident 13's clinical record indicated Resident 13 was admitted March of 2021 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood), polyneuropathy (a condition characterized by damage to multiple peripheral nerves causing numbness, burning pain, and muscle weakness), and muscle weakness.A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/19/26, indicated Resident 13 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 13 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 13's MDS Functional Abilities, dated 3/19/26, indicated Resident 13 was dependent with toileting hygiene and putting on/taking off footwear, substantial/maximal assistance with shower/bathing self, lower body dressing, and personal hygiene, and partial /moderate assistance with upper body dressing. A further review of Resident 13's MDS Functional Abilities indicated Resident 13 was dependent on sitting to standing, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer, and needed partial/moderate assistance with rolling left and right, sitting to lying, and lying to sitting on side of the bed. During an interview on 3/23/26 at 10:44 a.m. with Resident 13, Resident 13 stated she was receiving exercises, but she does not think it was enough. Resident 13 stated she needed to get more exercise.A review of Resident 13's care plan, dated 10/24/24, indicated, Resident is at risk for physical decline and requires restorative nursing assistance (RNA) program for therapeutic exercises/range of motion.A review of Resident 13's care plan, dated 10/24/24, indicated, Resident is at risk for physical decline and requires restorative nursing assistance (RNA) program for Bed Mobility.A review of Resident 13's active physician's order, dated 1/8/26, indicated, [RNA PROGRAM]: Patient will complete bed mobilitymovements rolling L<>R [left and right] supine [lying flat on the back] in bed and complete supine<>sit [supine to sit or vice versa] .transitions using side bed rails for assist as necessary for 3x/wk [3x a week] or as tolerated. for 90 Days.A review of Resident 13's active physician's order, dated 1/8/26, indicated, [RNA PROGRAM]: Patient will complete RLE [Right lower extremity/ Right leg] PROM [passive range of motion] exercises targeting all planes of motion for 3x/wk or as tolerated. for 90 Days.During a concurrent interview and record review on 3/25/26 at 9:52 a.m. with Restorative Nurse Assistant (RNA) 1, Resident 13's RNA records for March 2026 were reviewed. RNA 1 confirmed that Resident 13 only received bed mobility exercises on 3/7, 3/13, 3/14, and 3/15. RNA 1 also confirmed that Resident 13 only received PROM exercises on 3/7, 3/13, 3/14, 3/15, and 3/24. RNA 1 further confirmed that Resident 13 did not get her exercises in accordance with the ordered RNA program frequencies which were three times a week. RNA 1 stated the RNA frequency order should have been followed. RNA 1 also stated there were only two RNAs in the facility and they also have to do checking of weekly weights and Monthly weights for residents so sometimes they could not complete the 3 times a week RNA program frequency. RNA 1 further stated there would be a risk of decrease in range of motion and decline in function if Resident 13's RNA program frequencies were not consistently followed.During an interview on 3/25/26 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated RNA program frequency should have been followed and there should have been documentation about why the exercises were not done and be reported to therapy. The DSD further stated Resident 13 would be at risk for decreased range of motion, could cause muscle weakness and possible contracture if the RNA program frequency was not followed.During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that she would expect that RNA program frequency to be followed. The DON further stated that the resident would be at risk for decrease in range of motion if the RNA program frequency was not followed.A review of the facility's policy and procedures titled, Restorative Nursing Services, revised 7/2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care .

Based on interview and record review, the facility failed to ensure one out of 30 sampled residents (Resident 147) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's orders when Resident 147's pain medication orders were not consistently followed. This failure had the potential for Resident 147 to experience unrelieved pain and/or over-medication and not attain her highest practicable well-being.Findings:A review of Resident 147's clinical record indicated Resident 147 was admitted March of 2026 and had diagnoses that included fracture (a break in the continuity of a bone) of the right femur (thigh bone), Pain due to internal orthopedic prosthetic devices, implants and grafts, muscle weakness, and rheumatoid arthritis (a chronic autoimmune disorder causing systemic inflammation, pain, and stiffness, primarily targeting joint linings).A review of Resident 147's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/21/26, indicated Resident 147 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 147 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 147's MDS Health Conditions, dated 3/21/26, indicated Resident 147 received scheduled and as needed pain medications and non-medication intervention for pain.A review of Resident 147's Care Plan Report, initiated 3/18/26, indicated, [Resident 147] is at risk for pain R/T [related to]: SURGICAL INC [incision]/CHRONIC PAIN SYNDROME [condition that involves persistent pain that lasts for weeks to years] .Administer medication as ordered .During an interview on 3/23/26 at 8:31 a.m. with Resident 147, Resident 147 stated she has been in pain because of her surgery. Resident 147 further stated that her pain has not been controlled because sometimes the medication does not relieve her pain and other times, the medication was too much which made her feel like things are floating. A review of Resident 147's physician's order, dated 3/17/26, indicated, Acetaminophen [a potent pain reliever] Oral Tablet 500 MG [milligrams- unit of measurement] .Give 2 tablet by mouth every 8 hours as needed for MILD PAIN (1-3) [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-7 is moderate pain, 8-10 is severe pain] .A review of Resident 147's physician's order, dated 3/17/26, indicated, oxyCODONE HCl [a controlled pain medication] Oral Tablet 5 MG .Give 1 tablet by mouth every 4 hours as needed for MODERATE PAIN (4-7).A review of Resident 147's physician's order, dated 3/17/26, indicated, oxyCODONE HCl Oral Tablet 5 MG .Give 2 tablet by mouth every 4 hours as needed for SEVERE PAIN (8-10) 2 TABS [tablets] = 10 MG.A review of Resident 147's medication administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of March 2026 indicated Resident 147 received 2 tablets of Acetaminophen which was indicated for Mild pain on the following occasion:3/21/26 at 8:36 p.m.- pain level was 6 (moderate pain)A review of Resident 147's MAR for the month of March 2025 indicated Resident 147 received 10 mg of oxycodone which was indicated for severe pain on the following occasions:3/18/26 at 12 a.m.- pain level was 7 (moderate pain)3/24/26 at 4:33 a.m.- pain level was 7 (moderate pain)During a concurrent interview and record review on 3/24/26 at 12:40 p.m. with Licensed Nurse (LN) 2, Resident 147's clinical records were reviewed. LN 2 confirmed that Resident 147's pain medication orders were not consistently followed. LN 2 stated that nurses should always follow the physician's order when administering pain medications. LN 2 also stated that if the resident requested for a different pain medication, then there should have been a documentation for it. LN 2 further stated that the resident would be at risk for unrelieved pain or over-medication if the physician's orders for pain medications are not followed.During an interview on 3/25/26 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated nurses should follow the physicians order and medicate the resident following the ordered parameters. The DSD further stated the resident would be at risk for unrelieved pain or over-medication which could cause undesired effects if the physician's order was not followed.During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated she would expect nurses to follow the doctor's order and set parameters in administering pain medications. The DON further stated the resident's pain would not be controlled if the physicians order is not consistently followed.A review of the facility's P&P titled, Pain Assessment and Management, revised 3/2020, indicated, 2. Pain management interventions shall reflect the sources, type and severity of pain .1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure strict controls were maintained for the accounting, storage, and documenting of controlled substances (medications with high potential for abuse and addiction under strict government control) as evidenced by:Medication physical inventory counts did not reconcile with the controlled substance record (CSR, for an inventory count sheet to record usage of controlled medications) for six medications for Residents 149, 155, 125, 166, and 133 during an inspection of two out of three medication carts sampled.Discontinued controlled substances remained stored in one of two medication refrigerators and one of three medication carts sampled for Residents 163,165,50, 69, 15 and 7.Medication Administration Records (MARs) did not reconcile with the Controlled Substance Records (CSRs) for two of four residents sampled (Residents 20 and 67). The medications were signed out on the CSRs, indicating removal from inventory, but there was no corresponding documentation on the MARs showing the residents received the controlled medications. These failures resulted in inaccurate documentation and inventory control and created the potential for medication errors, improper dosing, and placed the facility at risk for unaccounted for medication or risk of diversion (unlawful distribution or use) of controlled medications. Findings:1a. During an inspection of the 1C medication cart on 3/23/26 at 10:39 a.m. with Licensed Nurse (LN 6), a physical inventory was conducted, and the following discrepancies were noted between the physical inventory and the Controlled Substance Record (CSR): Buprenorphine (controlled substance medication used to treat opioid addiction or pain management) 5 microgram/hour patch (patch applied to the skin to deliver medication) for Resident 149: Inventory = 1; CSR = 2 (1 patch not accounted for) Oxycodone (controlled substance, strong pain medication) 5 milligram, mg (strength) for Resident 155: Inventory = 39; CSR = 41 (2 pills-unaccounted for) Pregabalin (controlled substance, medication for nerve pain or treatment of seizures) 200 mg for Resident 125: Inventory = 16; CSR = 17 (1 pill unaccounted for) Pregabalin 25 mg for Resident 125: Inventory = 44; CSR = 45 (1 pill unaccounted for)During an interview on 3/23/26 at 10:53 a.m. at the 1C medication cart, LN 6 stated the process is to sign medication out of the CSR and pop (remove the medication from bubble pack) as the medication is administered. LN 6 confirmed the 4 discrepancies and stated the morning nurse is on break and will sign out the medication when he returns. During an interview on 3/23/26 at 11:08 a.m. at the 1C medication cart LN 5 confirmed he did not sign out the 4 medications for Residents 149, 155, 125, during morning medication pass on 3/23/26 and stated he will sign them out now. He acknowledged the controlled substance medications should be signed out during medication administration.1b. During a concurrent inspection and interview of the 2B medication cart on 3/24/26 at 8:27 a.m. with Licensed Nurse (LN 10), the following discrepancies were identified: Lacosamide (controlled substance used to control seizures) 100 mg for Resident 166: physical count = 15; CSR = 14. LN 10 stated she did not sign out the medication during the a.m. medication pass. Lacosamide 100 mg for Resident 133: physical count = 25; CSR (Controlled Substance Record) count = 24. Licensed Nurse (LN 10) confirmed the discrepancy and stated she did not administer the medication that morning and did not know what happened to the missing dose.During an interview with the Director of Nursing (DON) on 3/25/26 at 8:30 a.m. stated her expectation is for the nurses to check the order, pull the medication from the cart then log it out of the CSR. She acknowledged nurses did not sign out medications at the time of removal or after administration.During a phone interview with the Consultant Pharmacist (CP) on 3/25/26 at 11:09 a.m., the CP stated nursing should follow the 5 R's [Rights] when administering medications. He acknowledged nurses should sign out the controlled medication at the time of administration this minimizes the risk of documentation errors and the risk of diversion.During a review of the facility's policy and procedure titled, Controlled Substances, revised date November 2022, indicated, 1. Controlled substance inventory is monitored to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records.2a. During an inspection of the medication refrigerator located in the 1A medication room on 3/23/26 at 4:06 p.m. with the Assistant Director of Nursing (ADON 2), a metal lockbox with the key inside was observed in the refrigerator. ADON 2 opened the lockbox, and a bottle of liquid lorazepam 2 milligrams per milliliter (mg/mL) (a controlled substance, concentrated liquid sedative medication) for Resident 163 was found inside. ADON 2 acknowledged the lorazepam stored in the lockboxA review of the clinical record for Resident 163 indicated admitting diagnoses which included, malignant neoplasm (cancerous tumor) and palliative care (care to provide relief of pain, stress of serious illness) further review indicated the resident was discharged on 2/23/26.During an interview and record review with the DON on 3/25/26 at 8:49 a.m. the DON confirmed she received Resident 163's lorazepam bottle (2 mg/mL concentration, approximately 30 mL) after it was identified during the survey. The DON confirmed the resident was discharged on 2/23/26 and acknowledged she received the medication 28 days after discharge.2 b. During an inspection and concurrent interview on 3/23/26 at 4:44 p.m. with LN 8 the following medications were observed wrapped with their corresponding CSR and stored in the 1B medication cart:Oxycodone (controlled medication, strong pain medication with potential for abuse) 5 mg (0.5 tab; 2.5 mg) quantity 59 half-tabs, for Resident 165.Oxycodone 5 mg tablets, quantity 14 tablets, for Resident 69.Oxycodone 5 mg tablets (0.5 tabs; 2.5 mg) quantity 60 half-tabs, for Resident 50.Tramadol (controlled medication, pain medication for moderate to severe pain) 50 mg tablets quantity 34 tablets for Resident 15Oxycodone 5 mg tablets, quantity 26 tablets for Resident 7.Oxycontin (controlled medication, long-acting pain medication) 10 mg tablets, quantify 14 tablets for Resident 7.LN 8 stated that she and the off going morning nurse did not count the discontinued controlled medications that were wrapped in the cart. She confirmed these discontinued medications were not included in the shift to shift controlled substance count and that only the active controlled substances were counted with the off going nurse. During an interview on 3/24/26 at 8:10 a.m. with LN 9 at the 1 C medication cart, LN 9 stated discontinued controlled medications are given to the DON right away.During an interview and record review on 3/24/26 at 8:52 a.m. with the DON, the DON acknowledged receiving the controlled substances and corresponding CSR's on 3/23/26 for Resident's 165, 69, 15, 50 and 7. The DON stated she encourages nurses to give discontinued medications to her and acknowledged the potential risk for diversion when discontinued controlled substances remain in the medication cart.During a follow-up interview and clinical record reviews on 3/25/26 at 8:53 a.m. the DON confirmed the following: Resident 163: discharged on 2/23/26; lorazepam liquid remained in the medication refrigerator 28 days past discharge. Resident 165: discharged on 2/26/26; oxycodone half tablets remained in the medication cart 25 days past discharge. Resident 69: discharged on 3/10/26; oxycodone tablets remained in the medication cart 13 days past discharge. Resident 50: discharged on 3/10/26; oxycodone half tablets remained in the medication cart 13 days past discharge.During a phone interview with the CP on 3/25/26 at 11:09 a.m., when asked if it was acceptable to keep discontinued controlled medications in the medication cart for a month, the CP stated No, that would not be acceptable. He acknowledged the risk of accidental administration and the potential for diversion, stating there is always that problem.During a review of the facility's policy and procedure titled, Controlled Substances, revised date November 2022, indicated, 1. Controlled substance inventory is monitored to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and nurse going off duty make the count together.3 a. A review of Resident 67's clinical record indicated the following physician order, dated 1/23/26:Oxycodone 5 mg, give 0.5 tablet (2.5 mg) by mouth every 4 hours as needed for moderate pain (pain scale 4-6).Oxycodone 5 mg, give 1 tablet by mouth every 4 hours as needed for severe pain (pain scale 7-10).During a concurrent interview and clinical record review on 3/25/26 at 8:39 a.m. with the DON the DON reviewed Resident 67's Controlled Substance Record (CSR) for oxycodone 2.5 mg (5 mg; 0.5 tablet) and the March 2026 Medication Administration Record (MAR). The CSR indicated that one half tablet (2.5 mg) of oxycodone was removed on 3/21/26 at 9:39 p.m. There was no corresponding administration documented on March 2026 MAR. The DON acknowledged the medication was signed out on the CSR and that there was no corresponding administration documented. 3b. A review of Resident 20's clinical record indicated the following physician order,Tramadol 50 mg tablet, give 0.5 tablet (25 mg) by mouth every 6 hours as needed for moderate pain.Tramadol 50 mg tablet, give 1 tablet by mouth every 6 hours as needed for severe pain.During a concurrent interview and clinical record review on 3/25/26 at 8:46 a.m. with DON, the DON reviewed Resident 20's CSR for Tramadol 50 mg tablets, CSR for Tramadol 25 mg (50 mg, 0.5 tabs) and March 2026 MAR. The CSR for Tramadol 50 mg indicated 1 tablet signed out on 3/14/26 at 5 p.m. and 1 tablet signed out on 3/14/26 at 10 p.m. There were no corresponding administrations on March 2026 MAR. The DON confirmed there were no tramadol administrations documented for 3/14/26 on the MAR and no nursing notes corresponding to the CSR removals on that date.During a review of the facility's policy and procedure titled, Controlled Substances, revised November 2022, indicated, The facility complies with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications. further review indicated, The system of reconciling the receipt, dispensing and .of controlled substances includes the following: a. records of personnel access and usage; b. medication administration records; c. declining inventory records .

Based on observation, interview and record review the facility had a medication error rate of 6.45% when four medication errors occurred out of 62 opportunities during the medication administration for three out of nine residents observed (Residents 9, 157 and 112).Resident 9 received a dose of cholecalciferol (Vitamin D3 supplement, used to prevent or treat Vitamin D deficiency) 25 times greater than prescribed. Resident 157 received the wrong dose of Humulin R (Regular Insulin, a short acting insulin used to lower blood sugar), and the ordered dose of Humulin N (NPH Insulin, an intermediate acting insulin providing basal coverage) was not administered.Resident 112 received acetaminophen (an over the counter medication to reduce fever and mild pain) not in accordance with the prescribed pain level.These failures resulted in incorrect medication doses, omitted medication and medications administered not per the physician orders and had the potential to adverse drug effect, low or high blood sugar levels and inadequate pain management.Findings:1. During a medication observation on 3/23/26 at 9:42 a.m. at the 1 A medication cart, LN 4 prepared 10 medications for Resident 9, including 1 capsule of cholecalciferol from a bottle labeled, BioTech D3-50 and proceeded to the resident's room for administration. Resident 9 was observed taking the prepared medications with soda.A review of Resident 9's clinical record indicated a physician order, dated 2/27/26, for cholecalciferol oral tablet 50 micrograms (mcg, strength), Give 1 tablet by mouth one time a day for supplement. It was scheduled for 8 a.m.During an interview and clinical record review on 3/24/26 at 1:05 p.m. at the 1 A medication cart with LN 4, when asked to identify the cholecalciferol bottle used for Resident 9's medication pass on 3/23/26, LN 4 removed a bottle labeled BioTech D3 50 Cholecalciferol. Upon further inspection, the label indicated: Vitamin D3 (cholecalciferol), serving size: 1 capsule, amount per serving: 1,250 mcg, % Daily Value: 6,250 %. LN 4 reviewed Resident 9's physician orders and acknowledged the order was for 1 tablet of cholecalciferol 50 mcg, and that 1 capsule of 1,250 mcg was administered.During an interview on 3/25/26 at 8:21 a.m. with the Director of Nursing (DON), the DON stated she expected nursing staff to follow physician orders when administering medications. She acknowledged Resident 9 received a 1,250-mcg dose of vitamin D (cholecalciferol)During a review of the facility's policy and procedure titled, Administering Medications, revised date April 2019, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame. and further indicated, .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time .before giving the medication.2. During a medication observation on 3/23/26 at 10:06 a.m. at the 1A medication cart, Licensed Nurse (LN 4) prepared 10 medications for Resident 157, including Humulin R. LN 4 stated she would administer a total of 8 units of insulin: 2 units for a blood sugar reading of 239 and 6 units as the fixed dose. LN 4 was observed removing Resident 157's Humulin R vial, swabbing the vial, and drawing up 8 units of Humulin R into an insulin syringe. The Humulin R was then observed being injected into Resident 157's left abdomen.A review of Resident 157's clinical record indicated 11 medications were due during the morning medication pass. Physician orders, dated 3/21/26 included:Humulin R 100 unit/milliliter (unit/mL, concentration) to be given per sliding scale, (a set of instructions for administering insulin dosages based on specific blood glucose readings), to give 2 units for a blood sugar between 201-250. Blood glucose checks were scheduled for 8 a.m., 1 p.m. and 5 p.m.Humulin N 100 unit/mL, inject 6 unit [s] two times a day for DM-2 (type 2, diabetes mellitus, condition causing high blood sugar), Hold for Finger Stick Glucose (FSG, method of pricking finger to obtain blood for testing sugar) < (less than) 100; Give Insulin after meal is consumed, dated 3/21/26. It was scheduled for 8 a.m. and 5 p.m. During an interview and record review on 3/23/26 at 2:28 p.m. at the 1A medication cart with LN 4, when asked to identify the insulin administered to Resident 157 during the morning medication pass, LN 4 removed the resident's Humulin R vial from the cart and confirmed the resident received 8 units that morning. Upon further review of Resident 157's clinical records, LN 4 acknowledged the resident should have received 2 units of Humulin R instead of 8 units per the sliding scale order. LN 4 also acknowledged she did not administer the resident's Humulin N as ordered by the physician.During an interview and clinical record review on 3/25/26 at 8:21 a.m., the DON acknowledged that on 3/23/26 the wrong dose of Humulin R was administered, and the Humulin N dose was omitted for Resident 157. The DON also stated she provided education to LN 4 regarding NPH and Regular Insulin.A review of the drug manufacturer's prescribing information (PI, a regulatory-approved document providing detailed drug information) for Humulin R, revised 6/2023, indicated, . Always check the insulin label before administration to confirm the correct insulin product is being used.Humulin R .injection should generally be used in regimens with intermediate-or long-acting insulin. Hypoglycemia (low blood sugar): May be life-threatening. Increase monitoring with changes to insulin dosage.A review of the drug manufacturer's PI, for Humulin N, revised 12, 2025, indicated, .Humulin N is an intermediate-acting insulin with a slower onset of action and a longer duration of activity than that of a regular human insulin.During a review of the facility's policy and procedure titled, Administering Medications, revised date April 2019, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame. and further indicated, .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time .before giving the medication.3. During a medication observation on 3/23/26 at 4:25 p.m. at the 1B medication cart with LN 8, LN 8 stated Resident 112 was requesting pain medication and that she would assess the resident's pain before administering it. LN 8 returned to the cart and stated the resident's back pain was rated as a 5 [pain scale from 0 to 10]. She then prepared one tablet of acetaminophen 325 mg (an over-the-counter medication to reduce fever and mild pain) and two tablets of ibuprofen 200 mg, [400 mg] (medication to lower fever and reduce pain.) Resident 112 was observed swallowing the three tablets with water.A review of Resident 112's clinical record indicated the following physician orders, dated 3/9/26:Acetaminophen oral tablet 325 mg, give one tablet by mouth every 4 hours as needed (prn) for MILD pain (1-3 pain scale)/ Headache.Ibuprofen oral tablet 400 mg, give one tablet by mouth every 4 hours as needed for MILD (1-3 pain scale) or Moderate (4 -6 pain scale) give with food.A review of the nursing administration notes written by LN 8 on 3/23/25 at 4:39 p.m. indicated that acetaminophen 325 mg 1 tablet was administered for complaint of (c/o) back pain rated 5 out of 10. During an interview and clinical record review on 3/25/26 at 8:11 a.m. with the DON, the DON stated pain medication is to be administered based on the physician ordered pain scale for mild, moderate, or severe pain. The DON reviewed Resident 112's clinical records, including the medication administration record (MAR) and nursing notes, and acknowledged the acetaminophen administration did not follow the pain scale as ordered.

Based on observation, interview, and record review, the facility failed to ensure one out of 30 sampled residents (Resident 160) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 160's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) bag was left on the floor.This failure had the potential for Resident 160 to develop infection and possible urinary catheter complications.Findings:A review of Resident 160's clinical record indicated Resident 160 was admitted March of 2026 and had diagnoses that included malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems), and obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract).A review of Resident 160's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/13/26, indicated Resident 160 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 which indicated Resident 160 had moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 160's MDS Bladder and Bowel Status, dated 2/13/26, indicated Resident 160 uses indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time).A review of Resident 160's care plan, dated 3/11/26, indicated, The resident [Resident 160] has Indwelling Catheter r/t [related to] URINARY RETENTION .The resident will show no s/sx [signs and symptoms] of Urinary infection through review date .The resident will be/remain free from catheter-related trauma through review date .A review of Resident 160's active physician's order, dated 3/12/26, indicated, SUPRAPUBIC catheter .Gravity drainage bag due to Dx [diagnosis] of OBSTRUCTIVE AND REFLUX UROPATHY.During an observation on 3/24/26 at 10:20 a.m. of Resident 160, in Resident 160's room, Resident 160 was observed lying on bed, awake and was connected to a urinary catheter tubing attached to a urinary catheter bag which was on the floor.During a concurrent observation and interview on 3/24/26 at 12:40 p.m. with Licensed Nurse (LN) 2, in Resident 160's room, Resident 160's urinary catheter bag was still on the floor. LN 2 confirmed the observation. LN 2 stated the urinary catheter bag should not be left on the floor because the catheter bag could get contaminated which may cause infection and urinary complications.During an interview on 3/25/26 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated urinary catheter bags should be hanging on the bedside and not touching the floor. The DSD stated there would be a risk of infection if the urinary catheter bag was left on the floor and the urine could also flow back which could cause potential urinary catheter complications.During an interview on 3/26/26 at 12:12 p.m. with the Director of Nursing (DON), the DON stated that urinary catheter bags should be hanging on the bedside and should not be touching the floor. The DON further stated that if the urinary catheter bag was on the floor, it could cause urinary complications like infection or possible back flow of the urine.A review of the facility's policy and procedures titled, Catheter Care, Urinary, revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .2. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to administer insulin (a medication used to lower blood sugar) according to the sliding scale in a timely manner (a set of instructions for administering insulin dosages based on specific blood glucose readings) when the insulin was administered more than 2 hours after the blood glucose reading for one of nine residents observed during the medication pass (Resident 157). This failure created the potential for inaccurate dosing and adverse effects from uncontrolled blood sugar.Findings: During a medication observation on 3/23/26 at 10:06 a.m. at the 1 A medication cart, Licensed Nurse (LN 4) was observed preparing 10 medications, for Resident 157, which included Regular Insulin (short acting insulin). At 10:15 a.m., LN 4 was observed administering the Regular Insulin to Resident 157's left lower abdomen. A review of Resident 157's physician order indicated the following order for Regular Insulin 100 unit/milliliter (concentration) to be given as per sliding scale, dated 3/21/26: Finger Stick Glucose (FSG, a method of pricking a finger to test blood sugar)less than 70 (milligrams/deciliter, mg/dL, concentration measurement) initiate facility hypoglycemia (low blood sugar) protocol and notify MD.71 to 150= 0 units 151- 200 = 1 unit201- 250= 2 units251-300= 4 units301-350= 6 units351-400= 8 units401-450=10 units recheck FSG in 1 hour and notify MD During a review of Resident 157's Medication Administration Record (MAR), the Insulin Regular 100 units/milliliter per sliding scale dose was scheduled for 8 a.m., 1 p.m. and 5 p.m., further review indicated on 3/23/26 the 8 a.m. dose of Insulin Regular was given at 10:11 a.m. During an interview and a review of Resident 157's clinical medication records on 3/23/26 at 2:28 p.m. at the 1A medication cart, LN 4 stated the resident's blood sugar was taken around 7:00 a.m., with a result of 239. She confirmed the Regular Insulin, scheduled for 8:00 a.m., and was administered after 10:00 a.m. LN 4 acknowledged the Regular Insulin dose was sliding scale based on the blood sugar level and should have been given sooner. During an interview and record review on 3/25/26 at 8:21 a.m., the Director of Nursing (DON) stated the facility's standard practice is to administer insulin within 30 minutes of obtaining the blood glucose reading. The DON reviewed Resident 157's March MAR, specifically the entry for 3/23/26, and confirmed the Regular Insulin was administered outside of this standard. She acknowledged the Regular Insulin was given over 2 hours after the blood glucose was obtained, creating the potential for inaccurate sliding scale dosing based on a non current blood sugar result. During a review of the facility's policy and procedure titled, Administering Medications, revised date April 2019, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interaction;

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 134 residents, when flies were observed in the residents' rooms.This failure decreased the facility's potential to maintain a pest free environment for the residents.Findings:A review of Resident 1's admission Record, dated 8/14/25, indicated Resident 1 was admitted to the facility in 2025.A review of Resident 2's admission Record, dated 8/14/25, indicated Resident 2 was admitted to the facility in 2021.During a concurrent observation and interview on 8/14/25 at 9:46 a.m. with Resident 1, Resident 1's room was observed. Resident 1 confirmed and stated there were flies in the room all the time. During a concurrent observation and interview on 8/14/25 at 9 a.m. with Resident 2, Resident 2's room was observed. The sliding door was opened and had no screen. Resident 2 confirmed and stated there were flies flying around the room.During an interview on 8/14/25 at 9:48 a.m. with Certified Nursing Assistance (CNA), CNA confirmed the sliding door in Resident 1 and Resident 2's room was opened and had no screen.During a concurrent observation and interview on 8/14/25 at 10:50 a.m. with the Administrator (ADM), ADM stated she had a blue light zapper to zap flies and bugs in her office.During a concurrent interview and record review on 8/14/25 at 11 a.m. with the Director of Maintenance (DOM), the May, June, and July 2025 invoices for pest control services were reviewed. DOM confirmed there was a fly issue in the building and stated 14 out of 16 sliding doors currently had no screening doors.During an interview on 8/14/25 at 11:43 a.m. with the Director of Nursing (DON), DON confirmed there were concerns regarding flies and expected staff to ensure the sliding doors were closed until maintenance install the screens.A review of the facility's policy titled, Pest Control, dated 5/2008, indicated, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure dignity was promoted for one of three sampled residents (Resident 1), when the resident was left with a soiled brief for an extended period of time. This failure had the potential to result in Resident 1 not attaining his highest practicable social, physical, mental and psychosocial well-being. Findings: Resident 1 was admitted to facility summer 2016 with diagnosis of Muscle Atrophy and Wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/11/25, the MDS indicated Resident 1 had incontinence. During a review of Resident 1's Care Plan Report , dated 1/25, the care plan indicated, The resident is total dependent on 1 staff for toileting. During a concurrent observation and interview on 3/20/25 at 10:40 a.m. with Infection Preventionist (IP) outside Resident 1's room, the IP confirmed there was a strong odor coming from Resident 1's room. During an observation on 3/20/25 at 10:43 a.m. in Resident 1's room, there was a strong odor coming from Resident 1's room as Certified Nursing Assistant 1 (CNA 1) exited the room. CNA 1 did not check or changed Resident 1's incontinent brief. During an observation on 3/20/25 at 10:53 a.m. in Resident 1's room, Resident 1's call light was turned on. The strong odor in the Resident 1's room continued. During a concurrent observation and interview on 3/20/25 at 10:55 a.m. with Resident 1 in bed, Resident 1's call light remained turned on. Resident 1 indicated stated he was uncomfortable and upset because he was soiled. During a concurrent observation and interview on 3/20/25 at 10:58 with CNA 2 in Resident 1's room, CNA 2 entered and turned off the call light, and stated, I will let your CNA know. CNA 2 then left Resident 1's room and did not change his soiled brief. During an interview on 3/20/25 at 11:00 a.m. with CNA 2, CNA 2 stated, We check the patient and turn the light off. CNA 2 indicated she would get the primary CNA to change Resident 1's soiled brief. During an interview on 3/20/25 at 11:03 a.m. with the IP, the IP stated, Residents should not be lying in BM [bowel movements]. During a concurrent observation and interview on 3/20/25 at 11:20 a.m. with CNA 1 in Resident 1's room, CNA 1 indicated she would get his assigned CNA to change his soiled brief, and stated, I do not expect the resident to sit in BM. CNA 1 verified Resident 1 was soiled, and stated, It [soiled brief] can cause skin tears. During a concurrent observation and interview on 3/20/25 at 11:21 a.m. with Resident 1, Resident 1 remained lying in bed with strong odor of BM from his soiled brief. Resident 1 indicated he was still in his soiled brief and felt uncomfortable, and stated, They told me to wait. During an interview on 3/20/25 at 11:25 with Licensed Nurse 1 (LN 1), LN 1 stated, A soiled resident should be changed in a timely manner because of skin issues and dignity concerns. During an interview on 3/20/25 at 12:20 p.m. with Social Service Director (SSD), the SSD stated, [Resident 1] can tell you what he always needs and is alert and oriented. During an interview on 3/20/25 at 1:35 p.m. with Director of Nursing (DON), the DON stated her expectations for staff to change residents' incontinent briefs in a timely manner to avoid having their dignity effected, and stated, If the CNA was on break another person on break should cover and change the resident's soiled brief. During a review of the facility policy and procedures (P&P) tilted Dignity, dated 2025, the P&P indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents for example .promptly responding to a residents request for toileting assistance.

Based on interview, and record review, the facility failed to protect 3 of 6 sampled residents (Resident 2, Resident 4, and Resident 6) from abuse by peer residents for a census of 136 when; 1. Resident 1 slapped Resident 2 in the face; 2. Resident 3 punched Resident 4 in the Thigh; and, 3. Resident 3 expressed verbal slurs to Resident 6. This failure resulted in 3 sampled residents being abused by peer residents and had the potential to cause physical injury and negatively impact their psychosocial well-being. Findings: 1. A review of Resident 1's Admission record , indicated Resident 1 was admitted in January 2025 with multiple diagnoses including Major depressive disorder (a disorder that causes persistent feelings of sadness and loss of interest) and Schizophrenia (a chronic mental condition that affects how a person thinks, feels, and behaves). A review of Resident 1's Minimum Data Set (MDS-Federally mandated assessment tool), Cognitive Patterns, dated 1/15/2025, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-tool to assess cognition) score of 15 out of 15 which indicated resident 1 was cognitively intact. During a concurrent observation and interview on 2/5/25 at 12:54 p.m. with Resident 1 in resident's room, Resident 1 was observed in wheelchair turning away from Department. Resident 1 stated does remember altercation last week with Resident 2. Resident 1 further stated, .I don't bug anyone I don't want anyone bugging me. It had to do something to make me mad . Resident no longer wanted to continue conversation regarding the altercation. A review of Resident 2's Admission Record , indicated Resident was admitted on [DATE] with multiple diagnoses including Dementia (a condition that affects memory, thinking, and behavior), Diabetes Mellitus (when the body can't regulate sugar from the blood into the cells properly) and Repeated falls. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score of 4 out of 15 which indicated severe cognitive impairment. During a concurrent observation and interview on 2/5/25 at 12:48 p.m. at Resident 2's bedside, Resident 2 was observed sitting in wheelchair and was unable to answer questions regarding how long had been admitted at facility. Resident 2 stated could not remember altercation with another resident. During a telephone interview on 2/5/25 at 1:47 p.m. with Licensed Nurse 4 (LN 4), LN 4 stated earlier in the day on 1/30/25, Resident 2 was confused and went into Resident 1's room and later that day Resident 1 yelled at Resident 2 in the hallway and Resident 1 slapped Resident 2 in the face. During a record review of Resident 2's ' summary of change of condition' note dated 1/30/25, the note indicated, .Witness saw (Resident 1) . punch at resident 3x [3 times] . resident was questioned . He could not recall incident . During a record review of Resident 2's progress notes dated 1/30/25, the progress notes indicated, .the other resident was able to make physical contact with (Resident 2) . before staff intervened . During a record review of Resident 1's progress note dated 1/30/25, the progress indicated, . resident opened up .stated, that man got me messed up touching my bag .just keep him away from me . 2. A review of Resident 3's Admission Record indicated Resident 3 was admitted [DATE] with multiple diagnoses including Cellulitis (bacterial skin infection) of abdominal wall and diabetes Mellitus. The record indicated resident was currently not at facility. A review of Resident 3's MDS dated [DATE] indicated Resident 3's BIMS score of 15 out of 15 which indicated Resident 3 was cognitively intact. A review of Resident 4's Admission Record , indicated Resident 4 was admitted August of 2022 with multiple diagnoses including End Stage Renal Disease (Kidneys can no longer filter waste and excess fluids from the blood) and Chronic Respiratory Failure with Hypoxia (lungs are struggling to get enough oxygen into the blood). A review of Resident 4's MDS dated [DATE] indicated Resident 4 had a BIMS score of 5 out of 15 which indicated Resident 4 had severe cognitive impairment. During a concurrent observation and interview on 2/5/25 at 1:03 p.m. with Resident 4 at bedside, Resident 4 was observed laying supine in bed, Resident 4 stated, .You will die today . to Department. Resident 4 did not want to continue with the interview. A record review of Resident 3's summary of change of condition note dated 1/31/25 indicated, . [Resident 3] was seen grabbing [Resident 4's] thigh area with left hand and striking in a punching motion with his right hand to other resident thigh area . asked other resident if he was hit and resident stated yes . [Resident 3] continued to show verbal aggression to staff . During a telephone interview on 2/5/25 at 1:53 p.m. with Licensed Nurse 3 (LN 3), LN 3 stated that on 1/31/25, she saw Resident 3 at Resident 4's bed and Resident 3 punched Resident 4 in the thigh. LN 3 further stated Resident 3 had behaviors with their previous roommate during that shift. 3. A review of Resident 6's admission record indicated Resident 6 was admitted in January 2025 with multiple diagnoses including difficulty in walking and muscle weakness. During a concurrent observation and interview on 2/5/25 at 3:26 p.m. in facility lobby, Resident 6 was observed sitting in wheelchair with family members present and resident requested family member to translate. Resident 6 stated he was not comfortable in previous room with roommate (Resident 3). During a review of Resident 3's progress note dated 1/31/25 indicated . [Resident 3] woke up from a nap around 1930 [7:30 p.m.] agitated because roommate [Resident 6] had visitors . stating I can't sleep because those taco vendors are in their talking so loudly (started mocking their language). If I wanted to go to Mexico, I would've moved to Mexico . During a record review of resident 6's progress notes dated 1/31/25, the progress note indicated . Patient found in tears and emotionally upset; according to pt [ patient] and staff members who heard the interchange his roommate [Resident 3], was calling him names including nigger pt and all belongings moved into room . During a telephone interview on 2/5/25 at 2:15 p.m. with Licensed Nurse 5 (LN 5), LN 5 stated on 1/31/25, during medication administration Resident 3 was angry at his roommate (Resident 6) who had visitors. LN 5 further stated they did a room change because Resident 6 had a panic attack over the racial slurs yelled at him by Resident 3. During a review of Resident 6's Medication Administration Record (MAR) dated 1/1/25-1/31/25, the MAR indicated, . Hydroxyzine pamoate Oral Capsule 50 mg (Hydroxyzine Pamoate) Give 1 capsule by mouth one time only for anxiety for 1 day Start Date -1/31/2025- 2030 [8:30 p.m.] During a record review of Resident 6's care plan dated 1/31/25, the care plan indicated . Noted with impairment in psychosocial well-being related to verbal experience with former roommate . During an interview on 2/5/25 at 3:10 p.m. with Director of Nursing (DON), the DON stated Resident 6's room was changed after a discussion with nursing staff and the comments told to Resident 6 by Resident 3. DON further stated she did not know Resident 4 was moved with Resident 3 because Resident 4 had a history of verbal behaviors. DON further stated she was notified after the altercation between Resident 3 and Resident 4. The DON stated it was not permitted for a resident to abuse another resident. During a review of facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program , Revised September 2025, the P&P indicated, . Residents have the right to be free from abuse . verbal, mental, or . physical abuse .

Based on observation, interview and record review, the facility failed to ensure food safety when: 1. The ice machine was not clean, 2. Various sizes kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had food particles 3. An air gap was not found on the food production sink, 4. Dietary Aide (DA) 1 did not verbalize the process of manual dishwashing correctly, 5. [NAME] (CK) 1 and CK 2 had beard and did not have beard restraint. These failures had the potential to result in food contamination which could cause illness in 128 out of 128 medically vulnerable residents who received and consumed food from the facility kitchen. Findings: 1. A concurrent observation and interview on 1/7/25 at 10:03 a.m. with Dietary Assistant Manager (DAM) and Director of Environmental Services (DES) regarding the ice machine was conducted. DAM stated the maintenance department was responsible for monthly cleaning and sanitizing for ice storage bin and the outside vendor was responsible for the deep cleaning (cleaning and sanitizing the machinery parts on the top section of the ice machine and ice storage bin on the bottom section of the machine with chemical solutions designed to remove lime scale and mineral deposits and to remove algae and slime, then sanitize with chemical agent) of the ice machine every three months. DES dissembled the top (machinery part) of the ice machine, it was noted there was significant dark brown and yellow substances on the bottom of the evaporator unit (a part where the water condenses and makes ice), and those substances were grainy and rough to touch. DES confirmed by touching the substances and stated it was calcium buildups. He stated he needed to call the outside vendor and put the machine out of order until it got cleaned. DES further stated the water filter was changed every three months. During the following up interview with DES on 1/8/25 at 10:50 a.m., DES stated he tried to look at the dark brown and yellow substances and tried to clean and scrub them. He further stated the ice machine was dirty. DES provided the last maintenance service invoice from the outside vendor, and it was performed on 12/9/24. A concurrent review of outside vendor invoice, it indicated the ice machine had maintenance, cleaning and sanitization performed, and water filter was renewed on 12/9/24. A review of facility policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2023, indicated, .the internal components [of the ice machine] cleaned monthly or per manufacturer's recommendations . A review of the ice machine manual titled, [Manufacturer's brand] Ice machine Installation, Use & Care Manual, dated 5/2013, the manual indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual .Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing . According to 2022 Federal FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits . 2. During a concurrent observation and interview on 1/7/25 at 9:37 a.m. with DAM, DAM confirmed several and various types of kitchenware were stored away at the clean and ready-to-use storage areas stacked wet and with food particles as followed: -Nine of 1/2 sheet metal pans (stacked wet) -Five of metal mixing bowls (stacked wet) -14 of 1/3 sheet metal pans (stacked wet) -Five of full sheet metal pans (stacked wet) -Two of 1/2 sheet metal pans (with food particles) -Two of 1/2 sheet metal pans (with white and brown substances) DAM stated the white and brown substances inside the metal pans were food debris. She stated the dishes, pots and pans should be clean and completely air dried before stored away. She further stated the dietary aide was responsible to check if they were dried and clean before stored away. During a follow up interview on 1/9/25 at 1:45 p.m. Registered Dietitian (RD), RD stated the dishes, pans and pans should be completely air dried before stored away. She stated the rationale for the kitchenware to be air-dried was to prevent bacteria growth from the moisture. A review of facility P&P titled, Sanitation, dated 2023, indicated, .All utensils, counters, shelves, and equipment shall be kept clean . A review of facility P&P titled, Dishwashing, dated 2023, indicated, .Gross food particles shall be removed by careful scraping and pre-rinsing in running water .Dishes are to be air dried in racks before stacking and storing . According to 2022 Federal FDA Food Code, on section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the document indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . 3. During an observation of the kitchen on 1/7/25 at 10:24 a.m., an air gap was not found for the fruit and vegetable prep sink. A concurrent interview with DES, he confirmed and agreed there was no visible break in the waste pipe under this sink. A review of facility P&P titled, Accident Prevention - Safety Precautions, dated 2023, indicated, .An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non-potable water supple systems by an air space. All steam tables, ice machines and bins, food preparation sinks .and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink .An air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. According to 2022 Federal FDA Food Code, Section 5-202.13 stated, .an air gap between the water supply inlet and the flood level rim of the plumbing fixture .shall be at least twice the diameter of the water supply inlet and may not be less than 25 millimeters (1 inch). 4. During an initial kitchen tour, an interview with Dietary Aide (DA) 1 regarding manual dishwashing process on 1/7/25 at 9:53 a.m., DA 1 verbalized the process of wash and rinse procedure. When it came to the sanitizing procedure, she stated the dishes would immerse into the sanitizer solution for two seconds, and then air dried. A concurrent confirmation interview with DAM, DAM stated the sanitizer immersion time should be 60 seconds (one minute). During an interview with RD on 1/9/25 at 1:45 p.m., RD stated the dietary aides should know the procedure of the manual dishwashing well. She further stated it was the process of sanitation in case the dishwashing machine was not working. A review of facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, .immerse all washed items for one minute . in the sanitizer compartment sink. 5. During an observation and concurrent interview with Director of Dietary Services (DDS) on 1/8/25 at 4:30 a.m., DDS acknowledged and confirmed [NAME] (CK) 1 and CK 2 did not have beard restraints on for their beard, instead they used the medical mask to cover the beard during the meal distribution service on 12:15 p.m. She stated they did not have beard net and thought they used the masks to replace the beard net. A review of facility P&P titled, Dress Code, dated 2023, indicated, .beards and mustaches (any facial hair) must wear beard restraint . According to 2022 Federal FDA Food Code, Section 2-402.11, it indicated, Food employees shall wear hair restraints such as hat, hair coverings or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils and linens .

Based on observation, interview, and record review, the facility failed to ensure the planned menu or spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) was followed for the therapeutic diets during the lunch meal distribution on 1/8/25 when: 1. 20 residents (Resident 16, 17,18, 26, 28, 41, 44, 47, 60, 62, 64, 71, 80, 82, 92, 98, 100, 101, 110, and 386) with CCHO (control carbohydrate) diets (diet uses for person with diabetes and maintain a stable sugar level throughout the day) with regular portion received margarine instead they should not receive margarine, 2. Two Residents (Resident 34 and 37) with CCHO, Renal (refer to the kidney) diet (diet that manage a person with diabetes and kidney disease) did not receive baked fish and/or wheat roll but they should have as indicated on the spreadsheet, 3. Nine Residents (Resident 15, 21, 25, 56, 74, 95, 96, 106, and 109) with puree diet (diet with texture that is soft and smooth and prepares in a food processor or blender for people who have difficulty chewing and/or swallowing) did not receive puree wheat roll but they should have as indicated on the spreadsheet, and 4. 128 of 128 residents consumed and received meals from the kitchen did not receive garnish with parsley for their meals. These deficient practices had the potential to result in 128 of 128 residents receiving meals from the kitchen facility that did not meet their nutritional needs. Findings: During a concurrent observation and spreadsheet review on 1/8/25 beginning at 12:15 PM, it was noted as followed: 1. 20 residents (Resident 16, 17,18, 26, 28, 41, 44, 47, 60, 62, 64, 71, 80, 82, 92, 98, 100, 101, 110, and 386) with CCHO diet received margarine. A concurrent review of facility spreadsheet titled, Winter Menus, Week 2 Wednesday, indicated CCHO diet should not receive margarine. 2. Two residents with CCHO, Renal diet, Resident 34 did not receive a wheat roll and Resident 37 received oven crisp fish (with potato chip crunches on top) and no wheat roll. A concurrent review of facility spreadsheet titled, Winter Menus, Week 2 Wednesday, indicated CCHO, Renal diet should receive baked fish and a wheat roll. 3. Nine residents (Resident 15, 21, 25, 56, 74, 95, 96, 106, and 109) with puree diet did not receive puree wheat roll. A concurrent review of facility spreadsheet titled, Winter Menus, Week 2 Wednesday, indicated puree diet should receive puree wheat roll. 4. All meals for 128 residents prepared without parsley garnish. A concurrent review of facility spreadsheet titled, Winter Menus, Week 2 Wednesday, indicated all diets should receive parsley garnish. During an interview on 1/8/25 at 2:21 p.m. with Director of Dietary Services (DDS), DDS acknowledged the issues were found during lunch meal distribution. DSS stated that was her fault regarding the garnish because she did not order any parsley. She stated she would do the in-service with the staff and especially the cooks. She stated the staff should follow the menu/spreadsheet. During an interview on 1/9/25 at 1:45 p.m. with Registered Dietitian (RD), RD was aware the issues that were found during lunch meal distribution on 1/8/25. RD stated the staff should follow the menu/spreadsheet. A review of the facility policy and procedure (P&P) titled, Menu Planning, dated 2023, indicated, .menus are planned to meet nutritional needs of residents in accordance with established national guidelines .the facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility .menus are written for regular and therapeutic diets in compliance with the diet manual . A review of document titled, Job Description, FNS (food and nutrition services) Director, dated 2023, indicated FNS Director (DDS) was to .ensures that approved menus and accompanying recipes are followed .

Based on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors when one of two garbage dumpsters, located outside the facility, was not closed securely with the dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility. Findings: During an observation and concurrent interview on 1/7/25 at 8:58 a.m. with Dietary Assistant Manager (DAM), observed one out of two outside garbage bins was covered with lids but not securely completely covered. The lids lacked integrity to securely cover the bin and left gaps on both sides. DAM confirmed and agreed the lids could not securely cover the bin. She stated it was not acceptable. During an interview with Registered Dietitian (RD) on 1/9/25 at 1:45 p.m., RD stated the dumpster garbage bins should be covered tightly with the lids. She added the bins should cover without any opening or gaps to prevent issues from the pests and rodents. A review of facility policy and procedure titled, Miscellaneous Areas, dated 2023, indicated, .1. All food waste must be placed in sealed leak proof, non absorbent, tightly closed containers .the trash collection area is a potential feeding ground for vermin and rodents and must be kept clean . According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 5-501.15 Outside Receptacle, (A) Receptacles and waste handling units for refuse .used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers .

50750 Based on observation, interview, and record review, the facility failed to ensure: 1. Accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents 58, 65, and 69) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Medication accountability when two out of four medication carts' controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 3. An efficient system was in place to accurately document and secure emergency medications (E-Kit) for a census of 132. 4. Medications were secured safely when multiple bottles containing crushed and partially crushed medications, including controlled medications were found to be retrievable in three out of four medication carts (Med Cart). These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 69 had a physician's order dated 11/27/23, for tramadol (a medication to treat pain) 50 milligrams (mg, a unit of measurement), 1 tablet by mouth every 6 hours as needed for moderate pain and 2 tablet by mouth every 6 hours as needed for severe pain. The CDR indicated 2 tablets were signed out on 12/29/24 at 7:50 a.m. and 2 tablets on 12/30/24 at 8:48 a.m. The MAR did not indicate tramadol was administered to Resident 69 on these dates or times. Resident 58 had a physician's order dated 12/12/24, for oxycodone (a medication to treat pain) 5 mg, 1 tablet by mouth every 4 hours as needed for moderate pain and give 2 tablets by mouth every 4 hours as needed for severe pain. The CDR indicated 2 tablets were signed out on 1/3/25 at 9 p.m. The MAR did not indicate oxycodone was administered to Resident 58 on that date or time. The CDR indicated 2 tablets were signed out on 1/5/25 at 8 p.m. and 2 tablets on 1/6/25 at 11:16 a.m. The MAR indicated only 1 tablet was administered on 1/5/25 and 1 tablet on 1/6/25 to Resident 58. Resident 65 had a physician's order dated 8/30/24, for tramadol 50 mg, 1 tablet by mouth every 12 hours as needed for moderate to severe pain and 1 tablet by mouth at bedtime for pain management. The CDR indicated 1 tablet was signed out on 12/6/24 at 5 p.m. but the MAR did not indicate tramadol was administered to Resident 65 on that date or time. During an interview on 1/8/25 at 11:03 a.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to document administered doses of controlled medication on both the MAR and CDR. DON stated it was important to document administered doses on the MAR to inform the next nurse as to when a medication was last administered and the CDR was for accountability of how much controlled medication was in the medication cart. During a review of the facility's policy and procedure (P&P) titled, IIA-7 Controlled Medications, dated 3/2018, the P&P indicated, .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered . 2. During a concurrent interview and record review on 1/7/25 at 4:55 p.m. with Licensed Nurse 7 (LN7), the Shift to Shift Narcotic Count Verification for Controlled Drug Record (CDR), dated 1/2025 for Medication Cart 2A was reviewed. The sign-in/sign-out sheet indicated nine missing signatures. LN 7 confirmed the finding and stated the outgoing and incoming nurses were to both sign between shift changes to confirm the count of the controlled medications. During a concurrent interview and record review on 1/7/25 at 5:08 p.m. with LN 8, the Shift to Shift Narcotic Count Verification for Controlled Drug Record (CDR) dated 1/25 for Medication Cart 1C was reviewed. The sign-in/sign-out sheet indicated five missing signatures. LN 8 acknowledged there were missing signatures, including his own, and stated he should have signed the sheet at the beginning of his shift. During an interview on 1/8/25 at 11:03 a.m. with the DON, the DON stated the nurses were expected to do a shift-to-shift controlled medication count. She stated the nurses were expected to sign the sign-in/sign-out sheet every single shift and every single date should have been filled out. During a review of the facility's P&P titled, Controlled Substance, dated 4/19, the P&P indicated, .Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift . 11. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together . 3. During an inspection of the Medication Storage Room at Station 2 on 1/7/25 at 12:46 p.m. with LN 5, the E-kit containing controlled medications was observed with a red tag (indication the E-kit had been opened by the facility). The E-kit log inside indicated 1 tablet of oxycodone 5 mg was removed on 1/7/25. An inspection of the list of contents affixed to the outside of the E-kit indicated it was provided to the facility with 8 oxycodone 5 mg tablets, 1 that was documented on an E-kit log was removed, which left 1 tablet undocumented and unaccounted for. During an interview on 1/7/25 at 12:48 p.m. at Station 2 Medication Storage Room with LN 5, LN 5 confirmed there were 6 tablets of oxycodone left in the E-kit. LN 5 stated the nurse incorrectly documented on the E-kit removal log that 2 tablets were removed. During an inspection of the Medication Storage Room at Station 2 on 1/7/25 at 12:53 p.m. with LN 5, the E-kit inside the medication storage refrigerator was observed with a red lock. Two E-kit logs inside indicated that two Ativan (a medication used for anxiety and certain other conditions) 2 mg/ml vials were removed on 11/4/24 and 12/17/24. LN 5 stated nursing staff were expected to re-order and replace the E-kit immediately after it was opened. LN 5 stated if the E-kit was not re-ordered and replaced right away there could be a possible delay in care for the residents. During an interview on 1/8/25 at 11:01 a.m. with the DON, the DON stated that nursing staff were expected to ensure the E-kit logs were filled out accurately and replacements were requested right away. She stated the refrigerated E-kit should have been checked by nursing staff and replaced. During a review of the facility's P&P titled, IC-3 Emergency Pharmacy Service and Emergency Kits, dated 3/2018, the P&P indicated .G. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit . I. The nurse opening the kit also records use of the kit in the Emergency kit log book. The nurse records the date, time, resident name, medication name, strength, and dose . opened kits are replaced with sealed kits within 72 hours of opening . 4. During an inspection of Med Cart 2A on 1/7/25 at 4:40 p.m. alongside LN 7, an amber vial was identified. Inside the vial there were partially crushed medications, dry cotton on top, and powdery dry substance on the bottom. When asked what the vial was LN 7 stated the vial is used for drug destruction of controlled and non-controlled medications. The directions on the amber vial indicated, Drug destruction container. Please crush all meds. For refused doses, loose tablets found in drawers, and contaminated tablets solution from partially used ampules. All medication must be rendered unusable prior to placing in vial. During an inspection of Med Cart 2B on 1/7/25 at 5 p.m. alongside LN 4, an amber vial was identified. Inside the vial was dry cotton, opened capsules, whole medication tablets, partially crushed medications, and powdery dry substance on the bottom about a quarter full. LN 4 stated any kind of medication could go inside the vial so long as it was crushed. LN 4 opened the vial and a white puff of medication powder was observed going into the air. LN 4 confirmed there were whole pills in the container and agreed the disposed medications could easily be retrieved and had potential for unwanted exposure to nursing staff when the vial was opened. During an inspection of Med Cart 1A on 1/8/25 at 10:37 a.m. with LN 3, an amber vial was identified inside the controlled drugs drawer. Inside the vial were dry cotton, opened and unopened capsules, powdery dry substance on the bottom, and partially crushed medication tablets. LN 3 stated the vial was used for drug disposal. She confirmed the contents inside the vial were not all unusable. During an interview on 1/8/25 at 11:08 a.m. with the DON, the DON stated if a resident refused a controlled drug two nurses were to waste the medication and sign the CDR, then waste the medication in the vial. She stated nurses were expected to crush medications or open capsules and make them as irretrievable as they could before disposing in the vial. During a review of the facility's P&P titled, IE-5 Medication Destruction, the P&P indicated, .C. All non-controlled drugs that are eligible for disposal are placed in an approved waste container . E. Controlled medication destruction is done in the presence of a pharmacist and a registered nurse employed by the facility . G. All controlled drugs are placed in an approved waste container . The container shall be sealed and scheduled for destruction .J. Unintentional Wasting of Medication Doses . 2. If a single dose of medication is accidentally contaminated or is otherwise unusable . the following policies and procedures will apply . b. Controlled drugs-discarding shall be witnessed by one other licensed person . These are the same drugs for which the facility is required to maintain accountability and be destroyed by an RN and pharmacist .

Based on interview and record review, the facility failed to provide medication orders to meet the needs of one of five sampled residents (Resident 1), when Resident 1's anticoagulant (blood thinner to prevent clots) medication was not reordered after his external fixator (device to stabilize a broken bone) surgery was canceled. This failure resulted in Resident 1 being diagnosed with a deep vein thrombosis (DVT, blood clot in a deep vein) of his left leg that required hospitalization and an unnecessary invasive procedure (placement of an IVC [inferior vena cava]) filter (a device implanted in a major vein to prevent blood clot in leg from traveling to lungs). Findings: A review of Resident 1's Admission Record indicated that he was admitted [DATE], with diagnoses which included unspecified fracture (broken bone) of upper end of left tibia (shin bone), encounter for other specified surgical aftercare and encounter for prophylactic (preventative) measures. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/12/23, the MDS indicated that Resident 1 was cognitively (ability to think and reason) intact. During a review of Resident 1's Order Recap Report (ORR) dated 5/6/23, the ORR indicated, [Name of first anticoagulant medication] Injection Solution Prefilled Syringe 30 MG [milligrams, a unit of measure]/0.3 ML [milliliter, a unit of measure] Inject 30 mg. subcutaneously [beneath the skin] two times a day for DVT prophylaxis until 5/12/23 OK to give the dose on the day of surgery. During a review of Resident 1's Nursing Progress Note (NPN), dated 5/12/23, at 4:54 a.m., the NPN indicated, Resident went to Orthopedic [branch of medicine dealing with bone deformities] surgery appt. via gurney [stretcher] at around 4:15 a.m. in stable condition. Resident 1's NPN dated 5/12/23, 6:14 a.m., indicated, Resident returned from Ortho [orthopedic] Surgery appt. Per patient and transport the pre-op center said that surgery was rescheduled to 5/22/23. During an interview and record review on 6/1/23, at 12:30 p.m., with Nurse Practitioner (NP) 1, NP 1 stated the (name of first anticoagulant medication) should have been renewed 5/12/23 after the cancelled surgery but there was no order from the surgeon to do so. NP 1 acknowledged she was responsible for writing medication orders for the residents in the facility. NP 1 was unable to find documentation in Resident 1's record that she communicated with the hospital team regarding the cancelled surgery. During a review of Resident 1's (hospital name) ED (emergency department) Provider Notes (EDPN), dated 5/17/23, at 6:04 p.m., the EDPN indicated, Exam for warmth and mild tenderness over his left lower extremity [leg]. CT [computerized x-ray] of the lower extremity with contrast notable for DVT and surrounding cellulitis [skin infection]. [Name of second anticoagulant medication] drip ordered. During a review of Resident 1's (hospital name) Internal Medicine Daily Progress Note (IMPN), dated 5/19/23, at 10:21 a.m., the IMPN indicated, .status post [meaning after] IVC filter [device to help prevent blood clots from moving into the lungs] placement with IR [interventional radiology] today, as he has LLE [left lower extremity] DVT and want to prevent embolization [movement] of clot during surgery. During a review of Resident 1's (hospital name) Discharge Summary (DS), dated 5/28/23, at 1:30 p.m., the DS indicated, .initially treated with [name of second anticoagulant medication] then switched to [name of third anticoagulant medication]. discharged with [name of third anticoagulant medication] ensure that it is taken for at least 6 months, prior to discontinuing, consider re-imaging .IVC filter retrieval when indicated. During a review of the facility's policy and procedure (P & P) titled, Physician Services, revised February 2021, the P & P indicated, Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician nurse practitioner [NP] .Supervising the medical care of residents includes [but is not limited to]: .participating in the resident's assessment and care planning .prescribing medications and therapy.

Based on interview and record review, the facility failed to ensure the staff's safe operation of a mechanical lift (medical device used to lift and transfer handicapped individuals) during a transfer for one of one resident (Resident 13). This failed practice resulted in a fall that caused Resident 13's hematoma (bruising) and bump on the head. Findings: During an interview with Resident 13 on (MONTH) 20, 2019, at 3:09 PM, Resident 13 stated she fell while being transferred in a mechanical lift last year. Resident 13 stated there was only one Certified Nurse Assistant (CNA) who transferred her from the shower lift to the bed using a mechanical lift and the CNA did not fasten the straps of the mechanical lift properly. Resident 13 further stated CNA 3 assisted her with mechanical lift transfer. When she was lifted up, she heard a snap and then fell on the floor by the bed. A review of Resident 13's Face Sheet indicated Resident 13 was admitted to the facility in (YEAR) for [MEDICAL CONDITION] (paralysis of one side of the body), hypertension (high blood pressure), low back pain, and muscle weakness. A review of Resident 13's Patient Progress Note dated, (MONTH) 4, 2019, indicated Resident 13 was alert, comfortable, and oriented to time, place, and person. The Minimum Data Set (MDS - resident assessment tool), dated (MONTH) 14, (YEAR), indicated a Brief Interview for Mental Status Score (BIMS - a test to help determine a person's cognitive understanding) of 15, which indicated Resident 13 was cognitively intact. A review of Resident 13's Progress Notes, dated (MONTH) 6, (YEAR), indicated, CNA (name of CNA - CNA 3) reported resident fell on the floor during transferring at 09:25 am. She stated one side of sling came loose when she was transferring resident from shower chair to bed using (brand name of mechanical lift) lift, the resident fell on the floor in lying position. The Patient Transfer Form, dated (MONTH) 6, (YEAR), indicated under nursing assessment, Pt (Patient) fall (fell ) on the floor during transfer. Rt (Right) side of back head bump 6 x 5 cm (centimeters - unit of measurement) noted. The following orders were included in Resident 13's Order Summary Report: 1. An order, dated (MONTH) 6, (YEAR), indicated, send resident to (name of hospital) ER (emergency room ) r/t (related to) large hematoma (bruise) to right occiput (back of the head) s/p (status [REDACTED]. 2. An order, dated (MONTH) 6, (YEAR), indicated, monitor Rt (right) side of occiput hematoma Q (every) shift until resolved. 3. An order, dated (MONTH) 11, (YEAR), indicated, monitor back of neck bruise with bump 7 x 3.5 cm Q shift until resolved. A review of Resident 13's care plan for fall, initiated on (MONTH) 6, (YEAR), indicated, Resident had a fall incident with Rt (right) side of occiput hematoma 6x5 cm noted during transferring. The intervention included, In-serviced staff regarding lift transfer policy. Two staff in attendance during lift transfers. During an interview with the Director of Nursing (DON) on (MONTH) 23, 2019, at 11:48 AM, the DON stated Resident 13 had a fall while in a mechanical lift. The DON stated there was only one staff assisting the resident during a transfer using a mechanical lift from shower chair to the bed. During an interview with the Director of Staff Development (DSD) on (MONTH) 23, 2019, at 1:26 PM, the DSD stated, There needs to be two CNAs for (brand name of mechanical lift) lift assist at all time. It doesn't matter if the (brand name of mechanical lift) lift transfer is from the bed to the (brand name of mechanical lift) lift or (brand name of mechanical lift) lift to the bed. There must be two staff during the transfer. One maneuvers the equipment and one is with the resident. The DSD further stated, To ensure safe transfer, there must be two staff all the time. During an interview with Licensed Vocational Nurse (LVN 2) on (MONTH) 23, 2019, at 1:52 PM, LVN 2 stated she was on duty the time Resident 13 fell from a mechanical lift. LVN 2 verified CNA 3 was assisting Resident 13 during the transfer. LVN 2 indicated she checked the mechanical lift after Resident 13 fell and did not see any defects. LVN 2 stated, My only assumption is one of the loops was not placed properly on the hook. LVN 2 further stated, Staff need to transfer with two person assist, check (mechanical lift) battery and make sure it is fully charged, check for any defects in either the sling itself, the body of the sling, and the loops. A review of the facility's in-service record titled, (Brand name of mechanical lift) Lift Training 2 CNAs at all time, dated 10/6/18, indicated CNA 3 did not attend the in-service. During an interview and record review with the DON on (MONTH) 24, 2019, at 8:55 AM, the DON verified CNA 3 did not receive the in-service on (MONTH) 6, (YEAR) for (brand name of mechanical lift) Lift training. The DON confirmed CNA 3 did not sign the attendance sheet. The DON further stated, She (CNA 3) of all people should be here. During an interview and a concurrent record review with CNA 3 on (MONTH) 24, 2019, at 9:08 AM, CNA 3 verified she did not receive the in-service training on mechanical lift on (MONTH) 6, (YEAR). CNA 3 stated she transferred Resident 13 on her own because there was nobody to be found. CNA 3 stated, I am not going to leave her on her own. So I hooked her up on my own. I lifted her up, moved her towards the bed, and that's when she fell . CNA 3 further stated, She fell straight back down and hit her head. She had a nice sized bump at the back of her head.

Based on interview and record review, the facility failed to provide needed care and services: 1. To prevent recurrent falls and follow care plan for one of 119 Residents (Resident 86). This failure had the potential to result in Resident 86 having a right [MEDICAL CONDITION] (broken hip bone) which led to functional decline. 2. When there were no ID (identification) bands for Residents 15 and 28. These failed practices had the potential to result in medication, diagnostic, and therapeutic errors that could affect resident safety. Findings: 1. During an interview with Resident 86's Representative, on (MONTH) 21, 2019, at 1:31 PM, she stated that Resident 86 had two previous falls one day last month and was the reason Resident 86 was sent to the hospital. During a review of Resident 86's Face Sheet indicated Resident 86 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 86, the Morse Fall Scale 2.0 (a tool to assess fall risk) with effective date on (MONTH) 19, 2019 at 8:40 AM, indicated that, Resident 86 had history of falling. The Morse Fall Scale 2.0 indicated that Resident 86 has Fall Score of 75 (High Risk for Fall is with Score of 45 and higher). During a review of Resident 86's MDS (Minimum Data Set - clinical assessment tool that measures health status of residents in the nursing home), Section G- Functional Status, dated (MONTH) 19, 2019, under the section: Toileting (how resident uses the toilet room; transfers on/off toilet): Self-Performance, indicated, 3. Extensive Assistance (resident involved in activity; staff provide weight-bearing support (support to the resident's body weight)). During a review of Resident 86's active (current interventions in place) nursing care plan initiated on (MONTH) 13, 2014, indicated The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia (memory loss), [MEDICAL CONDITION]'s disease, weakness, an intervention included in the section of Toilet use: The resident requires physical assistance from staff members to use the toilet. During a review of the clinical record for Resident 86, the nursing care plan, dated (MONTH) 5, 2019, indicated the resident had an unwitnessed fall. During a review of the clinical record for Resident 86, the nursing care plan, dated (MONTH) 7, 2019, indicated the resident had an actual fall with no injury r/t (related to) poor balance, unsteady gait (ability to walk). During a review of the clinical record titled Progress Notes dated (MONTH) 14, 2019, at 11:12 AM, the document indicated that the Resident 86 was found at the public restroom by Station One on both knees. The document further indicated that the resident was initiated on neuro check (assessment of brain functions and level of consciousness), was placed on alert charting (alerts staff to chart on residents who have had a change of condition), and had updated the care plan. During a review of the clinical record for Resident 86, the nursing care plan, initiated on (MONTH) 14, 2019, indicated that Resident 86 had a fall without injury. One of the interventions included was to do, neuro checks (monitoring of patient's eyes, level of consciousness, range of motion, and hand grips) x(every) 15 minutes every hour times 4 hours then Q (every) shift 72 hours. During an interview with Licensed Vocational Nurse (LVN 4), on (MONTH) 24, 2019 at 9:16 AM, she reviewed the clinical record for Resident 86 titled, Neuro Check, which indicated neuro checks were started at 11:30 AM. LVN 4 confirmed the document was for the date (MONTH) 14, 2019 after the resident had a fall in the morning. She further confirmed that according to the care plan, neuro checks were to be done every 15 minutes every hour for 4 hours. During a record review of the document Neuro Checks, there were no neuro checks documented at 12:45 PM, 1:15 PM, 1:45 PM, 2:15 PM, 2:30 PM, and 2:45 PM. During an interview with LVN 4, on (MONTH) 24, 2019, at 9:16 AM, she stated the measures she had in place for Resident 86 to reduce the risk of falling is to keep an eye on him and provide assistance when needed. LVN 4 further stated she did not do a Fall Risk Assessment. She further stated she does not know what a Fall Risk Assessment was and that she did not do any post fall risk assessment after the incident of fall that occurred on (MONTH) 14, 2019 at 11:00 AM. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, revised date of (MONTH) 2007, under the section Documentation: When a resident falls, the following information should be recorded in the resident's medical record: .5. Completion of a fall risk assessment. 6. Appropriate interventions taken to prevent future falls . A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing revised (MONTH) 2007, indicated, Monitoring Subsequent Falls and Fall Risk: The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. During further interview with LVN 4, on (MONTH) 24, 2019, at 9:16 AM, she stated that after a resident had a fall incident, a neuro check and an alert charting should be done. LVN 4 reviewed the document, Charting VS (vital signs- measurements of the heart rate, temperature, and respiration rate), I & O . and confirmed that this is the document where she would need to write down the resident's name after the first fall for alert charting so the nurses know which residents are on monitoring. LVN 4 confirmed that she did not put Resident 86's name on the alert charting document. During an interview with Registered Nurse (RN 4), on (MONTH) 24, 2019, at 11:57 AM, she confirmed she had worked on (MONTH) 14, 2019, and found Resident 86 on the floor. She further stated she was not aware that Resident 86 had a fall in the morning on (MONTH) 14, 2019, because she did not receive report from the Charge Nurse. During a review of the clinical record titled, Progress Notes dated (MONTH) 14, 2019, at 10:06 PM, it indicated that at 5:20 PM, Resident 86 was found lying on the floor inside the public restroom next to his wheelchair. The record further indicated that the LVN (Licensed Vocational Nurse) was unable to assess the resident due to a complaint by the Resident of pain to the bilateral lower extremities. The record also indicated that there was a 3 cm (centimeters - a unit of measurement) abrasion (wound) to the resident's right shin. Resident 86 was transferred to the hospital at 6:20 PM. During a record review of Resident 86's Discharge Summary from the hospital dated (MONTH) 20, 2019 at 3:33 PM, indicated that Resident 86 had an X-Ray of the Right Hip with Pelvis 2-3 Views (common views are front, side, and back) on (MONTH) 15, 2019, at 8:04 AM, with an impression of Acute superiorly displaced and impacted fracture (breaking of the bone) of the right femoral neck (below the head of the thigh bone). During a review of the clinical record for Resident 86, the Face Sheet indicated Resident 86 was readmitted to the facility in 2019 with [DIAGNOSES REDACTED]. During a review of the Physician's Telephone Orders for Resident 86, dated (MONTH) 4, 2019, it indicated admitted to hospice (name of hospice agency) with terminal [DIAGNOSES REDACTED]. A review of the nursing care plan for Resident 86, revised on (MONTH) 29, 2019, indicated, Resident's overall goal during assessment process was to remain at this facility due to Medical health condition. (MONTH) 26, 2019 .wish to enroll resident to hospice per hospital md (physician) recommendation due to his [MEDICAL CONDITION] and fx (fracture) hip not a good candidate for surgery. During a review of Resident 86's MDS (Minimum Data Set - clinical assessment tool that measures health status of residents in the nursing home), Section G- Functional Status, dated (MONTH) 19, 2019 before the fall on (MONTH) 14, 2019, indicated, under the section of: Bed mobility - supervision - 2. One person physical assist Transfer - supervision - 2. One person physical assist Walk in room - supervision - 1. Setup help only Walk in corridor - supervision - 1. Setup help only During a comparative review of Resident 86's MDS, Section G- functional Status, dated (MONTH) 4, 2019, after the resident fell on (MONTH) 14, 2019, indicated, under the section of: Bed mobility - supervision - 3. Two+ persons physical assist Transfer - supervision - 3. Two+ persons physical assist Walk in room - supervision - 8. ADL activity itself did not occur Walk in corridor - supervision - 8. ADL activity itself did not occur During an interview with Resident 86's Representative, on (MONTH) 21, 2019, at 1:31 PM, she further stated that Resident 86 is now always in bed and in pain because the resident had a [MEDICAL CONDITION] after those falls. 2. During a facility observation on (MONTH) 20, 2019, at 10:14 AM, Resident 28 yelled, I'm leaving! Resident 28 tried to open the exit door near room [ROOM NUMBER]. Certified Nurse Assistant (CNA 2) was inside room [ROOM NUMBER] assisting another resident. Housekeeping staff (HK) was mopping by room [ROOM NUMBER]'s door. HK went to the resident to stop her from leaving the facility. Resident 28 did not have an ID wristband. During an observation on (MONTH) 20, 2019, at 10:18 AM, CNA 2 verified Resident 28 did not have an ID band. CNA 2 stated, It (The ID band) should be on her wrist. During another facility observation on (MONTH) 20, 2019, at 10:20 AM, Resident 15 was sitting on a wheelchair in front of room [ROOM NUMBER]. Resident 5 stated, I also don't have an ID band. Resident 15 stated she wants an ID band on her wrist. Resident 15 stated, I used to have it, but we placed it on my wheelchair so it (wheelchair) doesn't get lost. They (facility staff) told me they will give me another ID band, but they haven't given me anything yet. Resident further stated she has not had her ID band for a month now. During an interview with Registered Nurse (RN 2) on (MONTH) 20, 2019, at 10:23 AM, RN 2 verified the finding and stated Resident 15 should have an ID band on her wrist. RN 2 confirmed Resident 15 wanted one ID band on the wheelchair and one ID band on the wrist. During an interview with the Director of Staff Development (DSD) on (MONTH) 23, 2019, at 1:21 PM, the DSD stated, Residents are supposed to wear their ID bands. If they are not wearing ID bands, then the charge nurses need to be notified. A review of the facility's policy and procedure titled, Resident Identification System, with revised date of (MONTH) 2007, indicated, A resident identification system is used to help facility personnel provide medical and nursing care.