Every finding on record at Astoria Healthcare Center

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services for one of three residents (Resident 3) who was at risk for developing a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow the manufacturer guideline for a low air loss mattress (LAL- a mattress that uses air to help prevent and treat pressure wounds and maintain a comfortable temperature and moisture level for the patient).This failure had the potential to result in Resident 3 developing a pressure ulcer.Findings:During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified severe protein-calorie malnutrition (a dangerous health condition caused by not eating enough food, calories, and protein over a long time), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs).During a review of Resident 3's Care plan (CP) created on 8/20/2025, the CP indicated Resident 3 had the potential for impairment to skin integrity related to a history of sacral pressure injury and limited mobility. The CP interventions included low air loss mattress setting, placement and functioning, and to keep skin clean and dry, and use lotion on dry skin. During a review of Resident 3's Order Summary Report (OSR) dated 12/7/2025, the OSR indicated low air loss mattress, monitor setting, placement and functioning every day shift for skin management.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 7/10/2026, the MDS indicated Resident 3 had the ability to understand and be understood. The MDS indicated Resident 3 was dependent (help[er does all the effort) with toileting, showering, lower body dressing and putting on and taking off footwear, and required substantial assistance (helper does more than half the effort) with upper body dressing and personal hygiene, requires supervision (helper provides verbal cues, touching, steadying and or contact guard assistance as resident completes activity) with oral hygiene, and requires setup or clean up assistance (helper sets up or cleans up) with eating. During a review of Resident 3's OSR dated 8/1/2026, the OSR indicated to apply zinc oxide ointment to bilateral buttocks for skin management every day shift for 30 Days. During a review of Resident 3's Weights and Vitals Summary dated 8/3/2026, the Weights and Vitals Summary indicated Resident 3 weighed 145 pounds (lbs.- a unit of measurement) on 8/3/2026.During a concurrent observation and interview on 8/20/2026 at 11:36 a.m. with Certified Nursing Assistant (CNA) 1, of Resident 3's LAL mattress, CNA 1 stated the LAL mattress for Resident 3 is set in between 320 lbs. to 350 lbs. CNA 1 stated the treatment nurses and or the charge nurses are responsible to change the setting of the LAL mattress. CNA 1 stated for Resident 3 the LAL mattress must be set at 120 lbs. to 150 lbs. CNA 1 stated when the LAL mattress is set at 320 lbs. to 350 lbs., it makes the mattress firm. CNA 1 stated she did not change the setting to the LAL mattress for Resident 3. During a concurrent observation and interview on 8/20/2026 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 1, of Resident 3's LAL mattress, LVN 1 stated Resident 3's LAL mattress needs to be set at 120 lbs. to 150 lbs. the LAL mattress is set way off if it is at about 330 lbs. LVN 1 stated he (LVN 1) did not change the setting for Resident 3's LAL mattress. LVN 1 stated the LAL mattress is set according to the residents' weight if the setting is set over 150 lbs. the mattress will be too hard on Resident 3's skin. L VN 1 stated if LAL mattress is set incorrectly and is too hard it can become a risk for Resident 3 to develop a pressure ulcer.During an interview on 8/20/2026 at 3:17 p.m. with the Treatment Nurse (TN) 1, TN 1 stated Resident 3 is on a LAL mattress because Resident 3 had an excoriation (a scrape, scratch, or minor break in the top layer of the skin) three months ago but is now resolved. TN 1 stated Resident 3 is on the LAL mattress for skin management and because Resident 3 is bed bound, Resident 3 is at risk for skin breakdown. TN 1 stated TN is aware Resident 3's LAL mattress was set incorrectly. TN 1 stated charge nurses, treatment nurses and the Registered Nurse (RN) are the only ones who are able to change the setting on the LAL mattress. TN1 stated for Resident 3 the setting should be at 120 lbs. to 150 lbs., it is based on weight and Resident 3 is about 145 lbs. TN 1 stated setting the LAL mattress at 320 lbs. to 350 lbs. has a potential risk especially with Resident 3 having a history of excoriation, it can be a potential for skin breakdown and or opening of the skin. TN 1 stated this is because the setting is not set according to the weight, it is firmer and will give pressure to Resident 3's bony parts. During an interview on 8/20/2026 at 4 p.m. with the Director of Nursing (DON), the DON stated for Resident 3 if the LAL mattress is not properly set it can be a concern for skin integrity. The DON stated if the LAL mattress is set too high there is potential for the LAL mattress to be too firm and it will not distribute Resident 3's weight appropriately and can cause pressure at a specific site. During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines, last reviewed 1/15/2026, the P&P indicated the facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcers development. During a review of the facility provided Dynarex Manual, the Manual indicated set a comfortable pressure level by using the weight scale as a guide.

Based on interview and record review, the facility failed to follow the comprehensive care plan to ensure that one of seven sampled residents (Resident 6) had their bed alarm activated on 8/17/2026.This failure had the potential to result in Resident 6 experiencing an unwitnessed fall and related injury.Findings:During a review of Resident 6's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with admitting diagnosis including encephalopathy (brain malfunction), dementia (memory loss), atrial fibrillation (an abnormal heart rhythm), hypertension (elevated blood pressure), and muscle weakness.During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment tool), dated 6/23/2026, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting, bathing, and dressing. The MDS indicated Resident 1 requires maximal assistance with oral hygiene and personal hygiene.During a review of Resident 6's History of Present Illness, dated 7/24/2026, the History of Present Illness indicated Resident 6 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR) for the active orders as of 8/18/206, the OSR indicated a physician order for bed pad alarm to prevent injury and falls when Resident 1 attempts to get out of bed per family request with an order date of 8/10/2026.During a review of Resident 1's Care Plan Report (CP), dated 8/10/2025, the CP indicated Resident 1 was at risk for falls related to weakness, impaired mobility, confusion, unsteady gait, and history of falls. The CP indicated interventions to activate bed alarm and verify that it is functioning properly.During a review of Resident 1's Progress Notes (PN), dated 8/17/2026 at 6:59 a.m., PN indicated roommate notified staff that Resident 1 was slipping off the bed. Two Certified Nurse Assistants (CNA) were there by the time Registered Nurse Supervisor (RNS) and Licensed Vocational Nurse (LVN) arrived at the room and found Resident 1 sitting on the floormat. Bed was at the lowest setting with the visible bed alarm not ringing.During a review of Resident 1's Change of Condition (COC), dated 8/17/2026 at 6:03 a.m., the COC indicated roommate notified that Resident 1 was slipping off the bed. The COC indicated, .with the visible bed alarm not ringing.During a review of Resident 1's IDT (Interdisciplinary Meeting), dated 8/18/2026 at 11:30 a.m., the IDT indicated Resident 1 was found sitting on top of the floor mat. Resident 1 was unable to provide description of what happened. The IDT indicated the fall was likely due to Resident 1's attempts to get out of bed unassisted and advanced dementia (memory loss).During an interview with CNA1 on 8/18/2026 at 11:10 am., CNA 1 stated that she was working with Resident 1 the night of 8/17/2026 and Resident 1 was attempting to get out of bed unassisted. CNA1 stated Resident 1 was incontinent of bowel and bladder and after she was done changing Resident 1, she went to assist another resident. CNA1 stated she made Resident 1 comfortable, lowered the bed to the floor, and placed the call light next to Resident 1 before she left the room. CNA 1 stated that another nurse called her after five minutes to notify her that Resident 1 was sitting on the floor mat next to her bed. CNA 1 stated she did not hear the bed alarm.During a telephone interview with Registered Nurse (RN1) on 8/19/2026 at 2:20 p.m., RN 1 stated she was notified that Resident 1 was found sitting on the floor mattress next to her bed and does not recall exactly the time. RN 1 stated she did not hear Resident 1's alarm at the time of the fall. RN 1 stated she assessed Resident 1 and her blood pressure was elevated and she decided to call the paramedics due to the blood pressure being elevated. RN 1 stated that the staff must ensure that the bed alarm is working prior to leaving the room as indicated in their care plan.During a review of the facility's policy and procedure (P&P), titled Fall Management Program, dated February 24, 2026, the P&P indicated the purpose of the policy is to prevent resident falls and minimize complications associated with falls. The P&P indicated the facility will provide the highest quality care in the safest environment for the residents residing in the facility. The fall management program is designed to prevent resident falls through meaningful assessments, interventions, education, and re-evaluation. The Nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls.

Based on observation, interview and record review, the facility failed to offer and assist the residents' choice to drink regular coffee (standard caffeinated coffee) for three of seven sampled residents (Residents 56, 26, and 113) interviewed during the Resident Council (an independent, organized group of residents who meet regularly to discuss and offer suggestions about facility policies and procedures affecting resident care, treatment, and quality of life) Task. This failure has the potential to result in a decline in the residents' quality of life and psychosocial wellbeing. Findings: a. During a review of Resident 56's admission Record (AR), the AR indicated the facility admitted the resident on 1/02/2026 with diagnoses including spinal stenosis (narrowing of one or more spaces within the spinal canal) cervical region (neck area), polyneuropathy (generalized disorders of the peripheral nervous system), and unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 56's History and Physical (H&P), dated 4/28/2026, the H&P indicated the resident had the ability to understand and make decisions. During a review of Resident 56's Minimum Data Set (MDS -resident assessment tool), dated 7/9/2026, the MDS indicated the resident was able to make himself understood and understood others. b. During a review of Resident 26's AR, the AR indicated the facility admitted the resident on 5/16/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) affecting the left non-dominant side, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dysphagia (difficulty swallowing). During a review of Resident 26's H&P, dated 6/3/2026, the H&P indicated the resident had the ability to understand and make decisions. During a review of Resident 56's MDS, dated [DATE], the MDS indicated the resident usually was able to make herself understood and usually understood others. c. During a review of Resident 113's AR, the AR indicated the facility admitted the resident on 4/26/2022 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). During a review of Resident 113's H&P, dated 7/10/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated the resident was able to make herself understood and understood others. During a Resident Council Interview on 8/10/2026 at 2:10 p.m., in the Administrator`s office, three of seven residents stated they wanted regular coffee, but only decaffeinated coffee was provided by the facility. Resident 56 stated the only reason the staff (did not specify specific staff members) gave for not providing regular coffee was that they didn't want the residents running around the facility. During an interview on 8/11/2026 at 12:08 p.m. with the Dietary Manager (DM), the DM stated the facility only serves decaffeinated coffee and the decision to serve decaffeinated coffee was not approved by the medical staff. The DM stated the potential outcome of serving only decaffeinated coffee was that the residents were calmer. During an interview on 8/12/2026 at 9:13 a.m., with Resident 56, Resident 56 stated he (Resident 56) felt frustrated and it was ridiculous that regular coffee was not provided to the residents of the facility. During a concurrent interview and record review on 8/19/2026 at 9:52 a.m., the Director of Nursing (DON) reviewed the facility policy and procedure (P&P) regarding resident choices. The DON stated residents have the right to request and be served their preferences for food and drinks in the facility. The DON stated he ( DON) was not aware that the facility only served decaffeinated coffee and not regular coffee. The DON stated residents have the right to be served regular coffee, and the facility P&P was not followed when the residents' requests for regular coffee were not honored potentially resulting in psychosocial issues like frustration and less social opportunities. During a review of the facility's P&P titled, Privacy and Dignity, last reviewed 1/15/2026, the P&P indicated, The Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality The Facility promotes independence and dignity in dining. During a review of the facility's P&P titled, Food Preferences, last reviewed 1/15/2026, the P&P indicated, POLICY: Resident's food preferences will be adhered to within reason

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for six of six sampled residents (Resident 1, 19, 14, 52, 113, and 186) reviewed under environmental tasks. These failures had the potential to result in delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: 1. During a review of Resident 1's admission Record (AR- front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 4/23/2026 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) affecting the left non-dominant side, obstructive and reflux uropathy (urinary tract disorder due to a structural or functional obstruction of urinary flow), and other symptoms and signs involving cognitive functions following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 1's Minimum Data Set (MDS – resident assessment tool), dated 7/27/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident was totally dependent on staff for transfers, lower body dressing, bathing, and toileting. During a review of Resident 1's History and Physical (H&P), dated 4/23/2026, the H&P indicated that the resident was able to understand and make decisions. During a review of Resident 1's Care Plan (CP) titled, (Resident 1) is at risk for falls related to . hemiplegia and hemiparesis. affecting the left non-dominant side., initiated 5/4/2026, the CP indicated interventions that included to keep the CL within reach and encourage the resident to use it for assistance as needed. During a review of Resident 1's CP titled, (Resident 1) has an activities of daily living performance deficit and limited mobility related to . hemiplegia and hemiparesis. affecting the left non-dominant side., initiated 5/4/2026, the CP indicated a goal that the resident would maintain current level of function with interventions that included to encourage the resident to use the CL to call for assistance. During a concurrent observation and interview on 8/12/2026 at 9:29 a.m., inside Resident 1's room, observed the call light cord was wrapped around the resident's bedside rail (SR - rigid plastic bars attached to the bed) and hanging toward the floor next to the resident's left arm. Observed the CL was not within reach of the resident's functioning right hand. Observed Treatment Nurse (TN) 1 and TN 2 entered Resident 1's room and provided wound care to the resident then exited the room and the CL remained out of reach of the resident's right hand. Resident 1 then stated he (Resident 1) could not move the left side of his body and was not able to reach the call light. Resident 1 stated he (Resident 1) did not know why the staff placed the CL on his left side. During a concurrent observation and interview on 8/12/2026 at 10:32 a.m., with Certified Nursing Assistant (CNA) 9, inside Resident 1's room, observed the CL remained wrapped around the SR on Resident 1's left side. CNA 9 entered Resident 1's room and stated she (CNA 9) was not assigned to the resident but had provided his care in the past. CNA 9 stated Resident 1 could not move his left arm or hand, and the CL was not within reach for the resident to call for assistance. CNA 9 stated it was important to place Resident 1's CL on the right side of the bed so the resident would have access to staff when he needed attention. Observed CNA 9 moved the CL to the right side of the bed. During a concurrent interview and record review on 8/14/2026 at 9:52 a.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure (P&P) regarding CLs. The DON stated the CL should be within easy reach of residents to summon assistance and get the help needed. The DON stated when CLs are not within reach of residents, they may not be able to get assistance resulting in a delay in care and potential harm to residents. The DON stated the facility P&P was not followed when Resident 1's CL was not within reach on the resident's non-affected side. 2. During a review of Resident 19's AR, the AR indicated the facility admitted the resident on 6/4/2026 with diagnoses including acute embolism (a condition that happens when a blood clot breaks off and travels through the bloodstream) and thrombosis (a blood clot that forms inside a deep vein and can block flow causing pain, swelling, warmth or redness) of right upper extremity, left below the knee amputation (also known as BKA, a procedure where a part of the leg is removed), and kidney transplant status (a procedure where a healthy kidney from a donor is placed into a person whose kidneys no longer work properly). During a review of Resident 19's H&P dated 7/24/2026, the H&P did not indicate Resident 19's capacity to understand and make decisions. During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make his needs known. The MDS further indicated Resident 19 required supervision or touching assistance with eating, substantial or maximal assistance with upper body dressing and roll to left and right, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 19's fall risk assessments dated 6/5/2026, 6/15/2026, and 7/25/2026, the fall risk assessments indicated Resident 19 was at moderate risk for falls. During a review of Resident 19's CP on risk for falls initiated on 6/18/2026, the CP indicated to ensure the resident's call light is within reach and encourage resident to use it for assistance as needed as the resident needed prompt response to all requests for assistance as one of the interventions for the resident to be free of falls. During a concurrent observation and interview on 8/10/2026 at 9:40 a.m. inside Resident 19's room, observed Resident 19 lying in bed in supine position awake with the call light coiled around left side rail and hanging on the side. Resident 19 stated he (Resident 19) did not know where the call light was at. During a concurrent observation and interview on 8/10/2026 at 9:50 a.m. inside Resident 19's room with Licensed Vocational Nurse (LVN) 5, LVN 5 stated that Resident 19's call light was coiled around the left side rail and hanging on the left side and was unable to reach. LVN 5 stated staff are supposed to ensure the call lights are within the residents' reach prior to leaving the room so they can ask for assistance when needed. LVN 5 stated that Resident 19's call light should have been within reach as the resident would not be able to call for assistance when needed and a delay in meeting his needs. During a concurrent interview and record review on 8/12/2026 at 10:33 a.m., reviewed Resident 19's fall risk assessments and CP on risk for falls with Quality Assurance Nurse (QAN) 1. The QAN 1 stated that Resident 19's fall risk assessments indicated the resident was at a moderate risk for falls and that the CP indicated to ensure that the call light is within reach and encourage the resident to use it for assistance. The QAN 1 stated that the staff are supposed to make sure that the residents' call lights are within reach prior to leaving the room so the residents would be able to call for assistance. The QAN 1 stated that the staff should have ensured Resident 19's call light was within reach as the resident would not be able to call if he (Resident 19) needed assistance which could result to a delay in meeting his needs. During an interview on 8/14/2026 at 11:40 a.m. with the DON, the DON stated that the staff are supposed to ensure that the residents' call lights are within reach after providing care and prior to leaving the room. The DON stated that Resident 19's call light should have been within reach as the resident would not be able to call for assistance when needed, try to get out of bed unassisted and fall. The DON stated that it could also result in a delay in meeting Resident 19`s needs. 3. During a review of Resident 14's AR, the AR indicated the facility admitted the resident on 2/4/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (a type of stroke, loss of blood flow to a part of the brain) affecting right dominant side. During a review of Resident 14's H&P dated 4/30/2026, the H&P indicated that Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make his needs known. The MDS further indicated Resident 14 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 14's fall risk assessments dated 2/4/2026, 3/7/2026, and 4/29/2026, the fall risk assessments indicated Resident 14 was at high risk for falls. During a review of Resident 14's CP on risk for falls initiated on 2/7/2026, the CP indicated to ensure the resident's call light is within reach and encourage resident to use it for assistance as needed as one of the interventions for the resident to be free of falls. During an observation on 8/10/2026 at 1:41 p.m. inside Resident 18's room, observed Resident 14 lying in bed facing the towards the right side with the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) dangling on the left side rail. Resident 14 was unable to talk. During a concurrent observation and interview on 8/10/2026 at 1:59 p.m. inside Resident 14's room with CNA 5, CNA 5 stated that Resident 14 was facing towards the right side of the bed and that the pad call light was hanging on the left side. CNA 5 stated that the staff are supposed to make sure the call lights are within the residents' reach prior to leaving the room so they can ask for assistance when needed. CNA 5 stated that Resident 14's call light should have been placed next to the resident's left hand or next to the face or head as the resident would not be able to call for assistance when needed. During a concurrent interview and record review on 8/12/2026 at 10:45 a.m., reviewed Resident 14's fall risk assessments and CP on risk for falls with QAN)1. The QAN 1 stated that Resident 14's fall risk assessments indicated the resident was at a high risk for falls and that the CP indicated to ensure that the call light is within reach and encourage the resident to use it for assistance. The QAN 1 stated that the staff are supposed to make sure that the residents' call lights are within reach especially for residents with pad call light prior to leaving the room so the residents can call for assistance with a light touch on the pad call light. The QAN 1 stated that the staff should have ensured Resident 14's call light was placed on resident's left hand or next to the face as the resident would not be able to call if she needed assistance which could result to a delay in meeting her needs. During an interview on 8/14/2026 at 11:40 a.m. with the DON, the DON stated that the staff are supposed to ensure that the residents' call lights are within reach after providing care and prior to leaving the room. The DON stated that Resident 14's call light should have been within reach as the resident would not be able to call for assistance when needed, try to get out of bed unassisted and fall. 4. During a review of Resident 52's AR, the AR indicated the facility admitted the resident on 2/1/2024, and readmitted the resident on 2/7/2024, with diagnoses including adult neglect or abandonment, other lack of coordination, and age-related osteoporosis (a common condition where bones become thin, weak, and brittle over time). During a review of Resident 52's H&P, dated 2/16/2026, the H&P indicated the resident was alert, oriented to person, place, and time, normal mood, behavior, speech, dress, motor activity, and thought processes. The H&P indicated the resident was assessed for decision making capacity and has limited decision-making capacity. During a review of Resident 52's MDS dated [DATE], the MDS indicated the resident usually made self-understood and understood others and had impaired vision. The MDS indicated the resident had cognitive impairment (having trouble with brain functions like thinking, learning, remembering, and paying attention) and was needing partial to set up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 52's Fall Risk (Morse) Assessment (FRA), dated 4/8/2026, the FRA indicated the resident was at moderate risk for falls. During a review of Resident 52's CP Report regarding the resident having an ADL self-care performance deficit related to anemia (a condition where the body does not have enough healthy red blood cells), cognitive loss, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and osteoporosis, last revised on 5/7/2026, the CP indicated an intervention of call light within reach. During a concurrent observation and interview on 8/10/2026, at 11:18 a.m., with CNA 3, inside Resident 52's room, observed Resident 52's call light was on the floor. CNA 3 stated the call light was on the floor. CNA 3 stated the call light should always be within the reach of the resident so they can call for help when needed. During a concurrent interview and record review on 8/12/2026, at 11:04 a.m., with Registered Nurse (RN) 1, Resident 52's Medical Diagnosis, FRA and CPs were reviewed. RN 1 stated the resident was at moderate risk for falls and the call light should always be within the reach of the resident so they can call for help when needed. RN 1 stated the resident can also fall while reaching for the call light on the floor. RN 1 stated all staff should be checking for the placement of the call light of the resident when they are doing their environmental rounds. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, facility's P&P titled, Communication- Call System was reviewed. The DON stated the call light of Resident 52 should always be within the reach of the resident so the resident can call for help when needed. The DON also stated there is a potential for the resident to fall while reaching for the call light. The DON stated that all staff should be checking for the placement of the call light every time they do their environmental rounds. The DON stated the facility failed to follow the policy and procedure (P&P) titled, Communication- Call System when they were not able to keep the call light of the resident off the floor. 5. During a review of Resident 113's AR, the AR indicated the facility admitted the resident on 4/26/2022, with diagnoses including muscle weakness, lack of coordination, and obesity. During a review of Resident 113's H&P, dated 7/10/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (means a person has clear, noticeable trouble with memory, thinking, and daily reasoning that actively disrupts their independence and routine tasks.). The MDS indicated the resident was needing substantial to set up assistance on mobility and ADLs. During a review of Resident 113's FRA, dated 6/6/2026, the FRA indicated the resident was high risk for falls. During a review of Resident 113's Care Plan (CP) Report titled, Actual Fall Balance Problems, last revised on 6/15/2026, the CP indicated an intervention to attach call light within reach and encourage resident to use it for assistance as needed. During a concurrent observation and interview on 8/10/2026, at 11:50 a.m., with Licensed Vocational Nurse (LVN) 5, inside Resident 113's room, observed Resident 113's call light was on the floor. LVN 5 stated the call light should always be within the reach of the resident so they can call for help when needed. LVN 5 stated it was everyone's responsibility to ensure the call light is always within the reach of the resident. During a concurrent interview and record review on 8/12/2026, at 11:04 a.m., with RN 1, Resident 113's Medical Diagnosis, FRE and CPs were reviewed. RN 1 stated the resident was high risk for falls and the call light should always be within the reach of the resident so they can call for help when needed. RN 1 stated the resident can also fall while reaching for the call light on the floor. RN 1 stated all staff should be checking for the placement of the call light of the resident when they are doing their environmental rounds. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, reviewed the facility's P&P titled, Communication- Call System. The DON stated the call light of Resident 113 should always be within the reach of the resident so the resident can call for help when needed. The DON also stated there is a potential for the resident to fall while reaching for the call light. The DON stated that all staff should be checking for the placement of the call light every time they do their environmental rounds. The DON stated the facility failed to follow the P&P titled, Communication- Call System when they were not able to keep the call light of the resident when it was found on the floor. 6. During a review of Resident 186's AR, the AR indicated that the facility admitted Resident 186 on 6/29/2026 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unsteadiness on feet, and glaucoma (an eye disease that damages the optic nerve). During a review of Resident 186's MDS, dated [DATE], the MDS indicated Resident 186 had moderate cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed moderate assistance (helper does less than half of the efforts) for toileting hygiene, showers, lower body dressing, and putting on/taking off footwear. During a review of Resident 186's CP titled, The Resident (Resident 186) is at risk for falls , initiated on 6/29/2026, the CP indicated an intervention to Be sure the resident's (Resident 186) call light is within reach and encourage the resident to use it for assistance as needed. During a review of Resident 186's Fall Risk assessment dated [DATE] and timed 2:12 p.m., the fall risk assessment indicated that Resident 186 was at high risk for fall. During an observation on 8/10/2026 at 9:19 a.m. inside Resident 186's room, Resident 186 observed sitting at the edge of the bed with no call light within reach. During a concurrent observation and interview on 8/11/2026 at 2:12 a.m. inside Resident 186's room with CNA 1, CNA 1 stated that Resident 186 did not have call light within reach. CNA 1 stated that she (CNA 1) did not know where Resident 186's call light was. CNA 1 further stated that Resident 186 needed a call light to be able to call for assistance. During an interview on 8/13/2026 at 3:50 p.m. with Licensed LVN 1, LVN 1 stated that it was important for residents to have call light within easy reach to call for assistance. During an interview on 8/14/2026 at 11:14 a.m. with the DON, the DON stated that ensuring call lights are within easy reach of residents is a responsibility shared by all staff members. The DON further stated that if call lights are not accessible to residents, they may be unable to contact staff for assistance, potentially compromising their safety and well-being. During a review of the facility's recent P&P titled, Communication- Call System, last reviewed on 1/15/2026, the P&P indicated to provide a mechanism for residents to promptly communicate with the nursing staff. Policy I. The facility will provide a call system to enable residents to alert the nursing staff form their beds and toileting/bathing facilities. A. The call system should be accessible to a resident lying on the floor in toileting and bathing facilities. Procedure II. Call cords will be placed within the resident's reach in the resident's room. During a review of the facility P&P titled, Fall Management Program, last revised 2/24/2026, the P&P indicated, Purpose. To prevent resident falls and minimize complications associated with falls. The Facility will provide the highest quality care in the safest environment for the residents residing in the facility. The Fall Management Program is designed to prevent resident falls through meaningful assessments, interventions, education, and re-evaluation. II. Universal Fall Prevention Measures for all Residents. The following are suggested measures that can be used in the prevention of falls. A. Environmental. ii. Position call bell . within reach.

Based on observation, interview, and record review, the facility failed to provide a safe, homelike environment by failing to: 1. Maintain the cleanliness of Resident 229's electric stand fan during a random observation. 2. Ensure there was not a hole in the wall with exposed wires at the head of one randomly sampled resident (Resident 215). These failures had the potential to result in resident harm from exposed wires and the potential to negatively affect the residents' psychosocial wellbeing leading to the resident feeling uncomfortable in their living space. 3. Protect against potential loss of Resident 73`s cell phone reviewed under personal property. The device was held in Social Services Department safe for two weeks without timely return and was not recorded in the theft and log file. This failure had the potential to cause distress to the resident and cause family distrust. Findings: 1. During a review of Resident 229's admission Record (AR), the AR indicated the facility admitted the resident on 8/4/2026 with diagnoses including alcohol dependence, lack of coordination, and generalized muscle weakness. During a review of Resident 229's History and Physical (H&P) dated 8/5/2026, the H&P indicated that Resident 229 had the capacity to understand and make decisions. During a review of Resident 229's Minimum Data Set (MDS – a resident assessment tool), dated 8/10/2026, the MDS indicated Resident 229 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was sometimes able to understand others and make his needs known. The MDS further indicated that Resident 229 required supervision or touching assistance with eating and oral hygiene; partial or moderate assistance with personal hygiene, bed mobility and transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 8/10/2026 at 12:20 p.m., inside Resident 229's room, observed an electric stand fan facing the resident. The fan was turned on and had strips of gray powder like material lining the outward front and back panel and the blades. During a concurrent observation and interview on 8/10/2026 at 12:42 p.m. inside Resident 229's room with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 229's electric stand fan had a lot of gray colored dust in the front and back panel and the blades. LVN 9 stated the housekeepers are supposed to ensure that the electric stand fans are clean. LVN 9 stated if the housekeeping staff observe the electric stand fans are not clean, they are supposed to bring it to the maintenance department. LVN 9 also stated that if nursing staff observe the fan is not clean, they are supposed to notify the housekeeping or maintenance department staff. LVN 9 stated if the electric fan was in use and full of dusts, Resident 229 can inhale the dust particles and the resident can get sick. LVN 9 stated that Resident 229's electric fan should have been cleaned regularly as it does not provide a homelike environment to the resident as the facility is already their home. During a concurrent interview and record review on 8/12/2026 at 2:59 p.m., a photograph of Resident 229's electric fan was reviewed with the Quality Assurance Nurse (QAN) 1. The QAN 1 stated that the electric stand fan had a lot of gray dusts. The QAN 1 stated that from her knowledge, the housekeeping and maintenance department were responsible in ensuring that any resident care equipment or furnishings cleanliness should be maintained at all times, but all staff are supposed to report if they see any equipment of furnishings that is not clean. The QAN 1 the electric stand fan that was not was not promoting or providing the resident a homelike environment. During an interview on 8/10/2026 at 11:45 a.m. with the Director of Nursing (DON), the DON stated the housekeeping and maintenance department were responsible in maintaining the cleanliness of furnishings such as electric fans and other resident care equipment in the facility. The DON stated that the nursing staff are supposed to notify the housekeeping or maintenance department for any resident care equipment that is not clean. The DON stated that the electric stand fan in Resident 229's should have been cleaned regularly by the housekeeping and maintenance as it was not promoting or providing the resident a homelike environment. During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, last reviewed on 1/15/2026, the P&P indicated that the facility provides residents with a safe, clean, comfortable and homelike environment. 2. During a review of Resident 215's AR, the AR indicated the facility admitted the resident on 1/9/2024 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic (persistent and ongoing), pulmonary embolism (blood clot in lung), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 215's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident was dependent on staff for bathing and toileting, required substantial / maximal assistance for upper body dressing and personal hygiene, and required supervision for oral hygiene. During a review of Resident 215's H&P, dated 12/7/2025, the H&P indicated the resident had decision making capacity. During a review of Resident 215's Care Plan (CP) regarding having no plans for discharge, initiated 1/28/2026, the CP indicated a goal that the resident would participate in decisions for their stay in the facility with the implementation of interventions that included to encourage the resident to decorate/adjust the room environment to help the resident feel at home. During a concurrent observation and interview on 8/11/2026 at 2 p.m., inside Resident 215`s room, the resident was observed lying awake in bed. Observed a hole in the wall above the resident's head exposing multicolored wires. Resident 215 stated there was a hole in the wall from when the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) system was changed about a month ago. Resident 215 stated the hole did not look very attractive. During a concurrent observation and interview on 8/12/2026 at 3 p.m., with Certified Nursing Assistant (CNA) 10, observed Resident 215 was not in his room. Upon the request of the surveyor, CNA 10 entered Resident 215's room and stated a new call light was installed a week ago and they did not cover the hole in the wall and there were wires showing. CNA 10 stated the Housekeeping, Laundry, and Maintenance Supervisor (HLMS) should know to cover the hole, but he (HLMS) did not. CNA 10 stated it did not seem safe to have the wires exposed and she (CNA 10) would not want her house to have a wall with a hole and exposed wires. During a concurrent observation and interview on 8/12/2026 at 2:15 p.m., with the HLMS, the HLMS entered Resident 215's room and confirmed there was a hole in the wall with exposed wires. The HLMS stated a technician from outside the facility replaced the resident's CL and he (the HLMS) did not remember seeing the hole exposing wires after the technician left. The HLMS stated wires should not be exposed on the wall at the head of the resident's bed because there was a potential for electrocution and it was not homelike. During a concurrent interview and record review on 8/14/2026 at 9:52 a.m. with the DON, the DON reviewed the facility policy and procedure (P&P) regarding homelike environment and resident rooms. The DON stated resident live in the facility and their rooms should have a homelike environment. The DON stated all staff should identify and report any environmental issues when making rounds. The DON stated a hole in the wall with exposed wires is not a homelike environment and could potentially be a fire hazard if the wires had electrical current running through them. The DON stated the facility policy, and procedure was not followed when Resident 215's wall had a hole with wires exposed potentially resulting in psychosocial issues and resident harm. During a review of the facility P&P titled, Resident Rooms and Environment, last reviewed 1/15/2026, the P&P indicated, Purpose. To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment. This shall include ensuring that residents can receive care and services safely and that the physical layout of the facility. does not pose a safety risk. 3. During a review of Resident 73's AR, the AR indicated the facility admitted the resident on 3/26/2026 with diagnoses including chronic (persistent and ongoing) congestive heart failure (CHF – a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM – a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 73's MDS dated [DATE], the MDS indicated that the resident had severe cognitive impairment (person has major trouble with memory, short-term recall, or knowing the current date and time. The MDS further indicated that the resident needed set-up and clean-up assistance with eating and oral hygiene, and with supervision and touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting, showers/bathing self, with transfers and ambulation. During an interview on 8/10/2026 at 10:00 a.m. with Resident 73's family representative (FR), the FR stated that the resident's cellphone had been missing for approximately two weeks. The FR stated that the cellphone was missing within three days of being brought into the facility. The FR stated that she (FR) immediately notified both the nurse on duty and the charge nurse at the time of the loss. The FR further stated that she (FR) continued to request staff assistance nearly every time she (FR) came to visit the resident searching for the missing cellphone. The FR stated that she (FR) did not initially file a grievance anticipating the phone would be found promptly. The FR stated that despite the length of time it has been lost, the FR stated she (FR) continues to hope for its return and remains eager to recover the cellphone as it serves as a way she can communicate faster to Resident 73. During an interview on 8/12/2026 at 9:46 a.m. with CNA 14, CNA 14 stated that she (CNA 14) learned about Resident 73's missing phone when the FR was searching for it and that the phone was still missing to date. CNA 14 stated that the charge nurse was also notified at the time that phone went missing. CNA 14 stated that any belongings received from the residents must be documented in the inventory list as this procedure is important. CNA 14 stated that if an item is lost and cannot be located, the facility is responsible for covering the cost of the missing item. During an interview on 8/12/2026 at 10:10 a.m. with LVN 10, LVN 10 stated the FR informed her of the missing cellphone two weeks ago. LVN 10 stated she (LVN 10) promptly notified the Social Services Department regarding the matter. LVN 10 stated she (LVN 10) is unaware whether the cellphone has been recovered. During an interview on 8/12/2026 at 10:16 a.m. with the Social Services Director (SSD), the SSD stated that she (SSD) was not aware of Resident 73's missing cellphone and further stated that she (SSD) will verify with the rest of the staff regarding the issue. During a concurrent interview and record review on 8/12/2026 at 10:26 a.m., with Social Services Assistant 1 (SSA 1) upon record review, SSA 1 stated that Resident 73's missing phone was not listed on the theft and loss sheet for the months of July and August 2026. SSA 1 stated that she (SSA 1) was notified about the missing cellphone by one of the nurses approximately two weeks prior. SSA 1 stated that upon receiving the report, she (SSA 1 immediately approached Resident 73 and conducted a search for resident's personal belongings and further stated that the cell phone could not be located and continued to search for the items over the following days. SSA 1 stated that after several days without success in finding the cellphone, a grievance should have been filed to ensure a thorough review and investigation be made in identifying what may have contributed to its disappearance. During a subsequent interview on 8/12/2026 at 10:40 a.m., with SSD, the SSD stated that she (SSD) made a call to verify with SSA 2, if SSA 2 had any knowledge of the missing cellphone. The SSD stated that there was a cellphone inside the safe in the Social Services office, but it did not have a name on it so they could not identify whose missing cellphone it was. The SSD stated that there must have been miscommunication amongst themselves. During an interview and record review on 8/13/2026 at 9:09 a.m. with SSA 2, the SSA 2 stated that the missing phone was endorsed to her two weeks ago by the laundry supervisor. SSA 2 stated the cellphone did not have a resident's name on it and did not know whom it belonged to and since then it had been kept in the office for safekeeping in case someone reported a missing cellphone. SSA 2 stated that there was no documentation in the theft and loss sheet that Resident 73 had a missing cellphone. SSA 2 stated that there should have been a log to account of missing items found and it should have been documented in the theft and lost sheet. SSA 2 stated that it should have been communicated to figure out whom the cellphone belonged to. SSA 2 stated that grievance should have been initiated at the time the missing cellphone was reported to facilitate the need to recover the missing cellphone. During an interview on 8/14/2026 at 10:10 a.m. with the Laundry Supervisor (LS), the LS stated that when laundry staff finds something like remote control, cellphones, dentures and any other items, the staff personally hands it to him right away or place the found items inside the maintenance office. The LS stated he immediately gives any items to the Social Services Department. The LS stated that he (LS) did not recall handing over a cellphone to the Social Services Department and further stated that he does not have any log to monitor what comes in and out of the office regarding personal belongings that have been found. During an interview on 8/14/2026 at 2:38 p.m. with the DON, the DON stated that residents' personal belongings must be listed or documented in the inventory log with the purpose of preventing lost, stolen, or misplaced belongings, to ensure residents' rights to personal property are respected. The DON stated that the facility's policy and procedure was not followed when Resident 73's missing cellphone was not documented in the theft and loss sheet and was not labeled to identify resident's belongings. During a review of the facility's policy and procedures (P&P), titled Theft Prevention, last reviewed on 1/15/2026, the P&P indicated a purpose to assist residents in safeguarding their personal property. The P&P furthermore indicated The Facility is committed to preventing the misappropriation of resident property. The Facility will exercise reasonable care for the protection of the resident's property from theft or loss. The Facility investigates all reports of stolen items, makes reports to authorities as required by law, and maintains documentation of all reports of lost or stolen property. (.). All inquiries regarding lost or stolen items are reported to the Administrator. (11) Measures to Secure Personal Property (A.ii) Items brought into the Facility after admission are added to the Resident Inventory at the request of the resident or his/her representative. (C)Items brought to the Facility are marked, to the extent possible, identifying the owner of the item. (i.e. engraving, tagging, marking clothing tags, etc.) (D) Items found on the grounds of the Facility are turned into the business office within 24 hours. During a review of the facility's P&P, titled Resident Rights – Personal Property, last reviewed on 1/15/2026, the P&P indicated a purpose to ensure the quality of life of all residents to create a home-like environment. (V) The resident's personal belongings and clothing are inventoried and documented upon admission. (VII) the Facility promptly investigates any complaints of misappropriation, theft, or mistreatment of resident property.

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom from movement or normal access to one's body) for four of four sampled residents (Residents 14, 226, 106, and 205) reviewed for physical restraints by failing to: 1. Ensure Resident 14 did not have a wedge pillow tucked under the fitted sheet on the left side. 2. Obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and develop and implement a care plan (a document outlining a detailed approach to care customized to an individual resident's need) on the use of bilateral pillows tucked under the sheets on Resident 226. 3. Ensure that Resident 205 and Resident 106 use of restraint bed against the wall had a current physician's order, informed consent, restraint assessment, and a care plan. These failures had the potential to result in restriction of the residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from the resident limbs getting entrapped from bed spaces leading to fractures (a broken bone) and not able to move around freely and at risk of further injuries. Findings: 1. During a review of Resident 14's admission Record (AR-front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 2/4/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (a type of stroke, loss of blood flow to a part of the brain) affecting right dominant side. During a review of Resident 14's History and Physical (H&P) dated 4/30/2026, the H&P indicated that Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 5/11/2026, the MDS indicated Resident 14 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make his needs known. The MDS further indicated Resident 14 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 14's fall risk assessments dated 2/4/2026, 3/7/2026 and 4/29/2026, the fall risk assessments indicated Resident 14 was a high risk for falls. During an observation on 8/10/2026 at 1:41 p.m. inside Resident 14's room, observed Resident 14 lying in bed asleep turned towards the right side with a blue colored wedge pillow tucked under the fitted sheet on the left side of the bed. During a concurrent observation and interview on 8/10/2026 at 1:59 p.m., inside Resident 14's room with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 14 had a wedge pillow tucked under the fitted sheet on the left side. CNA 8 stated she just continued what she had observed at the start of her shift. CNA 8 stated that she placed the wedge pillow under the fitted sheet to reposition Resident 14. CNA 8 stated she does not know if that is a correct practice, but she tucks the wedge pillow under the fitted sheet. CNA 8 stated that Resident 14 was unable to remove the wedge pillow by herself if tucked under the fitted sheet and would not be able to move freely. During a concurrent observation and interview on 8/10/2026 at 1:59 p.m., inside Resident 14's room with Licensed Vocational Nurse (LVN) 7, LVN 7 stated Resident 14 had a wedge pillow tucked under the fitted sheet. LVN 8 stated that Resident 14 would to be able to move freely if the wedge pillow was tucked under the fitted sheet and can be considered a restraint. LVN 8 stated that from her knowledge, placing pillows tucked under the fitted sheet is not an acceptable practice in the facility. LVN 7 stated that CNA 8 should have not tucked the wedge pillow under Resident 14's fitted sheet. During a concurrent interview and record review on 8/12/2026 at 10:45 a.m., with Quality Assurance Nurse (QAN) 1, Resident 14's fall risk assessments, physician's orders, and a photo of the resident's bed were reviewed. The QAN 1 stated that Resident 14's fall risk assessments indicated that Resident 14 was at a high risk for falls, and there was no physician's order to place a wedge pillow under the fitted sheet. The QAN 1 stated that was not an acceptable practice in the facility and can be considered a restraint as it restricts the residents' freedom of movement. The QAN 1 stated that Resident 14 was unable to remove the pillows if tucked under the fitted sheet due to the resident's condition. The QAN 1 stated that the wedge pillow can be used only for repositioning but should be placed on top of the fitted sheet or under the flat sheet. The QAN 1 stated that Resident 14's pillows should have been placed on top of the fitted sheet as it restricts Resident 14 to move freely and placed the resident at risk for further decline in functioning. During an interview on 8/14/2026 at 11:45 a.m. with the Director of Nursing (DON), the DON stated that when applying a restraint on a resident, there should be a restraint assessment, physician's order, informed consent, and care plan. The DON stated that pillows or wedge pillows are primarily used as positioning devices and are supposed to be placed by staff on top of the fitted sheet or under the flat sheet where the residents can remove it on their own and be able to move freely. The DON stated that placing the wedge pillow under the fitted sheet is not an acceptable practice in the facility and restricts a resident's movement, hence considered a restraint. The DON stated that the staff should not have placed the wedge pillow under Resident 14's fitted sheet and restricted the resident to move freely which can lead to a further decline in physical functioning. During a review of the facility's policy and procedure (P&P) titled, Restraints, last reviewed on 1/15/2026, the P&P indicated that residents shall be provided an environment that restraint-free, unless a restraint is necessary to treat a medical symptom in which care the least restrictive measure shall be used. The P&P further indicated: Physical restraint is defined as any manual method or physical mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Postural supports will only be used to improve a resident's mobility and independent functioning, or for positioning, rather than to restrict movement. The use of postural support and the method of application will be specified in the resident's care plan. Postural supports will be applied pursuant to an Attending Physician's order, under the supervision of a licensed nurse, and in accordance with principles of good body alignment and with concern for circulation and allow for change of position. 2. During a review of Resident 226's AR, the AR indicated the facility admitted the resident on 8/7/2026, with diagnoses including metabolic encephalopathy (a temporary brain malfunction caused by a body-wide chemical imbalance or illness, rather than a direct injury or disease inside the brain), muscle weakness, and mild cognitive impairment (having trouble with brain tasks like thinking, remembering, learning, or making choices). During a review of Resident 226's H&P, dated 8/7/2026, the H&P indicated the resident did not have the capacity to understand and make decisions and confused. During a review of Resident 226's Order Summary Report (OSR), dated 8/13/2026, the OSR did not indicate an order for pillows tucked under the sheets. During a review of Resident 226's Fall Risk (Morse) Assessment (FRA), dated 8/8/2026, the FRA indicated the resident was at high risk for falls. During a review of Resident 226's Care Plan (CP) Report titled, At risk for falls due to poor safety awareness, muscle weakness, and polypharmacy, last revised on 8/8/2026, the CP indicated to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. During an observation on 8/10/2026, at 11:05 a.m., inside Resident 226`s room, observed Resident 226 was in bed with upper bilateral half (1/2) bedrail with pillows tucked on both side of the bed under the sheets. During a concurrent observation, interview, and record review on 8/10/2026, at 11:10 a.m., with Registered Nurse (RN) 3, inside Resident 226's room, observed Resident 226 had bilateral pillows tucked under the sheets. RN 3 stated it will be hard for the resident to remove the pillows tucked under the sheets and it will inhibit movement of the resident in bed. RN 3 stated by placing the resident with bilateral pillows tucked under the sheets they were restraining the resident's movement in bed thus the pillows act now as a restraint. RN 3 stated they need to obtain a physician's order, informed consent, restraint assessment, and a care plan on its use. RN 3 reviewed Resident 226's Medical Diagnoses, OSR, FRA, and CP. RN 3 stated there was no physician's order, informed consent, restraint assessment and a care plan developed on the use of resident's pillows tucked under the sheets. RN 3 stated the failure of the licensed nurses to obtain the four components had predisposed the resident to deconditioning and higher risk for accidents with injury. During an interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's policy and procedure (P&P) on Restraints was reviewed. The P&P titled Restraints indicated Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body, a physical restraint shall be used only after the Interdisciplinary Team (IDT, is a group of different health professionals who team up to create, review, and update a resident's personalized care plan, ensuring that medical, therapy, dietary, and social needs are all met) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device, the Attending Physician must be notified of such use and the reason for the order, and an assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The DON stated that all the necessary steps before applying a restraint was not followed and it predisposed the resident to harm and entrapment (when a person gets accidentally caught, stuck, or tangled in the gaps around a bed). 3. During a review of Resident 205's AR, the AR indicated that the facility admitted the resident on 8/28/2025 and readmitted on [DATE], with diagnoses including neuropathy (damage or a problem with the nerves that stops them from working the right way), emphysema (a long-term lung disease where the tiny air sacs in the lungs get damages, break open, and trap old air), unsteadiness of feet, and lack of coordination. During a review of Resident 205's H&P, dated 4/22/2026, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 205's MDS, the MDS indicated that the resident's cognitive function is intact with normal thinking and memory. The MDS indicated that the resident needed setup or cleanup assistance with eating and oral hygiene, and partial to moderate assistance (helper does less than half the effort) with toileting and showers, and substantial to maximal assistance (helper does more than half the effort) to transfers. During a review of Resident 205's Care Plan (CP) under Focus: Risk for injury/entrapment due to use of bilateral half upper side rails up to aid with bed mobility and repositioning and independence and to assist with transfer, indicated an intervention including to assess resident for the risk of entrapment. During a concurrent observation and interview on 8/10/2026 at 10:22 a.m. with CNA 12, Resident 205's bed was observed against the wall. Resident 205 stated that she (Resident 205) wants her bed close to the window but that it was not her choice for the bed being placed against the wall and further stated, it would be nice to have some space. During a concurrent interview and record review on 8/12/2026 at 2:25 p.m. with RN 1, RN 1 stated that if the bed is placed against the wall, it is considered a restraint. RN 1 reviewed Resident 205's medical record and stated that there was no assessment, no doctor's order, no consent, and care plan made for the resident`s bed against the wall. RN 1 stated that assessment is important for the safety of the resident and consent that the resident agreed for the bed placed against the wall as well as doctor's order and care plan. RN 1 stated that the resident could possibly hurt herself when her limbs get caught which could potentially lead to injury. During an interview on 8/14/2026 at 2:35 p.m. with the DON, the DON stated that when bed is placed against the wall, it is considered a restraint. The DON stated that there must be an assessment, consent, doctor's order, and care plan before putting the bed against the wall. The DON stated that it can cause entrapment and potentially lead to injury to the residents. The DON stated that the policy for restraints was not followed. 4. During a review of Resident 106's AR, the AR indicated the facility admitted the resident on 10/11/2026, and readmitted the resident on 7/6/2026, with diagnoses including muscle weakness, lack of coordination, and history of falling. During a review of Resident 106's H&P, dated 7/7/2026, the H&P indicated the resident was alert with baseline cognitive impairment and intermittent confusion. Oriented primarily to self and place. During a review of Resident 106's MDS, dated [DATE], the H&P indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (when a person gets accidentally caught, stuck, or tangled in the gaps around a bed). The MDS indicated the resident had lower extremity impairment and uses a wheelchair to mobilize in the facility. The MDS also indicated that the resident was dependent to needing supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 106's OSR, dated 8/13/2026, the OSR did not indicate an order to place the bed against the wall. During a review of Resident 106's Nursing Quarterly Assessment (NQA), dated 7/11/2026, the NQA indicated on Fall Risk Assessment that the resident was at moderate risk for falls. During a review of Resident 106's CP Report regarding the resident was at high risk for further falls and/or injuries related to .cognitive impairment, decreased strength/endurance, history of falls, poor safety awareness/judgement., last revised on 2/16/2026, the CP indicated an intervention resident needs a safe environment. During a concurrent observation and interview on 8/10/2026, at 11:19 a.m., with CNA 3, inside Resident 106's room, observed Resident 106's bed was placed against the wall at the right side of the bed with upper grab bars (a sturdy metal handle attached to a bed frame) on. CNA 3 stated the bed was placed against the wall because the resident was a fall risk resident. During a concurrent interview and record review on 8/12/2026, at 11:07 a.m., with RN 1, Resident 106's Medical Diagnoses, OSR, NQA, and CP were reviewed. RN 1 stated there was no physician's order, informed consent, restraint assessment and a care plan developed and implemented on the use of restraint bed placed against the wall. RN 1 their failure to obtain all four components before applying a restraint had predisposed the resident to injuries such as entrapment and they failed to honor the resident's right to agree or disagree with the proposed treatment. During an interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's P&P on Restraints was reviewed. The P&P titled Restraints indicated Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body, a physical restraint shall be used only after the Interdisciplinary Team (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device, the Attending Physician must be notified of such use and the reason for the order, and an assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The DON stated that all the necessary steps before applying a restraint was not followed and it predisposed the resident to harm and entrapment. During a review of the facility's recent P&P titled, Restraints, last reviewed on 1/15/2026, the P&P indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. Policy I. Definitions Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, bed against walls, restrictive clothing, etc. X. Except in emergency situations, a physical restraint shall be used only after the Interdisciplinary Team (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. B. the Attending Physician must be notified of such use and the reason for the order. Procedure I. Assessment - An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The assessment will be repeated quarterly thereafter. If a resident is admitted with a restraint, the assessment will be completed upon admission. VII. Informed Consent A. before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/responsible party and that the resident/responsible party was educated regarding the risks and benefits if restraint use. XI. Care Planning- Care plans for residents with restraints will reflect: A. The type of restraint to be used; B. The medical symptoms requiring the use of restraints; C. The treatment team's goals in using the restraint; D. Interventions that address the immediate medical symptom(s) and the underlying problems that may be causing the symptom(s).

Based on interview, and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 2 and 185) were free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures (P&P) by failing: 1. to monitor occurrences of anxiety manifested by repetitive anxious complaints for Resident 185. As a result, Resident 185 did not have monitoring for occurrences of anxiety with the use of alprazolam (a psychotherapeutic used for anxiety, also referred to as anxiolytic [anti-anxiety]) between 7/10/2026 and 8/12/2026. 2. ensure to have accurate indication for the use of celexa (an antidepressant [against depression] medication) for Resident 2, starting 7/21/2026. This failure had the potential to place Resident 2 and 185 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotherapeutic drugs, which could result in impairment or decline in the residents' mental, physical condition, mental, functional, and psychosocial status. Findings: During a review of Resident 2's admission Record (a document containing demographic and diagnostic information) dated 8/13/2026, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including psychotic disturbance, mood disturbance, anxiety, depressive disorder, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, making it difficult to carry out day-to-day tasks). During a review of Resident 2's Order Summary (a document containing orders prescribed by the doctor), dated 8/13/2026, the report indicated Resident 2 was prescribed celexa 20 milligram ([mg]- a unit of measure of mass) via gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) in the evening for depression manifested by crying, starting 7/21/2026. During a review of Resident 2's Care Plan, revised on 6/11/2026, the Care Plan indicated that Resident 2 was using antidepressant medication celexa related to depression manifested by crying. During a review of Resident 2's Medication Administration Record (MAR - a record of mediations administered to residents) for July and August 2026, the MAR indicated Resident 2: 1. was prescribed brexpiprazole (a medication used for dementia) 2 mg via G-tube once a day for dementia, starting 7/22/2026. 2. was prescribed donepezil (a medication used for dementia) 10 mg via G-tube once a day for dementia, starting 7/22/2026. 3. was prescribed quetiapine (a medication used for bipolar psychosis) 50 mg via G-tube in the morning for bipolar psychotic disorder manifested by screaming for no apparent reason, starting 7/22/2026. 4. was prescribed quetiapine 75 mg via G-tube in the evening for bipolar psychotic disorder manifested by screaming for no apparent reason, starting 7/29/2026. 5. was prescribed trazodone (an antidepressant medication) 50 mg via G-tube at bedtime for depression manifested by inability to sleep 6 hours per night, starting 7/22/2026. 6. was prescribed valproic acid (a medication for bipolar disorder) 500 mg via G-tube twice a day for bipolar disorder manifested by mood swings from calm to hostile behavior, starting 7/22/2026. 7. was prescribed and administered celexa 20 mg via G-tube in the evening for depression manifested by crying, at 5 p.m. 8. was prescribed behavior monitoring for celexa and to document number of episodes per shift of target behavior (depression manifested by crying) every shift, starting 7/21/2026. 9. had zero (0) episodes of depression manifested by crying documented, for day, evening and night shifts between 7/21/2026 and 7/31/2026. 10. had one (1) episodes of depression manifested by crying documented, for evening shift on 8/7/2026, between 8/1/2026 and 8/13/2026. During a review of Psychiatric Progress note, dated 6/11/2026, the note indicated that celexa was initiated due to persistent dementia-related mood and behavioral symptoms with increased evening agitation/sundowning.celexa selected to better target agitation, anxiety, and depressive symptoms. During a review of Resident 185's admission Record, dated 8/13/2026, the admission Record indicated Resident 185 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including anxiety disorder. During a review of Resident 185's Order Summary, dated 8/13/2026, the report indicated Resident 185 was prescribed alprazolam 0.5 mg orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, starting 7/10/2026. During a review of Resident 185's Care Plan, initiated on 10/5/2025, and revised 1/7/2026, 5/15/2026, and 7/10/2026, the Care Plan indicated that Resident 185 was using alprazolam related to anxiety disorder, with a goal of decreased number episodes of anxiety and to monitor/record occurrence of target behavior symptoms and document per facility protocol. During a review of Resident 185's MAR for July 2026, the MAR indicated Resident 185 was prescribed and administered: 1. alprazolam 0.5 mg orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, between 7/10/2026 and 7/31/2026, at 6 a.m., 2 p.m. and 10 p.m. 2. The MAR did not contain documentation for monitoring/recording occurrences of anxiety disorder manifested by repetitive anxious complaints. During a review of Resident 185's MAR for August 2026, the MAR indicated Resident 185 was prescribed and administered: 1. alprazolam 0.5 mg orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, between 8/1/2026 and 8/12/2026, at 6 a.m., 2 p.m. and 10 p.m. 2. The MAR did not contain documentation for monitoring/recording occurrences of anxiety disorder manifested by repetitive anxious complaints. During a concurrent record review and interview on 8/12/2026 at 3:30 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 2's Order Summary, Care plan revised 6/11/2026, MAR for July and August 2026, Psychiatric Progress noted dated 6/11/2026. The DON acknowledged: 1. The Order Summary, MARs and Care Plan indicated Resident 2 was using celexa related to depression manifested by crying. 2. Resident 2 was using: a. brexpiprazole and donepezil for dementia b. quetiapine for bipolar psychotic disorder manifested by screaming for no apparent reason. c. trazodone for depression manifested by inability to sleep for six hours per night. d. valproic acid for bipolar disorder manifested by mood swings from calm to hostile behavior. The Psychiatric Progress Note indicated that celexa was added to the medication list for persistent dementia-related mood and behavioral symptoms with increased evening agitation/sundowning, and to better target agitation, anxiety, and depressive symptoms. The DON stated between the different clinical documents (Care Plan, Order Summary, MARs, Psychiatric Progress Note) there was no clear indication for the use of celexa for Resident 2. The DON stated not having a clear indication for the use of celexa for Resident 2 could cause staff confusion, potentially leading to incorrect behavior manifestation monitoring and inability to determine the effectiveness of celexa for the intended indication/use. The DON added this could result in erroneous dose changes and unnecessary use of psychotropic medications for Resident 2. The DON stated that the facility failed to identify an accurate indication for the use of celexa placing Resident 185 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting Resident 2's well-being. The DON stated the facility will immediately review Resident 2's psychotropic medication list for accuracy. During the same interview, the DON reviewed Resident 185's Order Summary, Care plan revised 7/10/2026, MAR for July and August 2026, and acknowledged the Care Plan indicated to monitor/record occurrence of target behavior symptoms and document per facility protocol for use of alprazolam. The DON also acknowledged that the July and August 2026 MARs did not contain documentation that occurrences of anxiety by repetitive anxious complaints were monitored, for use of alprazolam. The DON stated that without monitoring occurrences of anxiety it was unknown if alprazolam was effective in treating the anxiety potentially resulting in the physician making inaccurate assessments of the medication's effectiveness, preventing dose reductions, discontinuation or even making unnecessary dose increases. The DON stated that the facility failed to monitor occurrences of anxiety by repetitive anxious complaints for use of alprazolam, placing Resident 185 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting Resident 185's well-being. The DON stated the monitoring will be immediately initiated in Resident 185's MAR. During a review of review facility's Policy and Procedures (P&P,) titled Psychotherapeutic Drug Policies, last reviewed 1/15/2026, the P&P indicated: All residents receiving routing.medication(s) prescribed for the control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness . The staff shall monitor and record the occurrence of each of the specifically identified aberrant behavior(s) in the resident's health record. During a review of review facility's P&P titled Recommended Anxiolytic Drug Documentation, last reviewed 1/15/2026, the P&P indicated: 1. Add the anxiolytic drug order to the [DATE]. Include Q (every) shift monitoring of the behavior [NAME] acting Drug: alprazolam. During a review of review facility's P&P titled Psychotherapeutic Drug Management, last reviewed 1/15/2026, the P&P indicated: C. Will monitor the presence of target behaviors on a daily basis. During a review of review facility's P&P titled Unnecessary Medications, last reviewed 1/15/2026, the P&P indicated: 1. Unnecessary Drug a. Each resident's medication regimen must be free from unnecessary drugs. b. An unnecessary drug is any drug used: iii. Without adequate monitoring iv.Without adequate indication for its use.

Based on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs to four of four sampled residents (Resident12, 17, 48, and 66) reviewed for Preadmission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) by failing to 1. Perform a PASARR screening for a resident with newly diagnosed major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality). 2. Submit a new Level I PASRR for the residents who had discrepancy in the previous PASRR Level I Screening. These failures had the potential to result in not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility, and to result in inappropriate placement and unidentified specialized services for the residents. Findings: 1. During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted the resident on 9/15/2026, and readmitted the resident on 2/9/2026, with diagnoses including psychosis and major depressive disorder. During a review of Resident 12's History and Physical (H&P), dated 6/20/2026, the H&P indicated the resident was alert, awake, oriented times 4 (AAOX4, is a quick medical shorthand meaning a person is fully awake and knows four key facts: their own identity, where they are, the current time or date, and their current situation). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (the mental faculties—such as memory, thinking, problem-solving, and attention—are working normally and without impairment). The MDS indicated the resident was on an antidepressant (a prescription drug that helps balance natural chemicals in the brain). During a review of Resident 12's Order Summary Report (OSR), dated 7/10/2026, the OSR indicated an order for Bupropion HCl ER (XL) Oral tablet Extended Release 24-hour 150 milligrams (mg, a unit of weight) (Bupropion HCl). Give 150 mg by mouth one time a day for depressive disorder monitor for behavior (m/b): verbalization of hopelessness. Verified informed consent obtained from resident representative (RP). During a review of Resident 12's PASARR Level I Screening, dated 12/26/2025, the PASRR indicated the Level I- Negative for serious mental illness (SMI)/Negative for ID/developmental disability (DD)/related condition (RC). During a review of Resident 12's admission Diagnosis Worksheet (ADW), dated 6/18/2026, the ADW indicated diagnoses of psychosis and major depressive disorder. During a review of Resident 12's Care Plan (CP) Report regarding the resident was on Wellbutrin 75 mg for depressive disorder m/b verbalization of hopelessness, last revised on 7/28/2026, the CP indicated an intervention to monitor/document/report if needed (PRN) adverse reactions (an unexpected, harmful, or unpleasant physical response to a medical treatment, drug, or substance) to antidepressant therapy (the use of prescription medicines to help fix chemical imbalances in the brain). During a concurrent interview and record review on 8/12/2026, at 2:18 p.m., with Quality Assurance Nurse (QAN) 1, reviewed Resident 12's Medical Diagnoses, OSR, ADW, and CP. QAN 1 stated they should have performed another PASARR screening on Resident 12 due to the new diagnoses of psychosis and major depressive disorder on 6/18/2026. QAN 1 stated their failure to perform another PASARR screening on Resident 12 had the potential for missed provision of care appropriate for the diagnosis. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASARR), was reviewed. The P&P Pre-admission Screening and Resident Review indicated the Facility also conducts PASRR Level I screening for current residents who have a mental illness or intellectual disability and experience a significant change in their condition based on MDS 3.0 guidelines. The DON stated the resident had new diagnoses of psychosis and major depressive disorder and the should have been screened for another PASSAR. The DON stated their failure to perform a PASARR had the potential for missed provision of care appropriate for the residents diagnoses. The DON stated the facility did not follow their policy Pre-admission Screening and Resident Review. 2. During a review of Resident 17's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 5/11/2026 with diagnoses including anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 17's History and Physical (H&P) dated 5/13/2026, the H&P indicated Resident 17 had the capacity to understand but cannot make medical decisions. The H&P further indicated that Resident 17 had a diagnosis of schizophrenia. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 17's diagnoses including major depressive disorder, generalized anxiety disorder, and schizophrenia and was taking psychotropic medications. The MDS further indicated that Resident 17's PASRR Level I Screening was negative for any SMI/ID/DD/RC. During a review of Resident 17's PASRR Level I Screening, dated 5/11/2026, the PASRR Level I Screening under section III question number ten (10) indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic (medications capable of affecting the mind, emotions, and behavior) medications. During a concurrent interview and review on 8/12/2026 at 10:05 a.m. with Quality Assurance Nurse (QAN) 1, Resident 17's admission Record, MDS, H&P, and PASRR Level I Screening dated 5/11/2026 were reviewed. QAN 1 stated that the admission Record, MDS, and H&P indicated that Resident 17 had diagnoses of anxiety disorder, major depressive disorder, and schizophrenia and that the PASRR Level 1 Screening did not indicate that Resident 17 had a MD. QAN 1 stated that she was usually responsible in checking the PASRR upon residents' admission for accuracy and resubmit a new Level I Screening if there is a discrepancy to ensure the residents are receiving the appropriate care and services. QAN 1 stated a new Level I Screening is also submitted if there is a new diagnosis of MD or for any significant change in condition. QAN 1 stated that she did not notice that there was a discrepancy with Resident 17's PASRR Level I Screening and further stated that she should have submitted a new Level I Screening. QAN 1 stated that it placed Resident 17 at risk for not being able to determine if his placement in the facility was appropriate and would not be receiving and meet the care and services he needs. During a concurrent interview and record review on 8/12/2026 at 11 a.m. with the MDS Coordinator (MDSC), Resident 17's MDS dated [DATE] indicated that the PASRR Level I Screening was negative for SMI/ID/DD/RC and that the resident had diagnoses of anxiety disorder, major depressive disorder, and schizophrenia. The MDSC stated he did not notice that there was a discrepancy with the PASRR Level I Screening when the MDS was completed. The MDSC stated that the discrepancy should have been brought up with the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) during completion of the MDS assessment and QAN 1 and resubmit a new Level I Screening as it placed Resident 17 at risk for possibly not receiving the care and services he needs. 3. During a review of Resident 48's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 4/17/2025 and readmitted in the facility on 2/4/2026 with diagnoses including anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and generalized muscle weakness. During a review of Resident 48's History and Physical (H&P) dated 2/4/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. The H&P further indicated that Resident 48 had diagnoses of anxiety disorder and psychosis. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 48's diagnosis anxiety disorder, and psychosis. The MDS further indicated that Resident 48's PASRR Level I Screening was negative for any SMI/ID/DD/RC and was not prescribed any psychotropic medications (medications capable of affecting the mind, emotions, and behavior). During a review of Resident 48's PASRR Level I Screening, dated 1/12/2025, the PASRR Level I Screening under section III question number ten (10) indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic medications. During a concurrent interview and review on 8/12/2026 at 10:05 a.m. with Quality Assurance Nurse (QAN) 1, Resident 48's admission Record, MDS, H&P, and PASRR Level I Screening dated 1/12/2025 were reviewed. QAN 1 stated that the admission Record, MDS, and H&P indicated that Resident 48 had diagnoses of anxiety disorder, and unspecified psychosis, and that the PASRR Level 1 Screening did not indicate that Resident 48 had a MD. QAN 1 stated that she was usually responsible in checking the PASRR upon residents' admission for accuracy and resubmit a new Level I Screening if there is a discrepancy to ensure the residents are receiving the appropriate care and services. QAN 1 stated a new Level I Screening is also submitted if there is a new diagnosis of MD or for any significant change in condition. QAN 1 stated that she did not notice that there was a discrepancy with resident 48's PASRR Level I Screening and further stated that she should have submitted a new Level I Screening. QAN 1 stated that it placed Resident 48 at risk for not being able to determine if his placement in the facility was appropriate and would not be receiving and meet the care and services he needs. During a concurrent interview and record review on 8/12/2026 at 11 a.m. with the MDS Coordinator (MDSC), Resident 48's MDS dated [DATE] indicated that the PASRR Level I Screening was negative for SMI/ID/DD/RC and that the resident had diagnoses of anxiety disorder. The MDSC stated he did not notice that there was a discrepancy with the PASRR Level I Screening when the MDS was completed. The MDSC stated that the discrepancy should have been brought up with the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) during completion of the MDS assessment and QAN 1 and resubmit a new Level I Screening as it placed Resident 48 at risk for possibly not receiving the care and services he needs 4. During a review of Resident 66's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 8/15/2022 and readmitted in the facility on 11/11/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 66's History and Physical (H&P) dated 11/13/2025, the H&P indicated Resident 66 did not have the capacity to understand and make decisions. The H&P further indicated that Resident 66 had a diagnosis of schizoaffective disorder. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 66's diagnoses including depression and was taking a psychotropic medication. The MDS further indicated that Resident 66's PASRR Level I Screening was negative for any SMI/ID/DD/RC. During a review of Resident 66's PASRR Level I Screening, dated 8/19/2022, the PASRR Level I Screening under section III question number ten (10) indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic (medications capable of affecting the mind, emotions, and behavior) medications. During a concurrent interview and review on 8/12/2026 at 10:05 a.m. with Quality Assurance Nurse (QAN) 1, Resident 66's admission Record, MDS, H&P, and PASRR Level I Screening dated 11/11/2025 were reviewed. QAN 1 stated that the admission Record, MDS, and H&P indicated that Resident 66 had diagnoses of schizoaffective disorder, psychosis, and depressive disorder and that the PASRR Level 1 Screening did not indicate that Resident 66 had a MD and was not prescribed a psychotropic medication. QAN 1 stated that she was usually responsible in checking the PASRR upon residents' admission for accuracy and resubmit a new Level I Screening if there is a discrepancy to ensure the residents are receiving the appropriate care and services. QAN 1 stated a new Level I Screening is also submitted if there is a new diagnosis of MD or for any significant change in condition. QAN 1 stated that IDT also reviews the PASARR and diagnosis with every MDS assessment. QAN 1 stated that she did not notice that there was a discrepancy with Resident 66's PASRR Level I Screening and further stated that she should have submitted a new Level I Screening. QAN 1 stated that it placed Resident 66 at risk for not being able to determine if her placement in the facility was appropriate and would not be receiving the care and services she needs. During a concurrent interview and record review on 8/12/2026 at 11 a.m. with the MDS Coordinator (MDSC), Resident 17's MDS dated [DATE] indicated that the PASRR Level I Screening was negative for SMI/ID/DD/RC and that the resident had diagnoses of anxiety disorder, major depressive disorder, and schizophrenia. The MDSC stated he did not notice that there was a discrepancy with the PASRR Level I Screening when the MDS was completed. The MDSC stated that the discrepancy should have been brought up with the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) during completion of the MDS assessment and QAN 1 and resubmit a new Level I Screening as it placed Resident 17 at risk for possibly not receiving and meet the care and services he needs. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), last reviewed on 1/15/2026, the P&P indicated that to ensure all facility applicants are screened for mental illness and/or intellectual disability and to ensure coordination with the appropriate state agencies: - All individuals regardless of payor source seeking admission to the facility must have a PASRR determination prior to the facility accepting the admission. - The facility ensures that PASRR Level I is completed either by the general acute care hospital (GACH) or by the facility for all applicants, regardless of payor, prior to admission to determine if they SMI and/or ID/DD/RD. - The facility also conducts PASRR Level I Screening for current residents who have a mental illness or ID and experience a significant change in condition based on MDS 3.0 guidelines. - In the event the resident, facility staff, and/or conservator disagree with the PASRR determination for SMI and/or ID/DD/RC, a request for reconsideration may be submitted. - If the MDS does not match the PASRR Level I from the GACH or there is a significant change in the resident's mental or physical condition, the facility is responsible for completing a new PASRR Level I.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of thirty-five sampled residents (Residents 34 and 185) by failing:1. To develop and implement a care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Resident 34 on the use of Antibiotic Invanz Injection 1 grams (gm, a unit of weight) (ertapenem sodium) Intravenously (giving medicine, fluid, or food directly into a vein using a tiny needle or tube) every 24 hours for urinary tract infection (UTI, an infection in the bladder/urinary tract) for seven days on Resident 34.These failures had the potential to result in medication errors, treatment failure, and increased microbial resistance (happens when tiny living germs-like bacteria, viruses, or fungi-change over time).2. Implement the Care Plan for Resident 185 to monitor occurrences of anxiety manifested by repetitive anxious complaints of Resident 185.As a result, Resident 185 did not have monitoring for occurrences of anxiety with the use of alprazolam (a psychotherapeutic [any medication capable of affecting the mind, emotions, and behavior] used for anxiety, also referred to as anxiolytic [anti-anxiety]) between 7/10/2026 and 8/12/2026. This deficient practice had the potential to result in Resident 185 to receive suboptimal (less than the highest standard or quality) care and for the facility to not be able to assess the effectiveness of alprazolam for anxiety, leading to the use of unnecessary medication for Resident 185 causing more harm than benefit and potential medication overdose (giving doses beyond the necessary amount), ultimately negatively impacting their physical, mental, and psychosocial well-being.Findings: 1. During a review of Resident 34's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2026, with diagnoses including sepsis (a life-threatening blood infection), acute cystitis (a sudden bladder infection), and lack of expected normal physiological development in childhood. During a review of Resident 34's Minimum Data Set (MDS, a resident assessment tool), dated 6/15/2026, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severely impaired cognitive skills (a person has a major, life-altering loss of mental capacity). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 34's Physician Order (PO), dated 7/5/2026, the PO indicated an order for Invanz Injection Solution Reconstituted 1 gm (Ertapenem Sodium). Use 1 gm intravenously every 24 hours for UTI for 7 days. During a review of Resident 34's History and Physical (H&P), dated 8/9/2026, the H&P indicated the resident had intellectual/developmental disability (a lifelong condition that starts during childhood) was awake, alert and follows commands. During a concurrent interview and record review on 8/12/2026, at 9:53 a.m., with Registered Nurse (RN) 1, Resident 34's Diagnoses, PO, and CP were reviewed. RN 1 stated there was no care plan developed and implemented on the use of Invanz for Resident 34. RN 1 stated it was important to have a care plan on the use of antibiotic Invanz to know if they were meeting the goal of using the antibiotic and to follow interventions written in the care plan, and to ensure the medication use was safe and effective. RN 1 stated their failure to develop and implement a care plan on Invanz predisposed the resident to unrecognized late reactions of the medications and delayed mitigation of the adverse reactions (any harmful or unpleasant reaction that happens when a person takes a normal dose of a medicine) for Resident 34. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Care Planning, last reviewed on 1/15/2026, was reviewed. The P&P Care Planning indicated, the Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. The DON stated the P&P Care Planning was not followed because the facility did not develop and implemented a care plan on the use of Invanz for Resident 34. The DON stated they need the care plan to ensure they were meeting the goal and all-important interventions were being provided to the resident, without the care plan important interventions can be missed. During a review of the facility's recent P&P titled, Care Planning, last reviewed on 1/15/2026, the P&P indicated to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.Procedure I. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission.X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including comprehensive and quarterly review assessments. During a review of the facility's recent P&P titled, Antibiotic Stewardship Program, last reviewed on 1/15/2026, the P&P indicated the Antibiotic Stewardship Program (ASP) is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of INVAZ (ertapenem for injection), for intravenous or intramuscular use, with initial U.S. approval in 2001, the HPI indicated Warnings and Precautions:-Serious hypersensitivity (anaphylactic) reactions have been reported in patients receiving B-lactams.-Seizures and other central nervous system adverse experiences have been reported during treatment.-Co-administration of INVANZ with valproic acid or divalproex sodium reduces the serum concentration of valproic acid potentially increasing the risk of breakthrough seizures.-Clostridioides difficile-associated diarrhea (ranging from mild diarrhea to fatal colitis). Evaluate if diarrhea occurs.-Caution should be taken when administering INVANZ intramuscularly to avoid inadvertent injection to a blood vessel. 2. During a review of Resident 185's admission Record (a document containing demographic and diagnostic information,) dated 8/13/2026, the admission Record indicated Resident 185 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including anxiety disorder. During a review of Resident 185's Care Plan, initiated on 10/5/2025, and revised 1/7/2026, 5/15/2026, and 7/10/2026, the Care Plan indicated that Resident 185 was using alprazolam related to anxiety disorder, with a goal of decreased number episodes of anxiety and to monitor/record occurrence of target behavior symptoms and document per facility protocol. During a review of Resident 185's Order Summary (a document containing orders prescribed by the doctor), dated 8/13/2026, the report indicated Resident 185 was prescribed alprazolam 0.5 milligram ([mg]- a unit of measure of mass) orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, starting 7/10/2026. During a review of Resident 185's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for July 2026, the MAR indicated Resident 185 was prescribed and administered alprazolam 0.5 mg orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, between 7/10/2026 and 7/31/2026, at 6 a.m., 2 p.m. and 10 p.m. The MAR did not contain documentation for monitoring/recording occurrences of anxiety disorder manifested by repetitive anxious complaints. During a review of Resident 185's MAR for August 2026, the MAR indicated Resident 185 was prescribed and administered alprazolam 0.5 mg orally every eight (8) hours for anxiety disorder manifested by repetitive anxious complaints, between 8/1/2026 and 8/12/2026, at 6 a.m., 2 p.m. and 10 p.m. The MAR did not contain documentation for monitoring/recording occurrences of anxiety disorder manifested by repetitive anxious complaints. During a concurrent record review and interview on 8/12/2026 at 3:30 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 185's Order Summary, Care plan revised 7/10/2026, MAR for July and August 2026, and acknowledged the Care Plan indicated to monitor/record occurrence of target behavior symptoms and document per facility protocol for use of alprazolam. The DON also acknowledged that the July and August 2026 MARs did not contain documentation that occurrences of anxiety by repetitive anxious complaints were monitored, for use of alprazolam. The DON stated that without monitoring occurrences of anxiety it was unknown if alprazolam was effective in treating the anxiety potentially resulting in the physician making inaccurate assessments of the medication's effectiveness, preventing dose reductions, discontinuation or even making unnecessary dose increases. The DON stated that the facility failed to implement the Care Plan for monitoring occurrences of anxiety by repetitive anxious complaints for use of alprazolam, placing Resident 185 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting Resident 185's well-being. The DON stated the monitoring will be immediately initiated in Resident 185's MAR. During a review of review facility's Policy and Procedures (P&P,) titled Care Planning, last reviewed 1/15/2026, the P&P indicated: The resident has the right to receive the services and/or items included in the plan of care. During a review of review facility's P&P titled Psychotherapeutic Drug Policies, last reviewed 1/15/2026, the P&P indicated: All residents receiving routing.medication(s) prescribed for the control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness . The staff shall monitor and record the occurrence of each of the specifically identified aberrant behavior(s) in the resident's health record. During a review of review facility's P&P titled Recommended Anxiolytic Drug Documentation, last reviewed 1/15/2026, the P&P indicated: 1.Add the anxiolytic drug order to the MAR2.Include Q (every) shift monitoring of the behaviorShor acting Drug: alprazolam. During a review of review facility's P&P titled Psychotherapeutic Drug Management, last reviewed 1/15/2026, the P&P indicated: C. Will monitor the presence of target behaviors on a daily basis.F. Implements and updates the Care Plan as indicated.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven of thirteen sampled residents (Residents 16, 90, 30, 132, 18, 227, and 216) reviewed for accidents by failing to: 1.Ensure Resident 30 did not keep Nail Polish Remover, a potentially hazardous substance-acetone at the bedside. 2.Ensure Resident 132 had physician orders for the medications left at the bedside and an order to self-administer these medications.3.Ensure Resident 227's tube of Neosporin ointment (a common over-the-counter cream or ointment used on the skin) and Albuterol HFA (a quick-relief rescue inhaler) were not left at the bedside. 4.Ensure Resident 18 and 90 did not have equipment and furniture on top of their floor mats (a cushioned floor pad designed to help prevent injury should a person fall).5.Ensure Resident 216's bed was left at the lowest position when not providing care to the resident. These failures had the potential to increase residents' risk of medication overdose or adverse drug effects (unwanted or harmful reactions to a medication), from the unsupervised self-administration of medications, as well as the risk of falls resulting in injuries such as fractures or lacerations. Findings: 1. During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted the resident on 8/9/2025, and readmitted the resident on 5/18/2026, with diagnoses including lack of coordination, dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 30's Care Plan (CP) Report regarding the resident being at risk for falls and/or injuries related to. psychotherapeutic medications (a prescription drug that changes chemical signals in the brain) ., last revised on 5/18/2026, the CP indicated resident needs a safe environment. During a review of Resident 30's History and Physical (H&P), dated 5/19/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 6/29/2026, the MDS indicated the resident usually makes self-understood and understands others and had moderate cognitive impairment (a mid-level decline in thinking and memory skills). During a concurrent observation and interview on 8/10/2026, at 10:38 a.m., with Treatment Nurse (TN) 1, inside Resident 30's room, Resident 30 had a bottle of acetone at the bedside. TN 1 stated there should be no chemicals at the resident's bedside because if the resident is confused the resident can drink the chemicals and other confused residents might have access to it. TN 1 later stated he kept the acetone inside the resident's drawer. During an interview on 8/12/2026, at 10:49 a.m., with Registered Nurse (RN) 1, RN 1 stated there should be no corrosive chemicals at the bedside of the resident such as acetone. RN 1 stated all staff are responsible for checking for hazards at the bedside of the residents and remove them. RN 1 stated the failure of the staff to keep the acetone away from the resident can potentially cause accidental chemical ingestion that can harm the resident. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Maintenance- Storage Areas was reviewed. The Maintenance- Storage Areas P&P indicated cleaning supplies and similar substances must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products. The DON stated acetone is a hazardous substance and should not be kept at the resident's bedside. The DON stated they did not follow the P&P because they left the acetone at the bed side of the resident. The DON stated the staff should check the residents' environment for hazards frequently during their environmental rounds. The DON stated the failure of the staff to keep the acetone away from Resident 30 had the potential to result in harm to the resident, such as accidental ingestion of corrosive substances. During a review of the facility's recent P&P titled, Maintenance- Storage Areas, last reviewed on 1/15/2026, the P&P indicated to protect the health and safety of residents, visitors, and Facility Staff. Procedure III. Cleaning supplies and similar substances must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products. During a review of the facility's Safety Data Sheet (SDS), revised date 12/21/2012, the SDS indicated Nail Polish Remover had a hazards statement: -Causes severe eye irritation -May cause respiratory irritation. May cause drowsiness or dizziness. -Highly flammable liquid and vapor. 2. During a review of Resident 132's admission Record (AR), the AR indicated the facility admitted the resident on 10/18/2025, and readmitted the resident on 11/12/2025, with an anxiety disorder (a mental health condition marked by extreme, ongoing fear and worry that do not go away), major depressive disorder, and gastro-esophageal reflux disease (GERD, a chronic, severe form of acid reflux). During a review of Resident 132's H&P, dated 11/13/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 132's CP regarding the resident's self-administration of medications related to strengths and resident understands proper storage of drug., last revised on 3/18/2026, the CP included interventions to assist the resident in securing medication after administration as needed and identify an area to store medication to prevent unauthorized access. During a review of Resident 132's Self Medication Administration Form (SMAF), dated 7/12/2026, the SMAF indicated the resident requested to self-administer medications and was deemed able to self-administer with assistance. During a review of Resident 132's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and to understand others and had intact cognition (the mental faculties—such as memory, thinking, problem-solving, and attention—are working normally and without impairment). During a concurrent observation and interview on 8/10/2026, at 10:32 a.m., with Certified Nursing Assistant (CNA) 12, inside Resident 132's room, Resident 132 had multiple medications at the bedside. CNA 12 verified the presence of unsecured medications at the bedside as follows: 1.Nitric Oxide capsules (an all-natural dietary supplement marketed primarily to men to support prostate health, improve urinary flow, and reduce nighttime bathroom trips).2.Jertaris capsules (are an all-natural dietary supplement marketed primarily to men to support prostate health, improve urinary flow, and reduce nighttime bathroom trips). 3.Beet Root extra strength formula. 4.Men's Complete Once daily multivitamin.5.Saw Palmetto 4000 mg. 6.Alpha Lipoic Acid 600 mg. 7.Cell Food Dietary Supplement 8.Artificial Tears 9.Polysporin ointment. During a review of Resident 132's Order Summary Report (OSR), dated 8/13/2026, the OSR did not indicate an order for the following: 1.Beet Root extra strength formula (a concentrated herbal pill or powder made from red garden beets).2.Men's Complete Once daily multi (is a daily pill or gummy that combines a wide mix of essential vitamins and minerals). 3.Saw Palmetto 4000 milligrams (mg, a unit of weight) (a herbal dietary supplement made from the dark berries of a small American palm tree). 4.Alpha Lipoic Acid 600 mg (a vitamin-like helper made by your body and found in foods). 5.Cell Food Dietary Supplement (is a liquid dietary supplement mixed with water). 6.Artificial Tears (over-the-counter lubricating eye drops used to moisten dry, irritated, or burning eyes). 7.Polysporin ointment (over-the-counter lubricating eye drops used to moisten dry, irritated, or burning eyes). During a concurrent interview and record review on 8/12/2026, at 11:14 a.m., with RN 1, Resident 132's Medical Diagnoses, OSR, SMAF, and CP were reviewed. RN 1 stated there was a physician's order and an order for self-administration of the nitric oxide capsules and Jertaris capsules; however, there were no physician's orders for the administration or self-administration of any other medications. RN 1 stated the medications should not be left at the bedside and should have orders for self-medication. RN 1 stated the failure of the staff to obtain an order for the remaining medications at the bedside which were left unsecured at the resident's bedside, had a potential for the resident to over or underdose the medication and can harm the resident. RN 1 stated other residents can also have access to them and if ingested can cause harm to them. RN 1 stated all staff were responsible for checking the resident's bedside for hazards and remove them to prevent adverse events to happen. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's recent P&P titled, Medication- Self Administration and Medication- Administration, were reviewed. The Medication-Self Administration P&P indicated the Facility is responsible to ensure medications are administered as ordered by the Attending Physician, even when self-administered. The P&P Medication Storage and Labeling indicated the manner of storage shall prevent access by other patients. Lockable drawers or cabinets need to be used unless alternate procedures, including storage on a patient's person or in an unlocked drawer or cabinet are ineffective. The DON stated both P&Ps were not followed as the staff were not able to ensure all medications had orders and had an order to self-administer, and ensure medications were not left unsecured at the bedside. The DON stated the failure of the staff to obtain orders for each medication and obtain an order that the resident may self-administer medication had the potential to result in the harm of over and under dosing the drug. The DON also stated there was also potential for other residents to have access to the medication which could cause harm due to accidental ingestion because the medications were left at the bedside unsecured. During a review of the facility's recent P&P titled, Medication- Self Administration, last reviewed on 1/15/2026, the P&P indicated residents who request to perform medication self-administration will be assessed for capability. The assessment of medication self-administration will ensure a clinically appropriate, effective process for the resident to provide self-care. The Facility is responsible to ensure medications are administered as ordered by the Attending Physician even when self-administered. Procedure VI. The IDT develops and implements a care plan for medication self-administration. B. The care plan will identify: I. Where the medications are stored. VIII. The IDT team and Attending Physician approve self-administration of medications; the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident. During a review of the facility's most recent policy and procedure titled, last reviewed on 1/25/2026, the P&P indicated to provide practice standards for safe administration of medications for residents in the facility. Policy VIII. Medications will not be left at the bedside. During a review of the facility's recent P&P titled, Medication Storage and Labeling, last reviewed on 1/15/2026, the P&P indicated on Procedure: (f) Storage of non-legend drugs at the bedside shall meet the following conditions: (1) The manner of storage shall prevent access by other patients. Lockable drawers or cabinets need to be used unless alternate procedures, including storage on a patient's person or in an unlocked drawer or cabinet are ineffective. During a review of the facility-provided Cell food Oxygen Mineral Supplement, with a publication date of 1/2008, the insert indicated always tell your healthcare professional if you are taking any ither medicine. Organic enzymes in CELLFOOD can damage clothing, stain counter tops and other surfaces. This medicine has not been evaluated by the Medicine Control Council. During a review of the facility-provided Alpha Lipoic Acid, water and lid soluble antioxidant; supports glucose metabolism and nerve health, dated 5/2021, the information indicated a Warning: If you are pregnant or lactating, have any health condition or are taking any medication, consult your health professional before use. During a review of the facility-provided Saw Palmetto 320, time-tested support for urinary function and prostate health, dated 3/2022, the information indicated a Warning: Not to be taken by pregnant or lactating women. If you have any health condition or are taking any medication, consult your health professional before use. During a review of the facility provided One A Day Men's Complete Multivitamin, version date of 2/28/2022, the information indicated if pregnant, breast-feeding, taking medication, or have any medical condition ask a health professional before use. For Adult Use only. Do not exceed recommended intake. During a review of the facility provided Just Ingredients Beetroot Powder dated 5/17/2018, the information indicated the following products which are or may contain allergens are regularly handled by Justingredients Limited and their approved suppliers. During a review of the undated facility-provided NEOSPORIN Ophthalmic Ointment Sterile, the information indicated a Warnings: NOT FOR INJECTION INTO THE EYE, NEOSPORIN Ophthalmic Ointment should never be directly introduced into the anterior chamber of the eye. Ophthalmic ointments may retard corneal wound healing. Topical antibiotics, particularly neomycin sulfate. may cause cutaneous sensitization. 3. During a review of Resident 227's admission Record, the AR indicated the facility admitted the resident on 8/4/2026, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a long-term lung disease where the tiny air sacs (alveoli) inside your lungs are slowly destroyed), and major depressive disorder. During a review of Resident 227's Nursing admission Assessment (NAA), dated 8/4/2026, the NAA indicated the resident did not request to self-administer medication. During a review of Resident 227's H&P, dated 8/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 227's OSR, dated 8/13/2026, the OSR did not contain an order for albuterol HFA, Neosporin ointment, or an order that the resident may self-administer medications. During a review of Resident 227's CP dated 8/5/2026, titled, The resident is receiving medications with Food and Drug Administration (FDA) Black Box Warning (the strictest safety alert required by the U.S. Food and Drug Administration (FDA) for prescription drugs or medical devices), the CP included an intervention to collaborate with the pharmacy, physician, and interdisciplinary team regarding medication effectiveness and safety. During a concurrent observation and interview on 8/10/2026, at 11:38 a.m., with Licensed Vocational Nurse (LVN) 5, inside Resident 227's room, Resident 227's albuterol HFA and Neosporin ointment was left at the bedside. LVN 5 stated there should be no medications left at the bedside due to potential over or underdosing of medications by the resident. LVN 5 stated medications should always be secured to prevent other residents from accessing them. During a concurrent interview and record review on 8/12/2026, at 11:14 a.m., with RN 1, Resident 227's Medical Diagnoses, OSR, NAA, and CP were reviewed. RN 1 stated there were no orders for the medications that were left at the bedside and there was no order indicating that the resident may self-medicate on the OSR. RN 1 stated the medications should not be left at the bedside and there should all have orders for self-medication. RN 1 stated the failure of the staff to obtain an order for the medications at the bedside and leaving the unsecured medications at the resident's bedside, had the potential to result in the resident to over or underdose the medication and can harm the resident, as there was not a physician's order. RN 1 stated other residents can also have access to them and if ingested can cause harm to them. RN 1 stated all staff were responsible for checking the residents' bedside for hazards and remove them to prevent adverse events to happen. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's recent P&P titled, Medication-Self Administration and Medication- Administration, were reviewed. The P&P Medication-Self Administration indicated the Facility is responsible to ensure medications are administered as ordered by the Attending Physician even when self-administered and the Facility is responsible to ensure medications are administered as ordered by the Attending Physician even when self-administered. The P&P Medication Storage and Labeling indicated the manner of storage shall prevent access by other patients. Lockable drawers or cabinets need to be used unless alternate procedures, including storage on a patient's person or in an unlocked drawer or cabinet are ineffective. The DON stated both P&Ps were not followed as the staff were not able to ensure all medications had an order and ensure there was an order that the resident may self-administer and also that there were no unsecured medications left at the bedside. The DON stated the failure of the staff to obtain orders for each medication and orders that the resident may self-administer, had the potential to result in harm of over and under-dosing the drug. The DON also stated there was also a potential for other residents to have access to the medication and can cause harm due to accidental ingestion because the medications were left at the bedside unsecured. During a review of the facility's recent P&P titled, Medication- Self Administration, last reviewed on 1/15/2026, the P&P indicated residents who request to perform medication self-administration will be assessed for capability. The assessment of medication self-administration will ensure a clinically appropriate, effective process for the resident to provide self-care. The Facility is responsible for ensuring medications are administered as ordered by the Attending Physician even when self-administered. Procedure VI. The IDT develops and implements a care plan for medication self-administration. B. The care plan will identify: I. Where the medications are stored. VIII. The IDT team and Attending Physician approve self-administration of medications; the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident. During a review of the facility's recent P&P titled, Medication- Administration, last reviewed on 1/25/2026, the P&P indicated to provide practice standards for safe administration of medications for residents in the facility. Policy VIII. Medications will not be left at the bedside. During a review of the facility's recent policy and procedure titled, Medication Storage and Labeling, last reviewed on 1/15/2026, the P&P indicated on Procedure: (f) Storage of non-legend drugs at the bedside shall meet the following conditions: (1) The manner of storage shall prevent access by other patients. Lockable drawers or cabinets need to be used unless alternate procedures, including storage on a patient's person or in an unlocked drawer or cabinet are ineffective. During a review of the facility-provided PROVENTIL HFA- albuterol sulfate aerosol, metered, copyright 2012, the information indicated Warnings: 1. Paradoxical Bronchospasm 2. Deterioration of Asthma 3. Use of Anti-inflammatory Agents 4. Cardiovascular effects. 5. Do Not Exceed Recommended Dose 6. Immediate Hypersensitivity Reactions 4a. During a review of Resident 18's admission Record, the AR indicated the facility admitted the resident on 5/4/2020 and readmitted the resident on 2/15/2022, with diagnoses including disorders of bone density and structure (the bones lose their internal strength, becoming fragile, porous, or misshapen), age-related osteoporosis (a common condition where bones become thin, weak, and brittle over time), and dementia (a progressive state of decline in mental abilities). During a review of Resident 18's CP Report, titled, Behavior of sliding from bed to floor mat, initiated on 4/30/2026, the CP included an intervention to perform frequent visual checks and ensure floor mat is placed at bedside. During a review of Resident 18's OSR, dated 5/1/2026, the OSR indicated an order for floor landing pad/floor mat to help cushion impact to prevent potential injury every shift. During a review of Resident 18's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition (having trouble with brain functions like thinking, learning, remembering, and paying attention). The MDS indicated that the resident had impairment on one side of the upper extremity and bilateral lower extremity impairment. The MDS indicated the resident was dependent and needed supervision assistance in mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a history falls. During a review of Resident 18's Fall Risk (Morse) Assessment V2 (FRA), dated 8/5/2026, the FRA indicated the resident was at a high risk for falls. During a review of Resident 18's H&P, dated 8/14/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a concurrent observation and interview on 8/10/2026, at 9:36 a.m., with CNA 16, inside Resident 18's room, Resident 18 was observed with bilateral floor mats. The floor mats had a bedside table on top. CNA 16 stated there should be no furniture on top of the floor mat, because if the resident slides down from the bed, the resident will hit the hard object, on top of the floor mat, which can cause injury. CNA 16 stated the resident might have used the bedside table to eat, but after eating the staff should have removed them on top of the floor mat. During a concurrent interview and record review on 8/12/2026, at 9:29 a.m., with RN 1, Resident 18's Medical Diagnoses, OSR, FRA, and CP were reviewed. RN 1 stated the resident was at high risk for falls and had an order for floor mats/pads to prevent injury if the residents falls. RN 1 stated there should be no equipment or furniture, such as the bedside table, on top of the floor mat, as it will defeat its purpose of having a soft-landing area for resident to fall into. RN 1 stated when a hard object is resting on top of the floor mat/pad the resident will land on that object causing injuries such as bruises, skin tears and even fractures (break in bone). RN 1 stated the failure of the facility to keep objects off the top of the floor mat predisposed Resident 18 to injuries such as bumps, bruises, and fracture. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's recent P&P titled, Fall Management Program, and the facility-provided Floor Mat (FM) 1 were reviewed. The P&P Fall Management Program indicated the Fall Management Program is designed to prevent resident falls through meaningful assessments, interventions, education, and re-evaluation and the facility-provided FLATMAT Dynarex Fall Mat with Beveled edge indicated never leave heavy objects on mat surface for extended periods, as indentations and damage may occur. The DON stated the P&P and the facility-provided information were not followed as the staff failed to assess the presence of a furniture on top of the floor mat which can increase the risk of injury to the resident and placing a heavy object on top of the floor mat can damage the mats. The DON stated the failure of the staff to keep objects off the top of the floor mat predisposed the resident to falls with injury. 4b. During a review of Resident 90's Face Sheet (FS), the FS indicated that the resident was admitted on [DATE] with diagnoses including peripheral vascular disease, vascular dementia, muscle weakness, acquired absence of left leg below the knee, and a history of falling. During a review of Resident 90's History and Physical (H&P) dated 7/18/2026, the (H&P) indicated that the resident had the capacity to understand and make decisions. During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 7/23/2026, the MDS indicated the resident had moderate cognitive impairment (the individual experiences mid-to-moderate memory loss and can generally understand and engage in basic conversations). The MDS indicated that Resident 90 needed partial/moderate assistance (helper does less than half the effort) with eating; substantial/maximal assistance (helper does more than half the effort) with oral hygiene; and was dependent (helper does all of the effort) with toileting, showers, and transfers. During a review of Resident 90's Care Plan (CP), titled Risk for Falls, initiated on 5/18/2026, the CP indicated a goal that the resident will be free of falls (.), with interventions including to anticipate and meet the resident's needs and use of a floor landing pad to help cushion impact to prevent potential injury. During a concurrent observation and interview on 8/10/2026 at 9:19 a.m. with Certified Nursing Assistant 13 (CNA 13), inside Resident 90's room, Resident 90 was lying in bed and the right side overbed table was on top of the floor mat. CNA 13 stated that the floor mat is used for fall prevention. CNA 13 stated that it is okay to have the overbed table because it is the resident's preference as he wants the remote control next to him. During a concurrent interview and record review on 8/12/2026 at 2:22 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that placing an object on top of the floor mat is unacceptable. RN 1 stated that floor mats are intended to provide cushioning in the event of a fall. RN 1 stated that Resident 10 was identified as being at risk for falls due to a history of falling. RN 1 stated that the resident will be educated on proper remote-control placement to ensure accessibility without obstruction by the overbed table positioned on the floor mat. RN 1 stated that a resident could potentially fall onto the overbed table, posing a risk of injury. During an interview on 8/14/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that placing any object on the floor mat is inappropriate. The DON stated that floor mats are intended to minimize injury if a resident falls. The DON stated that clutters like objects placed on top of the floor mat could increase the risk of harm should a resident fall onto the mat. During a review of the facility's recent P&P titled, Fall Management Program, last reviewed 1/15/2026, the P&P indicated the facility will provide the highest quality of care in the safest environment for the residents residing in the facility. The Fall Management Program is designed to prevent resident falls through meaningful assessments, interventions, education, and re-evaluation. Procedure III. Universal Fall Prevention Measures for all Residents. The following are suggested measures that can be used in the prevention of falls. This list is not all-inclusive. A. Environmental ii. Position call bell, urinal if applicable, and bedside stand within reach. iii. Keep walkways obstruction/spill free. v. Placed bed in lowest position with brakes locked, floor mats and bed alarm. During a review of the undated facility-provided FM 1, indicated never leave heavy objects on mat surface for extended periods, as indentations and damage may occur. See Warranty. 5. During a review of Resident 216's admission Record, the AR indicated the facility admitted the resident on 7/2/2026, with diagnoses including adult failure to thrive (a general term used when an older person experiences a slow, steady decline in physical and mental strength, loses weight and appetite, and stops being able to care for themselves), muscle weakness, and lack of coordination. During a review of Resident 216's H&P, dated 7/2/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 216's FRA, dated 7/3/2026, the FRA indicated the resident was high risk for falls. During a review of Resident 216's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (having trouble with brain functions like thinking, learning, remembering, and paying attention). The MDS indicated the resident was dependent with mobility and ADLs. During a review of Resident 216's CP Report titled, The resident is at risk for falls related to limited mobility, seizure, history of fall, last revised on 7/7/2026, the CP indicated a goal that the resident will be free of falls. During a concurrent observation and interview on 8/10/2026, at 10:21 a.m., with CNA 8, Resident 216's bed was placed in a high-position and there was no nursing care being provided to the resident. CNA 8 stated the bed was left in a high position. CNA 8 measured the height of the bed, from the floor to the mattress surface, with a measuring tape. The height measured 31 inches from the floor. CNA 8 stated the bed should always be left in the lowest position to prevent falls with injury to residents. During a concurrent interview and record review on 8/12/2026, at 10:34 a.m., with RN 1, Resident 216's Medical Diagnoses, FRA, and CP were reviewed. RN 1 stated the resident was at high risk for falls, therefore the bed should be left at the lowest position when staff are not providing care to Resident 216. RN 1 stated the failure of the facility to keep the bed at the lowest position predisposed the resident to falls with injury such as bumps, bruising, and even fracture. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's P&P titled, Fall Management Program was reviewed. The P&P Fall Management Program indicated to place the bed in the lowest position with the brakes locked, floor mats and bed alarm. The DON stated the bed in the facility can go as low as less than 10 inches from the floor. The DON further stated the staff did not follow the P&P for the Fall Management Program. The DON stated failure of the staff to keep the bed in the lowest position presented a high risk for falls for Resident 216 predisposing the resident to falls with injury. During a re

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of urine received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for four of four sampled residents (Residents 1,102,19 and 48) reviewed for Urinary Catheter (a hollow tube inserted into the bladder to drain urine) or UTI by failing to: 1. Ensure Resident 1`s urinary catheter drainage bag (collects urine) was not placed on the floor. 2. Ensure Resident 102's urinal bottles (portable container for collecting urine) were labeled with the name, room number, and date it was provided to the residents. These failures had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and UTI. 3. Ensure Resident 19's suprapubic catheter tubing (SP - a hollow flexible tube that is used to drain urine from the bladder inserted through a small cut in the abdomen) did not have a securement device and the drainage bag was left on top of the bed. 4. Ensure Resident 48's SP catheter tubing did not have a dependent loop, and the catheter was anchored in the securement device. These failures resulted in the urine not flowing freely and accidental pulling of the catheter tubing which may lead to the development of UTI. Findings: 1. During a review of Resident 1's admission Record (AR-front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 4/23/2026 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) affecting the left non-dominant side, obstructive and reflux uropathy (urinary tract disorder due to a structural or functional obstruction of urinary flow), and other symptoms and signs involving cognitive functions following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain). During a review of Resident 1's Minimum Data Set (MDS – resident assessment tool), dated 7/27/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident was totally dependent on staff for transfers, lower body dressing, bathing, and toileting. During a review of Resident 1's History and Physical (H&P), dated 4/23/2026, the H&P indicated the resident was recently hospitalized for a UTI, and the resident was able to understand and make decisions. During a review of Resident 1's Care Plan (CP) titled, (Resident 1) has indwelling foley catheter., initiated 4/26/2026, and last reviewed 8/6/2025, the CP indicated a goal that the resident would show no signs or symptoms of urinary tract infection. During a review of Resident 1's physician orders, the physician orders indicated to check every shift that the urine drainage bag was kept off the floor, dated 4/24/2026. During an observation on 8/10/2026 at 10:31 a.m., inside Resident 1`s room, observed Resident 1 awake in bed. Observe the indwelling catheter drainage bag placed inside a privacy bag (conceals catheter bag) and resting directly on the floor on the right side of the bed. Observed a pink basin to the side of the catheter. During an observation on 8/10/2026 at 10:57 a.m. observed Licensed Vocational Nurse (LVN) 4 and Certified Nursing Assistant (CNA) 4 inside Resident 1's room standing at the right side of the resident's bed while the indwelling catheter drainage bag remained resting directly on the floor within view. Observed LVN 4 and CNA 4 then exited the resident's room. During a concurrent observation and interview on 8/10/2026 at 11:09 a.m. with LVN 4 and CNA 4, observed CNA 4 again entered Resident 4's room and stated the indwelling catheter was touching the floor but should have been placed in the pink basin. CNA 4 stated the catheter was not in the correct position because the basin was stuck under the bed. Observed LVN 4 entered Resident 1's room and stated to CNA 4 to place Resident 1's catheter in the basin. LVN 4 stated she (LVN 4) was not assigned to care for Resident 1, but all staff are responsible when they enter a resident's room to identify when the catheter is on the ground. LVN 4 stated the catheter should not be on the floor to prevent the bag from becoming contaminated and spreading bacteria from the catheter to the resident. During an interview on 8/10/2026 at 11:21 a.m. with LVN 6, in the hallway outside Resident 1's room, LVN 6 stated he (LVN 6) was assigned to care for Resident 1. LVN 6 stated Resident 1's indwelling catheter drainage bag should be secured to the bed and kept off the floor for infection control purposes because the floor is considered dirty. LVN 6 stated when Resident 1's catheter bag was on the floor, the CNA or LVN should have identified and removed the catheter from the floor and notified him (LVN 6) so the bag could be changed, but they did not. LVN 6 stated when Resident 1's catheter bag was on the floor and not changed there was the potential that microorganisms could contaminate the catheter resulting in infection in the resident. During an interview on 8/12/2026 at 7:35 a.m. with the Infection Preventionist (IP), the IP stated it was important to keep indwelling catheter bags off the floor to prevent the transfer of bacteria to the catheter tubing that enters the resident's body from where bacteria can be introduced leading to UTIs. The IP stated indwelling catheter bags are maintained off the floor with the use of the pink basin. During a concurrent interview and record review on 8/14/2026 at 9:52 a.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure (P&P) regarding indwelling catheters and infection control. The DON stated indwelling catheter drainage bags should be maintained off the floor to reduce the possibility of pathogens from getting from the bag to the catheter tubing. The DON stated the catheter tubing is like a highway for bacteria to enter the resident's bladder. The DON stated the pink basins are a clean place to keep the indwelling catheters from touching the floor. The DON stated the facility P&P was not followed when Resident 1's indwelling catheter was not identified and removed from the resident's floor potentially leading to a catheter associated urinary tract infection (CAUTI). During a review of the facility P&P titled, Catheter – Care of, last reviewed 1/15/2026, the P&P indicated, Purpose. To prevent catheter-associated urinary tract infections while ensuring that residents are not given in­dwelling catheters unless medically necessary.A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. Collection Bags. Take care to ensure the collection bag does not touch the floor at any time. 2. During a review of Resident 102's AR, the AR indicated the facility admitted the resident on 4/18/2026, and readmitted the resident on 7/9/2026, with diagnoses including end stage renal disease (End Stage Renal Disease-irreversible kidney failure), immunodeficiency (the body's immune system is weak or does not work right), and dependence on renal dialysis (a person's kidneys no longer work well enough to keep them alive). During a review of Resident 102's H&P, dated 7/10/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 102's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person has clear, noticeable trouble with memory, thinking, and daily tasks). The MDS indicated the resident was needing maximal assistance on toileting hygiene and was occasionally incontinent of urine. During a review of Resident 102's Care Plan (CP) Report regarding the resident having an impaired immunity related to ESRD on hemodialysis (HD, a life-saving medical treatment that acts as an artificial kidney), diabetes mellitus type two (DM 2, a long-term health condition where your body turns food into sugar for energy, but it cannot move that sugar from your blood into your cells), history (hx) of recurrent serious infections (Sepsis (a life-threatening blood infection), pneumonia (PNA, a lung infection, cellulitis(a common, painful bacterial infection of the deep layers of the skin and the fat underneath)) ., last revised on 7/10/2026, the CP indicated an intervention to use universal precautions (treating all blood and certain body fluids as if they are infected with harmful diseases) as appropriate. During a concurrent observation and interview on 8/10/2026, at 10:11 a.m., with CNA 8, inside Resident 102's room, observed Resident 102's urinal hanging at the left upper grab bar (a sturdy metal bar attached to the side of a mattress or bed frame) with urine and had no label on them. CNA 8 stated the urinal did not have a label on them. CNA 8 stated the urinal should be labeled with the name of the resident and the date it was provided. During an interview on 8/12/2026, at 10:31 a.m., with Registered Nurse (RN) 1, RN 1 stated the urinal of Resident 102 should have been labeled with the name of the resident and the date it was provided to prevent UTI to resident. RN 1 stated they change the urinal weekly on Sundays by the 11 p.m. to 7 a.m., shift staff. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, reviewed the facility's policy and procedure (P&P) on Infection Prevention and Control Program. The DON stated that Resident 102's urinal should have been labeled with the name of the resident, room number, date of birth , and the date it was provided to prevent switching of urinals among residents that can cause cross-contamination leading to UTIs. The DON stated the facility did not follow their P&P on Infection Prevention and Control Program because they did not label the urinal to prevent cross-contamination on residents. During a review of the facility's recent P&P titled, Infection Prevention and Control Program, last reviewed on 1/15/2026, the P&P indicated to ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Procedure VIII. Healthcare-Associated Infections (HAIs) B. The Facility identifies healthcare-associated infections to: i. Identify and correct breaches in infection control practices that contribute to the spread of healthcare-associated infection. 3. During a review of Resident 19's AR, the AR indicated the facility admitted the resident on 6/4/2026 with diagnoses including acute embolism (a condition that happens when a blood clot breaks off and travels through the bloodstream) and thrombosis (a blood clot that forms inside a deep vein and can block flow causing pain, swelling, warmth or redness) of right upper extremity, and obstructive (a physical or functional blockage preventing normal urine flow) and reflux uropathy (a condition that involves urine flowing backward from the bladder toward the kidneys). During a review of Resident 19's H&P dated 7/24/2026, the H&P did not indicate Resident 19's capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make his needs known. The MDS further indicated Resident 19 required supervision or touching assistance with eating, substantial or maximal assistance with upper body dressing and roll to left and right, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) and had an indwelling catheter in place. During a review of Resident 19's Order Summary Report dated 8/14/2026, the Order Summary Report indicated the following physician's order dated 7/24/2026: Apply stat lock (a sticky medical anchor pad with a special plastic clip used to lock medical tubes such as urinary catheter in place) SP catheter stabilization change every day shift every seven (7) days for Foley catheter (FC - a device that drains urine from the bladder into a collection bag) in place change as needed if clinically indicated and as needed. Monitor stat lock SP catheter stabilization every shift for FC in place, assess and change when clinically indicated. During a review of Resident 19's care plan (CP) on presence of SP catheter initiated on 6/5/2026 and last revised on 7/25/2026, the CP indicated to apply stat lock stabilization device as one of the interventions for the resident to be free form catheter related trauma, signs and symptoms of UTI, and further complications from SP catheter. During a concurrent observation and interview on 8/10/2026 at 10:05 a.m. inside Resident 19's room with LVN 5, LVN 5 stated that Resident 19 did not have a stat lock and that the SP catheter tubing was attached to a leg bag that was just lying flat on top of the bed. LVN 5 stated that SP catheter tubing and/or FC tubing are supposed to be secured with a stat lock attached to the leg to prevent pulling and trauma, and that the drainage bags are supposed to hanging on the side of the bed at all times to prevent the urine from flowing back into the bladder. LVN 5 stated that Resident 19's SP catheter tubing should have been secured in a stat lock, and the drainage bag should have been hanging on the side of the bed as it placed Resident 19 at risk for developing urine infection. During a concurrent interview and record review on 8/12/2026 at 11:30 a.m. with Quality Assurance Nurse (QAN) 1, Resident 19's physician's orders and CP were reviewed. The QAN 1 stated Resident 19 had a physician's order and indicated in the CP to apply a stat lock for SP catheter stabilization. The QAN 1 stated that FC tubing and SP catheter tubing are supposed to be anchored with a stat lock and checked for placement to prevent the tubing from being pulled out by accident, causing trauma and UTI. The QAN 1 stated that drainage bags are supposed to be hanging on the side of the bed to prevent the urine from flowing back into the bladder and cause UTI. The QAN 1 stated that the staff should have ensured that the urinary drainage bag should have been hanging on the side of the bed and that there was a stat lock in place to secure the SP catheter tubing as it placed Resident 19 at risk for developing UTI due to trauma and backflow of the urine. During an interview on 8/14/2026 at 12:31 p.m. with the DON, the DON stated that the staff are supposed to apply the stat lock to residents with SP catheter or FC and change every 7 days and as needed to secure the catheter tubing in place and check for placement every shift. The DON stated that the stat lock is to prevent the catheter tubing from accidentally pulling or trauma which can lead dislodgement and development of UTI. The DON stated that urinary drainage bags should be placed on the side of the bed for the urine to flow freely. The DON stated that Resident 19's catheter tubing should have been secured with a stat lock, and the drainage bag should have been placed on the side of the side of the bed to prevent the urine from backing up into the bladder as it placed Resident 19 at risk for development of UTI. 4. During a review of Resident 48's AR, the AR indicated the facility originally admitted the resident on 4/17/2025 and readmitted in the facility on 2/4/2026 with diagnoses including anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and obstructive (a physical or functional blockage preventing normal urine flow) and reflux uropathy (a condition that involves urine flowing backward from the bladder toward the kidneys). During a review of Resident 48's H&P dated 2/4/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was sometimes able to understand and make his needs known. The MDS further indicated Resident 48 required substantial or maximal assistance with mobility and upper body dressing and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 48 had an indwelling catheter in place. During a review of Resident 48's Order Summary Report dated 8/14/2026, the Order Summary Report indicated the following physician's order: - 3/12/2026: Check SP catheter tubing for kinking every shift. Keep urine bag below the level of the bladder at all times every shift. Apply stat lock for FC stabilization change every day shift every 7 days change as needed if clinically indicated and as needed. - 5/6/2026: Provide SP catheter care daily every day shift During a review of Resident 48's care plan (CP) on presence of SP catheter initiated on 2/5/2025 and last revised on 7/28/2026, the CP indicated to apply stat lock stabilization device, monitor and assess stat lock daily and change when needed, position catheter bag and tubing below the level of the bladder, and to check the tubing for kinks each shift as a few of the interventions for the resident to remain free from catheter-related trauma and free from signs and symptoms of urinary infection. During a concurrent observation and interview on 8/10/2026 at 11:37 a.m. inside Resident 48's room with LVN 6, LVN 6 stated that Resident 48 had a stat lock on the left leg, but the SP catheter tubing was not secured on the stat lock and the tubing had a dependent with thick white colored urine sediments on the loop. LVN 6 stated that SP catheter tubing and/or FC tubing are supposed to be secured on the stat lock to prevent pulling and trauma, and that the drainage bag tubing was not supposed to have a dependent loop or kink as the urine will just stay in the loop and not flow freely. LVN 6 stated that Resident 48's SP catheter tubing should have been secured on the stat lock, and the drainage bag tubing should not have a dependent loop or kink as it placed Resident 48 at risk for developing urine infection. During a concurrent interview and record review on 8/12/2026 at 11:30 a.m. with the QAN 1, Resident 19's physician's orders and CP were reviewed. The QAN 1 stated Resident 19 had a physician's order and indicated in the CP to apply a stat lock for SP catheter stabilization. The QAN 1 stated that FC tubing and SP catheter tubing are supposed to be anchored with a stat lock and checked for placement to prevent the tubing from being pulled out by accident, causing trauma and UTI. The QAN 1 stated that drainage bags are supposed to be hanging on the side of the bed to prevent the urine from flowing back into the bladder and cause UTI. The QAN 1 stated that the staff should have ensured that the urinary drainage bag should have been hanging on the side of the bed and that there was a stat lock in place to secure the SP catheter tubing as it placed Resident 48 at risk for developing UTI due to trauma and backflow of the urine. During an interview on 8/14/2026 at 12:31 p.m. with the DON, the DON stated that the staff are supposed to apply the stat lock to residents with SP catheter or FC and change every seven days and as needed to secure the catheter tubing in place and check for placement every shift. The DON stated that the staff are supposed to check the tubing if it was secured on the stat lock. The DON stated that the stat lock is to prevent the catheter tubing from accidentally pulling or trauma which can lead dislodgement and development of UTI. The DON stated that there should be no dependent loop or kinks on the urinary drainage bag tubing for the urine to flow freely. The DON stated that Resident 48's catheter tubing should have been secured on the stat lock, and the drainage bag tubing should have been kept straight or not dependent loop to prevent the urine from not flowing freely as it placed Resident 48 at risk for development of UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter-Care of, last reviewed on 1/15/2026, the P&P indicated: - Anchor the catheter with a leg strap to prevent excessive tension on the catheter, which leads to urethral tears or dislodging the catheter. - An unobstructed flow of the urine should be maintained. In order to achieve a free flow of urine: - Collection bags should be kept below the level of the bladder. - The catheter and collection tubing should be free of obstruction and kinking. - Catheter tubing should be secured to prevent dependent loops.

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for four of four sampled residents (Resident 88) reviewed under the Respiratory care area by failing to: 1. Ensure Resident 88's nasal cannula (NC a small plastic tube, which fits into the nostrils for providing supplemental O2) tubing was identified and reported by CNA 8 when it was on the ground. 2. Ensure Resident 7's NC was labeled with date it was provided. 3. Ensure Resident 132's unlabeled nebulizer mask (a soft plastic cup that fits over your nose and mouth) and tubing placed inside a transparent bag on the top of the resident's bed side drawer was discarded and replaced with a new set up with the date it was provided to the resident. 4. Resident 197's oxygen set up dated 8/3/2026 was discarded and replaced with a new set dated with the day it was currently provided. These failures had the potential to place residents at risk for respiratory distress and respiratory infections from cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During a review of Resident 88's admission Record (AR), the AR indicated the facility admitted the resident on 10/15/2015, and readmitted the resident on 1/20/2022, with diagnoses including cerebral palsy (a group of disorders affecting a person's movement, balance, and posture) and dementia (a progressive state of decline in mental abilities). During a review of Resident 88's History and Physical (H&P), dated 1/30/2026, the H&P indicated the resident had a history of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and did not have the capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS, a resident assessment tool), dated 6/30/2026, the MDS indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and required partial/moderate assistance for mobility in bed. During a review of Resident 88's Care Plan (CP) titled, The resident has diagnosis of COPD. At risk for respiratory distress ., initiated on 8/2/2025, the CP indicated a goal that the resident would display optimal breathing patterns with interventions that included to provide continuous O2 via NC at 2 LPM. During a review of Resident 88's physician orders, the physician orders indicated O2 at two liters per minute (LPM – a unit of measurement) via NC, continuously for COPD, dated 8/2/2026. During an observation on 8/10/2026 at 10:07 a.m., observed Resident 88 lay in bed with O2 via NC administered. Observed the NC tubing extending to the floor and wrapped around the bed frame. Observed CNA 8 was in the resident's room, assisting the roommate. During an observation on 8/10/2026 at 10:26 a.m., observed Resident 88 lay in bed with O2 via NC administered. Observed Certified Nursing Assistant (CNA) 8 entered Resident 88's room, spoke the resident while standing at bedside, then exited the room. Observed the NC tubing remained extending to the floor and wrapped around the bed frame. Observed CNA 8 then re-entered the resident's room and closed the door to provide care. During an observation on 8/10/2026 at 11:35 a.m., observed Resident 88 lay in bed with O2 via NC administered. Observed the NC tubing continued to be extending to the floor and wrapped around the bed frame. During a concurrent observation and interview on 8/10/2026 at 11:38 a.m., with Licensed Vocational Nurse (LVN) 8, observed Resident 88 lay in bed with O2 via NC administered with the O2 tubing on the floor and wrapped around the bed frame. Observed LVN 8 entered the resident's room upon the request of the surveyor. LVN 8 stated the resident's O2 tubing was on the floor, and it should not have been. LVN 8 stated she (LVN 8) would replace the NC. During a follow up interview on 8/10/2026 at 11:47 a.m., with LVN 8, LVN 8 stated the NC tubing should not be on the floor because the floor is dirty and the NC extends to the resident's nose and there is potential for the transfer of bacteria that could cause a respiratory infection. During an interview on 8/12/2026 at 7:59 a.m. with the Infection Preventionist (IP), the IP stated NC tubing should be maintained off the floor to eliminate bacteria from the floor getting to the resident and causing respiratory infections. The IP stated all staff are responsible for identifying when the NC tubing is on the floor. The IP stated CNA 8 should have identified Resident 88's NC tubing on the floor and notified the LVN that it needed to be changed, but she did not. During a concurrent interview and record review on 7/17/2026, at 8:49 a.m., with the Director of Nursing (DON), reviewed the facility P&P for oxygen administration. The DON stated all staff are responsible for ensuring oxygen tubing is off the floor and the excess tubing can be maintained in the provided plastic bags. The DON stated the P&P was not followed when CNA 8 did not identify and report that Resident 88's NC was on the floor potentially resulting in the oxygen tubing becoming kinked and not delivering the oxygen or in pathogens transferring from the floor to the resident. During a review of the facility P&P titled, Oxygen Administration, last reviewed on 1/15/2026, the P&P indicated, Purpose. To prevent or reverse hypoxemia and provide oxygen to the tissues. Policy. Infection Control. A. All oxygen tubing, . and cannulas used to deliver oxygen:. Will be changed and labeled weekly and when visibly soiled. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 2. During a review of Resident 7's AR, the AR indicated that the facility admitted the resident on 2/21/2026, and readmitted on [DATE] with diagnoses including chronic respiratory failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), muscle weakness, and anxiety disorder (a mental health condition marked by extreme, ongoing fear and worry that do not go away). During a review of Resident 7's H&P, dated 6/20/2026, the resident had the capacity to understand and make a decision. During a review of Resident 7's MDS, the MDS indicated the resident had the capacity to make needs known and can understand others. The MDS indicated that Resident 7 needed substantial/maximal assistance (helper does more than half the effort) with eating and oral hygiene and was dependent (helper does all of the effort) to staff for personal hygiene, shower/bathe self, and transfers. During a review of Resident 7's Order Summary Report (OSR), the OSR indicated that Resident 7 had an order of oxygen at three liters per minute via nasal cannula continuous, with an order date on 6/20/2026. During a review of Resident 7's Care Plan (CP), initiated on 3/13/2026, the focus indicated that the resident has altered respiratory status/difficulty breathing related to anxiety, acute respiratory failure, heart failure and oxygen use with goals including the resident will have no complications related to shortness of breath. During a concurrent observation and interview on 8/10/2026 at 10:22 a.m. with CNA 12, observed Resident 7's was on oxygen using nasal cannula but was not labeled and did not have a bag for the oxygen tubing. CNA 12 stated that it should be reported to the supervisor right away. During a concurrent interview on 8/14/2026 at 11:30 a.m. with the Infection Preventionist (IP), the IP stated that nasal cannula tubing is routinely changed every week and as needed. The IP stated that Resident 7 has an order for continuous oxygen administration and the tubing should have been properly labeled and provided with a plastic bag. The IP stated that nursing staff are responsible for labeling the nasal cannula upon each change. The IP stated that labeling the nasal canula is essential as it serves as an identifier, ensuring that each piece of equipment belongs to the correct resident. The IP stated that failing to label nasal cannulas can result in cross-contamination between residents which may lead to respiratory problems. During an interview on 8/14/2026 at 2:32 p.m. with the DON, the DON stated that nasal cannula is being changed weekly, every Sunday and as needed. The DON stated that the licensed nurses are responsible for ensuring nasal cannula is labeled with date and room number to have proper and timely replacement. The DON stated that failure to label the nasal cannula may result in it being switched with another resident, which could lead to cross-contamination and potential respiratory infection. During a review of the facility's Policy and Procedures (P&P), titled Oxygen Administration last reviewed on 1/15/2026, the P&P indicated a purpose to prevent or reverse hypoxemia and provide oxygen to the tissues. The P&P further indicated in (III) Infection control (A) All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: (i) are for single use only. (ii) will be changed and labeled weekly and when visibly soiled. (B) Oxygen items will be stored in a plastic bag at resident's bedside to protect the equipment from dust and dirt when not in use. 3. During a review of Resident 132's AR, the AR indicated the facility admitted the resident on 10/18/2025, and readmitted the resident on 11/12/2025, with diagnoses including cervical disc disorder at C6-C7 level (a cushion between the sixth and seventh neck bones is bulging, wearing out, or herniated) with myelopathy (an injury or problem in the spinal cord caused by severe pressure or squeezing), anemia (a condition where the body does not have enough healthy red blood cells), and anxiety disorder (a mental health condition marked by extreme, ongoing fear and worry that do not go away). During a review of Resident 132's H&P, dated 11/13/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 132's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (the mental faculties—such as memory, thinking, problem-solving, and attention—are working normally and without impairment). During a review of Resident 132's Order Summary Report (OSR), dated 8/13/2026, the OSR did not indicate an order for nebulization (a simple medical process that turns liquid medicine into a fine mist). During a concurrent observation and interview on 8/10/2026, at 10:32 a.m., with CNA 12, inside Resident 132's room, observed Resident 132's nebulizer mask and tubing not dated of when it was provided. CNA 12 stated the nebulizer mask, and tubing should have a date of when it was provided. During an interview on 8/12/2026, at 7:48 a.m., with the Infection Preventionist (IP), the IP stated the staff should have labeled the nebulizer mask and tubing with the date it was provided on the tubing and the plastic bag to ensure it is current. The IP stated they were labeling the tubing and the plastic bag to know when to change them again and to make sure this cannula belongs to the resident. The IP stated the failure of the licensed staff to label the nebulizer mask and tubing with the date it was last provided had the potential for contamination and respiratory infections on residents. During a concurrent interview and record review on 8/14/2026, at 11:14 a.m., with the DON, the facility's policy and procedure (P&P) titled, Oxygen Administration was reviewed. The P&P Oxygen Administration indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use and will be changed and labeled weekly and when visibly soiled. The DON stated the P&P titled Oxygen Administration was not followed as the staff did not label the nebulizer mask and tubing with the date it was provided. The DON stated the failure of the staff to label the nebulizer mask and tubing of Resident 132 had predisposed the resident to respiratory infections. During a review of the facility's recent P&P titled, Oxygen Administration, last reviewed on 1/15/2026, the P&P indicated to prevent or reverse hypoxemia and provide oxygen to the tissues. Policy III. Infection Control A. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: II. Will be changed and labeled weekly and when visibly soiled. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 4. During a review of Resident 197's AR, the AR indicated the facility admitted the resident on 10/31/2021, and readmitted the resident on 1/21/2026, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) with exacerbation (COPD-a chronic lung disease causing difficulty in breathing), acute and chronic respiratory failure (when a person with long-term, ongoing breathing trouble (chronic) suddenly gets much worse (acute) with hypoxia (a medical condition where your body or a part of your body does not get enough oxygen to work the right way), and dependence on supplemental oxygen. During a review of Resident 197's H&P, dated 1/24/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 197's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderate cognitive impairment (a person has clear, noticeable trouble with thinking, memory, and reasoning that actively interferes with their daily routine and independent tasks, sitting at a stage of decline where they need regular help with complex activities). The MDS indicated the resident was on oxygen therapy while a resident in the facility. During a review of Resident 197's OSR, the OSR indicated an order for: - 7/18/2026 Change oxygen tubing as needed if tubing soiled/damaged. - 7/18/2026 Change oxygen tubing every night shift every Sunday. - 4/6/2026 Oxygen at 5 liters/minute via nasal cannula (a lightweight plastic tube that hooks over your ears and has two small prongs that rest inside your nostrils). Humidification: yes Frequency: Continuous every shift related to chronic obstructive pulmonary disease with (acute) exacerbation; acute and chronic respiratory failure with hypoxia; anxiety disorder, unspecified; essential (primary) hypertension (a lightweight plastic tube that hooks over your ears and has two small prongs that rest inside your nostrils) to maintain O2 saturation (a lightweight plastic tube that hooks over your ears and has two small prongs that rest inside your nostrils) greater than (>) 91 percent (%). During a review of Resident 197's CP Report titled, The resident has oxygen therapy related to ineffective gas exchange, respiratory illness, COPD, last revised on 9/29/2025, the CP indicated a goal of the resident will have no signs and symptoms of poor oxygen absorption. During a concurrent observation and interview on 8/10/2026, at 11:25 a.m., with CNA 8, inside Resident 197's room, observed Resident 197's oxygen tubing placed inside a transparent plastic bag dated 8/3/2026. CNA 8 stated the oxygen tubing was dated 8/3/2026 and should have been changed on Sunday (8/9/2026) to prevent infection. During a concurrent interview and record review on 8/12/2026, at 11:08 a.m., with Registered Nurse (RN) 1, Resident 197's Medical Diagnoses, OSR, and CPs were reviewed. RN 1 stated there was an order to change the tubing every Sunday. RN 1 stated the tubing should have been changed on 8/9/2026 to prevent respiratory infection to Resident 197. During a review of the facility's recent P&P titled, Oxygen Administration, last reviewed on 1/15/2026, the P&P indicated to prevent or reverse hypoxemia and provide oxygen to the tissues. Policy III. Infection Control A. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: II. Will be changed and labeled weekly and when visibly soiled. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for one of two sampled residents (Resident 185) reviewed for pain by failing to ensure the Licensed Nurse (LN) provided non-pharmacologic pain interventions (NPI) prior to the administration of as needed (PRN) oxycodone (an opioid [also called a narcotic - powerful pain-reducing medication) and administered the narcotic per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine). This failure had the potential to result in as adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from unnecessary administration of narcotics including constipation and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings: During a review of Resident 185's admission Record, the admission Record indicated the facility admitted the resident on 2/19/2022 and most recently readmitted the resident on 2/27/2026, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and low back pain. During a review of Resident 185's Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2026, the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident had pain and was prescribed PRN opioids. During a review of Resident 185's History and Physical (H&P) dated 2/28/2026, the H&P indicated the resident could make her needs known but could not make medical decisions. During a review of Resident 185's Order Summary Report, the Order Summary Report indicated orders for the following: - Pain Monitor using verbal/nonverbal zero (0) to 10 scale, 0 equals (=) no pain, one (1) to (-) three (3) = mild pain, four (4) - six (6) = moderate pain, and seven (7) - 10 = severe pain, dated 2/27/2026 - Oxycodone HCL oral tablet 5 milligrams (mg, a unit of measurement) every 4 hours (hrs.) as needed (PRN) for severe pain 7-10, non-pharmacological interventions: A-Heat, B Repositioning, C- Relaxation, Breathing, 0-Food/Fluids, E-Massage, F-Exercise, G- immobilization of Joints, H-Other (Document in Nurses note) dated 6/15/2026. - Acetaminophen oral tablet 325 mg, give 2 tablets by mouth every six hours PRN mild to moderate pain (1-6), dated 6/15/2026. During a review of Resident 185's Care Plan (CP) regarding pain, initiated 10/5/2025, the CP indicated a goal that the resident would have decreased behaviors of inadequate pain control through interventions that included assessing for pain, provide NPI, and administer pain medications as ordered. During a concurrent observation and interview on 8/10/2026 at 12:25 p.m., with Resident 185, inside Resident 185's room, observed Resident 185 lying in bed. Resident 185 stated she (Resident 185) had pain and received pain medication, but the medications were not working well. During a concurrent interview and record review on 8/12/2026 at 2:54 p.m., with Licensed Vocational Nurse (LVN) 2, reviewed Resident 185's physician orders and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2026 and 8/2026. LVN 2 stated the facility process for pain management is the resident is assessed, NPI are provided, and PRN medication is administered if the nonpharmacologic treatments are not effective. LVN 2 stated the MAR is used to document the residents' pain level, the NPI treatments provided, and the administration of PRN pain medication. LVN 2 stated Resident 185 received oxycodone PRN for severe pain 7 to 10. LVN 2 reviewed Resident 185's MAR and stated on 7/1/2026 at 2:07 p.m., she (LVN 2) administered oxycodone and there was no documented evidence that NPIs were attempted prior to administration. LVN 2 stated she (LVN 2) did not remember what happened, but sometimes the resident just asks for oxycodone and refuses to attempt NPI. LVN 2 stated if a resident refuses NPI, then the physician should be notified. LVN 2 stated there was no documented evidence that the physician was notified. LVN 2 then stated there were multiple days when oxycodone was administered for a pain level of zero and she (LVN 2) could not say what happened but maybe LVN 12 could explain. LVN 2 stated it appeared the medication was not administered per the physician's orders. LVN 2 stated when narcotics are administered without attempting NPIs or for pain below severe level, it can potentially result in adverse effects like respiratory depression and constipation. During a concurrent interview and record review on 8/12/2026 at 3:05 p.m., with LVN 12, reviewed Resident 185's physician orders, and MAR for 7/2026 and 8/2026. LVN 12 stated she (LVN 12) has cared for Resident 185 and administered oxycodone. LVN 12 stated documentation in the MAR is considered accurate and reflects what actually happened to a resident. LVN 12 stated Resident 185 has never given her a numeric pain level. LVN 12 stated she determines what PRN pain medication to administer by asking Resident 185 if she wants acetaminophen or oxycodone and the resident always just asks for oxycodone. LVN 12 stated sometimes the CNA's reposition Resident 185 prior to administering oxycodone. LVN 12 reviewed Resident 185's MAR and noted she administered PRN oxycodone for pain level 0 with no documented evidence of providing NPIs prior to administration on the following dates and times: - On 7/8/2026 at 2 p.m. - On 7/22/2026 at 11:50 a.m. - On 7/23/2026 at 2:55 p.m. LVN 12 stated she (LVN 12) did not remember what happened on those days. During a concurrent interview and record review on 8/12/2026 at 4:05 p.m., with Quality Assurance Nurse (QAN) 2, reviewed Resident 185's physician orders, Progress Notes, and MAR for 7/2026 and 8/2026. The QAN 2 stated the facility process for administering PRN pain medication is to assess the resident for pain, provide NPIs, re-assess the resident for continued pain and verbally ask the resident their numeric pain level or use an equivalent scale that determines the numeric pain level, administer the medication, document all the interventions provided in the MAR, and then re-assess the resident to determine if the pain medication was effective. The QAN 2 stated Resident 185 receives PRN oxycodone for severe 7-10 pain. The QAN stated the MAR is used by the interdisciplinary team to plan the care for the resident. The QAN 2 stated documentation in the MAR is considered accurate and what is documented is considered to be what actually happened to the resident. The QAN 2 reviewed Resident 185's MAR and noted PRN oxycodone for pain level 7 to 10 was not administered per physician's orders on the following dates and times: - On 7/1/2026 at 2:07 p.m., no NPIs were provided. - On 7/2/2026 at 5:31 a.m. no NPIs were provided. - On 7/4/2026 at 12 a.m. no NPIs were provided. - On 7/4/2026 at 4 a.m. no NPIs were provided. - On 7/5/2026 at 12:09 a.m. for a pain level of 0 and no NPIs were provided. - On 7/5/2026 at 5:57 a.m. no NPIs were provided. - On 7/6/2026 at 5:40 a.m. no NPIs were provided. - On 7/8/2026 at 6:03 a.m. no NPIs were provided. - On 7/8/2026 at 2 p.m. for a pain level of 0 and no NPIs were provided. - On 7/9/2026 at 2:29 p.m. no NPIs were provided. - On 7/11/2026 at 12:25 a.m. no NPIs were provided. - On 7/14/2026 at 5:56 a.m. no NPIs were provided. - On 7/22/2026 at 11:50 a.m. for a pain level of 0 and no NPIs were provided. - On 7/23/2026 at 2:55 p.m. for a pain level of 0 and no NPIs were provided. - On 7/31/2026 at 10:45 a.m. for a pain level of 0 and no NPIs were provided. - On 8/1/2026 at 10:08 a.m. for a pain level of 0 and no NPIs were provided. - On 8/8/2026 at 10:56 a.m. for a pain level of 0 and no NPIs were provided. The QAN 2 stated when oxycodone was administered for no pain and no NPIs were provided it is considered the unnecessary administration of narcotic medication that can lead to the medication not being as effective over time as the resident grows a tolerance for medication. The QAN 2 stated when Resident 185 was administered oxycodone for no pain and with no NPIs it was not considered effective pain management for the resident. During a concurrent interview and record review on 8/14/2026 at 9:52 a.m. with the Director of Nursing (DON), reviewed the facility P&P regarding pain medication administration. The DON stated NPIs are provided to allow the resident to attempt to manage their pain without the administration of narcotics. The DON stated narcotics are a high-risk medication with the potential for abuse and adverse effects like constipation and respiratory depression. The DON stated when narcotics are misused residents can build a tolerance over time resulting in ineffective pain management. The DON stated the MAR is considered to be accurate and when Resident 185's pain level was documented as zero with no NPIs, the parameters for the administration of PRN oxycodone were not met. The DON stated the facility P&P was not followed for Resident 185. During a review of the facility P&P titled, Administration of Pain Medication, last reviewed 1/15/2026, the P&P indicated, Purpose. The Licensed Nurse will only administer pain medications according to the physician's order . II. Before Administering Pain Medication A. Observe the resident's environment and implement non-pharmacological interventions. B. Review the resident's Care Plan to assess for any special needs of the resident. C. The Registered Nurse will assess and document the resident's intensity of pain prior to the administration of pain medication. i. Explain the purpose of assessing the resident's current pain prior to the administration of pain medication. Administration of Pain Medication. B. Review the physician order and administer the pain medications as ordered. i. Some physician orders may have different medications indicated for different levels of pain. V. Documentation Document the administration of pain medication on the Medication Administration Record (MAR).

Based on observation, interview, and record review, the facility failed to ensure residents' bed rails (also called side rails [SR], metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) were provided per facility policy and procedure (P&P), physician's order, and plan of care to ensure the correct use of SRs for five of eleven sampled residents (Residents 88, 3, 102, 227, and 18) reviewed for accidents by failing to: 1. Ensure Resident 88 and Resident 3 did not have bilateral grab bars (short metal or plastic handles attached to the side of a bed that function primarily as localized transfer or repositioning aids) installed for residents with physician orders, assessments, and care plans for bilateral half (1/2) upper SRs (typically 28 to 36 inches long covering roughly 50 percent of the bed's length, positioned at the head of the bed, which serves as a mobility/transfer aid and as a partial physical barrier). 2. Applied the appropriate bedrails for Residents 102 and 227 as ordered by the physician. 3. Obtained obtain physician's order, assessment, and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for bilateral half bedrails (short metal or plastic side bars that cover only the upper half of a bed next to a resident's torso) on Resident 18. These failures placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails. Findings: 1.a. During a review of Resident 88's admission Record (AR), the AR indicated the facility admitted the resident on 10/15/2015, and readmitted the resident on 1/20/2022, with diagnoses including cerebral palsy (a group of disorders affecting a person's movement, balance, and posture) and dementia (a progressive state of decline in mental abilities). During a review of Resident 88's History and Physical (H&P), dated 1/30/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS, a resident assessment tool), dated 6/30/2026, the MDS indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and required partial/moderate assistance for mobility in bed. During a review of Resident 88's Nursing Quarterly Assessment – Device and Restraint Screening (NQA), dated 10/1/2025, the NQA indicated the resident had bilateral 1/2 upper SRs for use as mobility aid to improve functional ability when in bed. During a review of Resident 88's Care Plan (CP) titled, [Resident 88] is at risk for injury/entrapment (occurs when a resident is caught between the mattress and SR or wall, or within the SR itself) due to the use of SR (bilateral 1/2 upper SRs) related to weakness, mobility issues., initiated on 8/19/2025, the CP indicated a goal to focus on safe use of SRs with interventions that included to monitor SR for placement and function. During a review of Resident 88's CP titled, The resident has an ADL Self Care Performance Deficit., initiated on 10/6/2025, the CP indicated interventions that included SRs full/half up as per physician order for safety during care provision, to assist with bed mobility. During a review of Resident 88's CP titled, The resident at risk for fall and/or injury related to cognitive impairment, poor safety awareness/judgement, initiated on 10/6/2025, the CP indicated a goal that the resident will reduce the risk of fall and/or injury through interventions that included to provide assistance with transferring as needed. During a review of Resident 88's physician orders, dated 6/28/2025, the physician orders indicated bilateral 1/2 upper SRs up to aid with bed mobility and repositioning and independence and to assist with transfers, every shift. During an observation on 8/10/2026 at 10:07 a.m., observed Resident 88 lay in bed with bilateral grab bars attached to the upper quarter of the bed. During a concurrent observation and interview on 8/12/2026 at 8:07 a.m. with Certified Nursing Assistant (CNA) 11, inside Resident 88's room, observed Resident 88 lying in bed with bilateral upper grab bars. CNA 11 stated she cared for Resident 88 and the resident had grab bars on the bed and had always used them. During a concurrent interview and record review on 8/12/2026 at 8:29 a.m. with Licensed Vocational Nurse (LVN) 9, Resident 88's physician orders, CPs, and NQA, were reviewed. LVN 9 stated SRs are used for resident mobility in bed and can provide safety during the provision of care and resident transfers. LVN 9 stated the facility has different sizes of SRs including the grab bar and the 1/2 SR. LVN 9 stated the difference in the grab bar and 1/2 SR is that the 1/2 SR is longer and provides more coverage of the bed to assist the resident with positioning during care and transfers to help prevent sliding or falling off the bed. LVN 9 stated the correct SR size is determined by following the facility process. LVN 9 stated there are safety risks associated with use of SRs, so a safety assessment is completed prior to installation, and SRs require a physician's order. LVN 9 stated Resident 88 had an assessment, physician's orders, and CP for bilateral 1/2 upper SRs, so the resident should have bilateral 1/2 upper SRs provided and did not when he was provided the grab rails. LVN 9 stated when the correct size SRs were not provided there was the potential that the resident would not get the assistance needed for proper and safe transfers potentially leading to falls and injuries. During a concurrent interview and record review on 7/17/2026 at 8:49 a.m. with the Director of Nursing (DON), the facility's P&P for SRs were reviewed. The DON stated grab bars are smaller than 1/2 SRs. The DON stated if there is an assessment, order, and CP for 1/2 SRs, then they should be provided. The DON stated the P&P was not followed when Resident 88 was not provided 1/2 SRs potentially resulting in the resident not having adequate mobility while in bed leading to increased risk for falls. During a review of the facility P&P titled, Bed Rails, last reviewed on 1/15/2026, the P&P indicated, Purpose. To determine the appropriateness of bed rail use for individual residents. Decisions to use . a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) with input from the resident or resident representative and will take into account the resident's medical needs, comfort, and freedom of movement. The Licensed Nurse and/or the IDT-Restraint (any physical device or chemical substance that limits freedom of movement or self-determination and that a resident cannot easily remove or that is used for discipline or staff convenience) Reduction Committee may refer to the Bed Rail Decision Tree . during the assessment. Before installing a bed rail the Facility must: a. Assess the resident for risk of entrapment from bed rails; and b. Ensure the bed's dimensions are appropriate for the resident's size and weight. The resident's plan of care will be updated to reflect the use of bed rails. Maintenance will also check bed rails regularly to ensure they are still installed correctly. 1.b. During a review of Resident 3's AR, the AR indicated the facility admitted the resident on 5/10/2025, and readmitted the resident on 4/30/2026, with diagnoses including unsteadiness on feet, lack of coordination, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's H&P, dated 5/1/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident was dependent on staff for bathing and required substantial/maximal assistance for toileting, dressing, and mobility in bed. During a review of Resident 3's NQA, dated 5/18/2026, the NQA indicated the resident had bilateral 1/2 upper SRs for use as mobility aid to improve functional ability when in bed. During a review of Resident 3's CP titled, [Resident 3] is at risk for injury/entrapment due to the use of bilateral 1/2 upper SRs., initiated on 9/5/2025, the CP indicated a goal to focus on safe use of SRs with interventions that included to monitor SR for placement and function. During a review of Resident 3's CP titled, The resident is at risk for fall ., initiated on 9/5/2025, the CP indicated a goal that the resident will be free from falls. During a review of Resident 3's physician orders, dated 4/29/2026, the physician orders indicated bilateral 1/2 upper SRs up to aid with bed mobility and repositioning and independence and to assist with transfers, every shift. During an observation on 8/11/2026 at 2:15 p.m., observed Resident 3 lay in bed with bilateral grab bars attached to the upper quarter of the bed. During a concurrent observation and interview on 8/12/2026 at 8:14 a.m. with CNA 15, inside Resident 3's room, observed Resident 3 lying in bed with bilateral upper grab bars. CNA 15 stated she cared for Resident 3 and the resident had SRs that were smaller than 1/2 SRs. During a concurrent observation, interview, and record review on 8/12/2026 at 8:29 a.m. with LVN 9, Resident 3's physician orders, CPs, and NQA were reviewed. LVN 9 stated SRs are used for resident mobility in bed and can provide safety during the provision of care and resident transfers. LVN 9 stated the facility has different sizes of SRs including the grab bar and the 1/2 SR. LVN 9 stated the difference in the grab bar and 1/2 SR is that the 1/2 SR is longer and provides more coverage of the bed to assist the resident with positioning during care and transfers to help prevent sliding or falling off the bed. LVN 9 stated the correct SR size is determined by following the facility process. LVN 9 stated there are safety risks associated with use of SRs, so a safety assessment is completed prior to installation, and SRs require a physician's order. LVN 9 stated Resident 3 had an assessment, physician's orders, and CP for bilateral 1/2 upper SRs, so the resident should have bilateral 1/2 upper SRs provided. Observed LVN 9 walked to Resident 3's room and stated Resident 3 did not have bilateral 1/2 SRs and he was provided grab rails. LVN 9 stated that when the correct size SRs were not provided there was the potential that the resident would not get the assistance needed for proper and safe transfers potentially leading to falls and injuries. During a concurrent interview and record review on 7/17/2026 at 8:49 a.m. with the Director of Nursing (DON), the facility's P&P for SRs was reviewed. The DON stated grab bars are smaller than 1/2 SRs. The DON stated if there is an assessment, order, and CP for 1/2 SRs, then they should be provided. The DON stated the P&P was not followed when Resident 3 was not provided 1/2 SRs potentially resulting in the resident not having adequate mobility while in bed leading to increased risk for falls. During a review of the facility P&P titled, Bed Rails, last reviewed on 1/15/2026, the P&P indicated, Purpose. To determine the appropriateness of bed rail use for individual residents. Decisions to use . a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) with input from the resident or resident representative and will take into account the resident's medical needs, comfort, and freedom of movement. The Licensed Nurse and/or the IDT-Restraint (any physical device or chemical substance that limits freedom of movement or self-determination and that a resident cannot easily remove or that is used for discipline or staff convenience) Reduction Committee may refer to the Bed Rail Decision Tree . during the assessment. Before installing a bed rail the Facility must: a. Assess the resident for risk of entrapment from bed rails; and b. Ensure the bed's dimensions are appropriate for the resident's size and weight. The resident's plan of care will be updated to reflect the use of bed rails. Maintenance will also check bed rails regularly to ensure they are still installed correctly. 2.a. During a review of Resident 102's AR, the AR indicated the facility admitted the resident on 4/18/2026, and readmitted the resident on 7/9/2026, with diagnoses including unsteadiness on feet, lack of coordination, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 102's H&P, dated 7/10/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 102's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person has clear, noticeable trouble with memory, thinking, and daily tasks). The MDS indicated the resident was needing substantial to setup assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a history of fall. During a review of Resident 102's Order Summary Report (OSR), dated 7/9/2026, the OSR indicated an order for bilateral half side rails up to aid with bed mobility and repositioning and independence and to assist with transfer. Every shift. During a review of Resident 102's Consent- Bed Rails/Alarms/Restraints (CB), dated 7/9/2026, the CB indicated a consent for bilateral half upper siderails to aid with bed mobility. During a review of Resident 102's Fall Risk (Morse) Assessment V2 (FRA), dated 7/29/2026, the FRA indicated the resident was high risk for falls. During a review of Resident 102's Care Plan (CP) Report titled, Risk for injury/entrapment due to use of bilateral half upper side rails up to aid with bed mobility and repositioning., last revised on 5/8/2026, the CP indicated an intervention to monitor side rails for placement and function. During an observation on 8/10/2026, at 10:11 a.m., inside Resident 102's room, observed Resident 102 had bilateral upper grab bars on. During a concurrent observation, interview, and record review on 8/12/2026, at 8:32 a.m., with Registered Nurse (RN) 1, inside Resident 102's room, observed Resident 102's bed with upper grab bars on. RN 1 stated the resident had bilateral grab bars on. Reviewed Resident 102's Medical Diagnoses, OSR, CB, FRA, and CP. RN 1 stated the order for Resident 102 was for bilateral half side rails however, the facility applied bilateral grab bars (a sturdy metal handle that attaches to the side of a mattress) on Resident 102. RN 1 stated the consent, restraint assessment, physician's order, and the care plan was for a half bedrail not for bilateral grab bars. RN 1 stated the failure of the licensed staff to apply the correct bed rail had the potential for resident for accidents such as entrapment (when a person gets stuck, caught, or tangled in the gaps around a bed). During a concurrent interview and record review on 8/14/2026 at 11:14 a.m. with the Director of Nursing (DON), the facility's P&P titled Bed Rails was reviewed. The P&P titled Bed Rails indicated before installing a bed rail the Facility must: (a) Assess the resident for risk of entrapment from bed rails; and (b) Ensure the bed's dimensions are appropriate for the resident's size and weight. The DON stated the policy was not followed by the licensed staff applying the wrong bed rails on Resident 102. The DON stated they have different typed of bed rails in the facility, they have grab bars, quarter side rails (short metal or plastic grab bars (about 18 inches long) attached near the head or foot of a hospital bed), and half side rails/bedrails. The DON stated the failure of the staff to apply the bedrail per physician's order had the potential for resident entrapment and injury. 2.b. During a review of Resident 227's AR, the AR indicated the facility admitted the resident on 8/4/2026, with diagnoses including muscle weakness, lack of coordination, and age-related osteoporosis (a common condition where bones become thin, weak, and brittle over time). During a review of Resident 227's H&P, dated 8/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 227's OSR, dated 8/4/2026, the OSR indicated an order for bilateral half side rails up to aid with bed mobility and repositioning and independence and to assist with transfer. Every shift. During a review of Resident 227's FRA, dated 8/5/2026, the FRA indicated the resident was high risk for falls. During a review of Resident 227's CB, dated 8/4/2026, the CB indicated a consent for bilateral half upper side rails/bed rails to aid with bed mobility. During a review of Resident 227's CP Report titled, Risk for injury/entrapment due to use of side rails, last revised on 8/5/2026, the CP indicated an intervention to monitor side rails for placement and function. During an observation on 8/10/2026, at 11:36 a.m., inside Resident 227's room, observed Resident 227 had bilateral upper grab bars on. During a concurrent observation, interview, and record review on 8/12/2026, at 8:32 a.m., with RN 1, inside Resident 227's room, observed Resident 227's bed with upper grab bars on. RN 1 stated the resident had bilateral grab bars on. Reviewed Resident 227's Medical Diagnoses, OSR, CB, FRA, and CP. RN 1 stated the order for Resident 227 was for bilateral half side rails however, the facility applied bilateral grab bars on Resident 227. RN 1 stated the consent, restraint assessment, physician's order, and the care plan was for a half bedrail not for bilateral grab bars. RN 1 stated the failure of the licensed staff to apply the correct bed rail had the potential for resident for accidents such as entrapment. During a concurrent interview and record review on 8/14/2026 at 11:14 a.m. with the DON, the facility's P&P titled Bed Rails was reviewed. The P&P titled Bed Rails indicated before installing a bed rail the Facility must: (a) Assess the resident for risk of entrapment from bed rails; and (b) Ensure the bed's dimensions are appropriate for the resident's size and weight. The DON stated the policy was not followed by the licensed staff applying the wrong bed rails on Resident 227. The DON stated they have different typed of bed rails in the facility, they have grab bars, quarter side rails, and half side rails/bedrails. The DON stated the failure of the staff to apply the bedrail per physician's order had the potential for resident entrapment and injury. 3. During a review of Resident 18's AR, the AR indicated the facility admitted the resident on 5/4/2020, and readmitted the resident on 2/15/2022, with diagnoses including age-related osteoporosis, history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 18's H&P, dated 8/14/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 18's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severe cognitive impairment (a major loss of brain function). The MDS indicated the resident had an impairment on one side of the upper extremity and impairment on both sides of the lower extremity and uses a wheel chair to mobilize. The MDS indicated the resident was dependent to needing supervisions assistance on mobility and ADLs. The MDS indicated the resident had history of falls. During a review of Resident 18's OSR, dated 8/13/2026, the OSR did not indicate an order for bed rails. During a review of Resident 18's FRA, dated 8/5/2026, the FRA indicated the resident was high risk for falls. During a review of Resident 18's CP Report titled, Risk for injury/entrapment due to use of bilateral half upper side rail up to assist with bed mobility, repositioning/independence and to assist with transfer, last revised on 5/19/2026, the CP indicated an intervention to monitor side rails for placement and function. During an observation on 8/10/2026, at 9:30 a.m., inside Resident 18's room, observed Resident 18 had bilateral half bedrail on. During a concurrent observation, interview, and record review on 8/12/2026, at 9:29 a.m., with RN 1, inside Resident 18's room, observed Resident 18's bed with bilateral half bed rails on. RN 1 stated the resident had bilateral half bedrails on. Reviewed Resident 18's Medical Diagnoses, OSR, CB, FRA, and CP. RN 1 stated the order for Resident 18 was for bilateral half side rails. RN 1 stated there was no consent, restraint assessment, physician's order for a half bedrail on the resident's medical record. RN 1 stated the failure of the licensed staff to obtain a physician's order, informed consent and bedrail assessment before applying the bilateral half bed rail had the potential for resident for accidents such as entrapment. During a concurrent interview and record review on 8/14/2026 at 11:14 a.m. with the DON, the facility's P&P titled Bed Rails was reviewed. The P&P titled Bed Rails indicated before installing a bed rail the Facility must: (a) Assess the resident for risk of entrapment from bed rails; and (b) Ensure the bed's dimensions are appropriate for the resident's size and weight. The DON stated the policy was not followed by the licensed staff applying the half bedrails without a physician's order, informed consent, and bedrail assessment. The DON stated they have different typed of bed rails in the facility, they have grab bars, quarter side rails, and half side rails/bedrails. The DON stated the failure of the staff to obtain a physician's order, informed consent, and bedrail assessment had the potential for resident entrapment and injury on Resident 18. During a review of the facility's recent P&P titled, Bed Rails, last reviewed on 1/15/2026, the P&P indicated to determine the appropriateness of bed rail use for individual residents. Procedure I. The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. A. The Licensed Nurse and/or the IDT-Restraint Reduction Committee may refer to the Bed Rail Decision Tree (see NP- 278-Form A- Bed Rail Decision Tree) during the assessment. i. Before installing a bed rail the Facility must: a. Assess the resident for risk of entrapment from bed rails; and b. Ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed. ii. For beds with rails that are incorporated or pre-installed, the Facility must determine whether or not disabling the bed rail poses a risk for the resident. III. The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of bed rails and the identification of how needs will be met during the use of bed rails (e.g., repositioning, hydration, etc.) IV. After installation of bed rails, the IDT will document the review of the use of bed rails at a minimum of quarterly. Re-evaluations should include a discussion of any adverse effects of bed rails and attempts to eliminate the need for the bed rail if it is being used as a restraint. V. Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing PE-01-Form D- Maintenance Inspection Checklist- Resident Rooms. Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or loose overt time. During a review of the facility-provided Hospital Bed (HB) 1 Owner's Manual, last revised on 4/1/2018, the OM indicated accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. Potential risks of bed rails may include: -Strangling, suffocating, bodily injury or death when patients of part of their body are caught between rails or between the bed rails and mattress. -More serious injuries from falls when patients climb over rails. -Skin bruising, cuts, and scrapes. -Inducing agitated behavior when bed rails are used as a restraint. -Feeling isolated or unnecessarily restricted. -Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.

Based on interview and record review the facility failed to reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication eKITs containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) with an inventory count for August 2026, in one (1) of two (2) inspected Medication Rooms (Medication room [ROOM NUMBER]). As a result, control and accountability of CM did not follow state and federal regulations and facility policy and procedures. This failure had the potential to increase the opportunity for CM diversion (the transfer of medications from a lawful to an unlawful channel of distribution or use), and the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, hospitalization and death. Findings: During a concurrent observation and interview on 8/10/2026 at 12:10 p.m., with the Infection Preventionist (IP), in Medication room [ROOM NUMBER], there was: 1. One (1) medication eKIT stored in the refrigerator containing lorazepam (a schedule IV CM), labeled E-Kit #2, without an accountability log for the reconciliation of CM inventory count at every shift change for August 2026. The IP stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift with an inventory count, like the inventory reconciliation of CMs in medication carts. The IP stated that the eKIT labeled E-Kit #2, in the refrigerator of Medication room [ROOM NUMBER] was not reconciled with an inventory count at every shift in August 2026. The IP stated it was important to account for all CMs by an inventory count to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an interview on 8/13/2026 at 1:10 p.m. with the Director of Nursing (DON), and in the presence of the Assistant DON (ADON), the DON acknowledged that medication eKITs containing CMs needed to be counted with an inventory count and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the eKIT containing lorazepam in Medication room [ROOM NUMBER] labeled E-Kit #2 was not reconciled with an inventory count at each shift change in August 2026. The DON stated that the facility will immediately implement an accountability log to include the inventory count for the reconciliation of eKITs at each shift change in Medication room [ROOM NUMBER]. During a review of the facility's Policy and Procedures (P&P) titled, Controlled Medications, last reviewed 1/15/2026, the P&P indicated: Controlled drug quantities will be verified and reconciled at the change of each nursing shift. At the completion of each nursing shift the 'on-coming' and 'out-going' nurses will count and reconcile controlled drugs subject to regulations and/or facility policies for individual counts. All controlled medications in federal schedule II, III or IV will be accounted for each shift.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting one (1) of three (3) residents observed for medication administration (Resident 227.) The medication errors were as follows: 1. Resident 227 was not observed rinsing mouth with water after the administration of Fluticasone Furoate-Umeclidin-Vilanterol (a corticosteroid [an anti-inflammatory medication also known as steroid] used for chronic obstruction pulmonary disorder [COPD - a condition with shortness of breath, cough and chest tightness]) inhalation (a form of a medication to be inhaled as a vapor or spray,) as ordered by Resident 227's physician and manufacturer guidelines. 2. Resident 227 received a dose of albuterol (a medication used for COPD and shortness of breath) that was different than ordered by Resident 227's physician. These failures resulted in administration of wrong medication dose and not following manufacturer guidelines, which increased the potential for Resident 227 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in their health and well-being to be negatively impacted. Findings: During a review of Resident 227's admission Record (a document containing demographic and diagnostic information), dated 8/11/2026, the record indicated Resident 227 was originally admitted to the facility on [DATE] with diagnosis including COPD. During a review of Resident 227's Order Summary Report, dated 8/11/2026, indicated Resident 227 was prescribed: 1. Fluticasone Furoate-Umeclidin-Vilanterol one (1) inhalation to inhale orally once a day for COPD and rinse mouth after use, starting 8/6/2026. 2. Albuterol two (2) puff inhale orally every four (4) hours as needed for shortness of breath, starting 805/2026. During a review of Resident 227's Medication Administration Record ([MAR] - a record of mediations administered to residents) for August 2026, the MAR indicated Resident 227 was prescribed: 1. Fluticasone Furoate-Umeclidin-Vilanterol one (1) inhalation to inhale orally once a day for COPD and rinse mouth after use, at 9 a.m. 2. Albuterol two (2) puff inhale orally every four (4) hours as needed for shortness of breath, last given 8/11/2026 at 3:24 a.m. During an observation on 8/11/2026 at 9:25 a.m., in Medication Cart 4, with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed handing Fluticasone Furoate-Umeclidin-Vilanterol inhaler to Resident 227. Resident 227 was observed self-administering one (1) inhalation of Fluticasone Furoate-Umeclidin-Vilanterol orally. Resident 227 was observed asking LVN 3 for albuterol inhaler. LVN 3 was observed informing Resident 227 to rinse mouth with water and placing two (2) cups filled with water along with one (1) empty cup on the resident's bedside table and walking out of the resident's room. During an observation on 8/11/2026 at 9:29 a.m., in Medication Cart 4, with LVN 3, LVN 3 was observed handing albuterol inhaler to Resident 227. Resident 227 was observed self-administering four (4) inhalations of albuterol orally. Resident 227's bedside table was observed to have two (2) cups filled with water along with one (1) empty cup. During an interview on 8/11/2026 at 9:30 a.m. with LVN 3, LVN 3 stated LVN 3 instructed Resident 227 to rinse mouth and spit after the oral inhalation of Fluticasone Furoate-Umeclidin-Vilanterol. LVN 3 stated that LVN 3 failed to observe Resident 227 rinse their mouth and spit out the water. LVN 3 acknowledged the manufacturer guidelines and physician orders instructed Resident 227 to rinse out mouth with water and spit after administering Fluticasone Furoate-Umeclidin-Vilanterol inhalation. LVN 3 stated LVN 3 needed to observe Resident 227 rinse their mouth with water and spit to ensure Fluticasone Furoate-Umeclidin-Vilanterol did not remain in the mouth, potentially harming Resident 227 by irritating the oral mucosa (membrane that lines the inside of the mouth) and resulting in oral thrush (a fungal infection of the mouth that causes creamy white lesions on the tongue, inner cheeks, and sometimes the roof of the mouth, throat, or gums, that can be painful and may bleed). LVN 3 stated this was considered a medication error and that LVN 3 will inform Resident 227 immediately. During the same interview, LVN 3 acknowledged the physician's order specified to administer two (2) inhalations of albuterol to Resident 227. LVN 3 stated that LVN 3 failed to instruct Resident 227 to take two (2) inhalations orally when handing Resident 227 the albuterol inhaler, resulting in Resident 227 receiving two (2) additional inhalations, which did not match the physician's order. LVN 3 stated that albuterol can increase heart rate and giving more than the intended dose can potentially harm Resident 227 by causing palpitation and tachycardia (fast heart rate). LVN 3 stated this was also considered a medication error. During an observation on 8/11/2026 at 9:35 a.m., LVN 3 walked into Resident 227's room, and informed Resident 227 that the cups containing the water on the bedside table were not used and reminded Resident 227 to rinse her mouth. LVN 3 also informed Resident 227 that she needed to only take two (2) inhalations of albuterol orally instead of four (4). Resident 227 was observed informing LVN 3 that she needed to rinse her mouth immediately after the inhalation of Fluticasone Furoate-Umeclidin-Vilanterol, and that it was already too late. Resident 227 proceeded to rinse her mouth with water and spit into the empty cup. During an interview on 8/13/2026 at 1:10 p.m. with the Director of Nursing (DON), and in the presence of Assistant Director of Nursing (ADON), the DON stated that LVN 3 failed to observe Resident 227 rinse their mouth with water after the administration of Fluticasone Furoate-Umeclidin-Vilanterol. The DON stated this was not according to the physician orders and manufacturer guidelines. The DON stated this failure placed Resident 227 at risk of developing oral thrush (infection inside the mouth). The DON stated that licensed nurses should follow facility medication administration guidelines to ensure that residents receive medications according to physician orders and manufacturer guidelines preventing adverse consequences. During the same interview, the DON stated that LVN 3 failed to instruct Resident 227 to take two (2) inhalations of albuterol orally resulting in Resident 227 taking four (4) inhalations, which was not according to Resident 227's physician order. The DON stated not administering medications according to physician orders and manufacturer guidelines were considered medication errors. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the five (5 rights of medication administration are followed to ensure residents receive the correct medication doses according to physician orders and manufacturer guidelines). During a review of the facility's policy and procedures (P&P), titled Guidelines for Medication Administration, last reviewed 1/15/2026, the P&P indicated: Observe the 'five rights' of administering medication. - The right dose Read the label on the medication container three (3) times before administering the medication. During a review of the facility's P&P titled Medication - Administration, last reviewed 1/15/2026, the P&P indicated: IV. Nursing staff will keep in mind the 'seven' rights of medication when administering medication: B. the right amount V.C. The 'rule of 3' - The licensed nurse administering medications will perform 3 checks comparing the physicians order, pharmacy label, and Medication Administration Record (MAR). VII. The Resident's MAR will be reviewed for .special considerations for administration including: A. Manufacturer's specifications.regarding the preparation and administration of the drug or biological B. Accepted professional standards and principles XV. The licensed nurse will remain with the resident until the medicine is actually swallowed. During a review of the facility's P&P titled, Medication Errors, last reviewed 1/25/2026, the P&P indicated: I. Definition - the preparation or administration of medications or biologicals which is not in accordance with: a. The prescriber's order b. Manufacturer's specifications .regarding the preparation and administration of the medication or biological, and/or c. Accepted professional standards and principles d. A medication error may be the administration or omission of medication: iii. at the wrong dose v. Which is not currently prescribed. During a review of the facility's P&P titled, Oral Medication Administration, last reviewed 1/15/2026, the P&P indicated to: Administer the medication as prescribed and remain with the resident while the medication is swallowed. During a review of the facility's P&P titled, Metered-Dose (Oral) Inhaler Administration, last reviewed 1/15/2026, the P&P indicated If steroid inhaler, have the patient thoroughly rinse mouth with water and spit out after use to minimize risk of oral pharyngeal candidiasis. During a review of manufacturer's guidelines titled, Highlights of Prescribing Information for Fluticasone Furoate-Umeclidin-Vilanterol, last revised June 2023, the document indicated: Candida albicans infection of the mouth and pharynx may occur. Advice the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. After inhalation, rinse the mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. Advise patients to rinse the mouth with water without swallowing after inhalation to help reduce the risk of thrush.

Based on observation, interview, and record review, the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures (P&P) by failing to: 1. Label one (1) open insulin (medication used to regulate blood sugar levels) Humalog (rapid-acting insulin) vial stored in the refrigerator for Resident 136, in one (1) of two (2) inspected med rooms (Medication room [ROOM NUMBER].) 2. Store one (1) expired Wixela (a medication used for asthma (a condition that causes shortness of breath) and chronic obstructive pulmonary disease ([COPD - a condition with shortness of breath, cough and chest tightness]) inhaler (a device that delivers medication to the lungs) for Resident 178 in a designated area intended for medication disposal, separate from in use medications, in one (1) of two (2) inspected med rooms (Medication room [ROOM NUMBER]). 3. Eesure externally (medications applied to outside parts of the body, like eye drops) administered medications were stored separately from internally (medications delivered into the body, like oral tablets, injections) administered medications, in one (1) of four (4) inspected Medication Carts (Medication Cart 2.) These failures increased the risk that Resident 136 and 178 and others in the facility could have received medication that had become ineffective or toxic due to inadequate storage, and labeling, and increased the risk of contamination and receiving medications via the wrong route (internal versus external routes) possibly leading to medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in the negative impact to their health and well-being, hospitalization and/or death. Findings: During a concurrent observation and interview on 8/10/2026 at 12:10 p.m., in Medication room [ROOM NUMBER], in the presence of Infection Preventionist (IP), the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date, expired and not discarded, or stored and labeled contrary to facility policies: 1. One (1) open and expired Wixela inhaler for Resident 178 was found stored at room temperature along with other non-expired medications, and covered with an open foil pouch (package made of foil protecting the inhalation solution from light and degradation) labeled with a date indicating the inhaler was opened on 6/3/2026. According to the manufacturer's product storage and labeling, Wixela inhaler should be stored at room temperature between 68 to 77 degrees Fahrenheit and discarded one (1) month after opening the foil pouch. 2. One (1) open and used insulin Humalog vial for Resident 136 was found stored in the refrigerator without a date indicating when use began or vial was opened. According to the manufacturer's product labeling, open Humalog vials should be stored below 86 degrees Fahrenheit and used or discarded within 28 days of opening vial. The IP stated the Wixela inhaler for Resident 178 was labeled with a date indicating the foil pouch was opened on 6/3/2026. The IP stated according to the manufacturer guidelines the Wixela inhaler for Resident 178 expired one (1) month later on 7/3/2026. The IP stated the expired Wixela inhaler needed to be placed in a designated area for disposal, separate from non-expired medications, to prevent accidental use. The IP stated expired medications have lost potency (strength) and will not be effective in treating Resident 178 condition and potentially harm the resident by not relieving the shortness of breath, possibly leading to hospitalization and death. The IP stated several licensed nurses failed to not store expired Wixela with other non-expired medications and place in a designated area intended for disposal in Medication room [ROOM NUMBER], increasing the risk of using expired medication for Resident 178. The IP stated insulin Humalog vial for Resident 136 was open, used, stored in the refrigerator and not labeled with a date when use began or when vial was opened. The IP stated insulin vials were considered a multi-dose (having more than one [1] dose) medication. The IP stated according to manufacturer directions the Humalog vial needed to be discarded after 28 days of use or of opening the vial. The IP stated after that timeframe the insulins lose potency (the strength of medication) and considered expired. The IP stated that IP was unaware when the Humalog vial for Resident 136 was opened therefore unknown when it would expire. The IP stated administering expired insulin in error will not be effective in keeping the blood sugar stable and can harm Resident 136 by causing high blood sugar levels, leading to shock and coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. The IP stated the Humalog vial needed to be removed from Medication room [ROOM NUMBER] to ensure expired insulin was not administered in error to Resident 136. During a concurrent observation and interview on 8/10/2026 at 12:48 p.m., in Medication Cart 2, with Licensed Vocational Nurse (LVN) 11, the following medications were stored in a manner contrary to the facility's P&P: 1. Three (3) injectable (medications that are injected with a needle) vials of cyanocobalamin (vitamin B12,) two (2) eye drop medication bottles (brimonidine, rhopressa,) and four (4) oral medication (seroquel, atenolol, levothyroxine, biktarvy) bottles were all stored in the same bin/compartment of the medication cart. 2. Five (5) oral medication (probiotic, cephacol, nephrovite, diphenhydramine, melatonin, loperamide) bottles and five (5) eye drop medication (pilocarpine, Xalatan, brimonidine, latanoprost, rhopressa) bottles were all stored in the same bin/compartment of the medication cart. LVN 11 stated that internally administered medications, such as oral tablets and injectable vials, and externally administered medications, such as eye drops, ear drops, creams, and nasal sprays, should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible infections/contaminations. LVN 11 acknowledged three (3) cyanocobalamin vials, brimonidine and rhopressa eye drop bottles and seroquel, atenolol, levothyroxine and biktarvy oral medication bottles were all stored in the same bin/compartment of the medication cart. LVN 11 also acknowledged that a probiotic, cephacol, nephrovite, diphenhydramine, melatonin and loperamide oral medication bottles, and pilocarpine, Xalatan, brimonidine, latanoprost, and rhopressa eye drop bottles were all stored together in another bin/compartment of the medication cart. LVN 11 stated the facility failed not to separate and store internally administered medications separate from externally administered medications. During an interview on 8/13/2026 at 1:10 p.m. with the Director of Nursing (DON) and in the presence of Assistant Director of Nursing (ADON), the DON stated the stated internally (such as oral and injectable medications) and externally (such as medications for the eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to separate the storage of internally and externally administered mediations in Medication Cart 2. The DON stated the insulin vials should be labeled with a date indicating when use began or when the vial was opened. The DON stated several LVN's failed to label Humalog vial for Resident 136 when opened or used in Medication room [ROOM NUMBER]. The DON stated without knowing when the Humalog vial was opened or used, it was unknown when it would expire, increasing the risk of administration of expired insulin to Resident 136. The DON stated expired insulins have lost potency and effectiveness and when administered in error were not effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar level) and adverse effects for Resident 136. The DON acknowledged Wixela inhaler for Resident 178 expired on 7/3/2026. The DON stated expired medications should be removed from use and placed in the expired medication bin to be disposed of and prevent accidental use. The DON stated that expired Wixela has lost its effectiveness and when administered in error will not treat the asthma or COPD further causing shortage of breath for Resident 178 and requiring immediate treatment. The DON stated several licensed nurses failed to remove expired Wixela inhaler from use and place in a designated area intended for disposal, increasing the potential for use of expired medication for Resident 178. During a review of the facility's P&P titled, Disposal of Non-Controlled Medications, last reviewed 1/15/2026, the P&P indicated: Outdated or discontinued non-controlled drugs will be removed from the medication cart or nursing station and transferred to the designated holding area. During a review of the facility's P&P titled, Medication Storage and Labeling, last reviewed 1/15/2026, the P&P indicated: b. External use drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use. During a review of the facility's P&P titled, Date Open Procedures, last reviewed 1/15/2026, the P&P indicated: b. External use drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use. h. Drugs shall not be in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. During a review of the facility's P&P titled, Facility Auditing & Removal of Expired and Discontinued Medications, last reviewed 1/15/2026, the P&P indicated: The medication nurse will remove expired medications from the drug storage areas so that they are not administered to residents. The facility staff will remove expired medications from the medication storage areas on a regular schedule and when encountered. 1. At least once a month, the nurse responsible for the medication cart for each station will inspect the medication cart and medication room for expiring medications. During a review of the manufacturer's guide titled, Instructions for Use, for Humalog vial, last revised July 2023, the guide indicated: Store opened vials in the refrigerator or at room temperature up to 86 degrees Fahrenheit for up to 28 days. Throw away all opened vials after 28 days of use, even if there is insulin left in the vial. During a review of the manufacturer's guide titled, Highlights of Prescribing Information, for Wixela, last revised August 2022, the guide indicated Discard Wixela 1 month after opening the foil pouch or when the counter reads 0, whichever comes first. During a review of the facility's P&P titled, Date Open Procedures, last reviewed 1/15/2026, the P&P indicated: 1. It will be the responsibility of the nursing staff to enter the opening date on all manufacturer's label or blank pharmacy labels. 2. The facility will follow published manufacturer's specifications for each product.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when: 1. Dietary staff did not follow the portion size of two (2) ounces (oz, unit of measurement) and served three (3) oz of edible portions of pork chops for regular (diet with no restrictions) and therapeutic diets (a personalized meal plan prescribed by a doctor to treat medical condition or manage symptoms). 2. Dietary Staff did not follow the recipe for the strawberry and pear dessert as it only had 1 thin slice of strawberry in the bowl. These failures had the potential to result in decrease in food flavor, decrease and increase in food and nutrient intake to 114 of 208 residents on regular, therapeutic diets, resulting in unplanned weight loss or unplanned weight gain. Findings: 1. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Summer 2026, dated 8/10/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray: - Pork chop 1 each - Seas beans 1/2 cup (c, a household measurement) - Smothered cabbage 1/2 c - Corn bread/margarine 1 each - Pineapple/mandarin oranges 1/2 c - Beverage 8 fluid oz During an observation on 8/10/2026 at 11:52 p.m., of lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) service, observed a pan of porkchop in trayline. During an interview on 8/10/2026 at 8:10 a.m., with [NAME] 1, [NAME] 1 stated the portion size for pork chops is 4 oz including the gravy. During a concurrent observation and interview on 8/10/2026 at 12:15 p.m., of the pork chops portion size with [NAME] 1 and the Dietary Manager (DM), observed [NAME] 1 weighing a serving of the pork chop using a facility scale. Observed the DM calibrated the food weighing scale. [NAME] 1 stated one serving is one piece of pork chop. The DM stated the following pieces of meat weighed: - 1st pork chop (1pc) 3.1 oz - 2nd pork chop (1 pc) 3.1 oz - 3rd pork chop (1 pc) 3 oz - 4th pork chop (1 pc) 2.8 oz - 5th pork chop (1 pc) 3.2 oz During an interview on 8/10/2026 at 12:23 p.m., with the DM, the DM stated she should be removing the portions of flour, and it should be 2 oz but it is at 2.8 portion size of pork chops when weighed. During a concurrent interview and record review on 8/10/2026 at 12:25 p.m. with the DM, the facility's recipe titled, Pork Chop, dated 2026 was reviewed. The recipe indicated, suggested portion 1 each. Pork chop 4 oz. Pork chop method: (4) Serve 1 chop per portion=approximately 2 oz edible meat. Gravy maybe served if desired. The DM stated, the pork chop size is 4 oz and the recipe indicated edible portion is 2 oz but the scale was reading 2.8 oz when I removed the flour and measured the meat only. The DM stated [NAME] 1 has been in the facility for a little over a year and received training with recipes. The DM further stated the recipe was not consistent with the edible portion of the meat indicating 2 oz, but the actual weight was 2.8 oz and there was nothing in the recipe about the total portion of the pork chop with flour and other ingredients combined. The DM stated residents could gain weight as potential outcome if they are given more than the portion size indicated in the recipe. During a review of the facility's policies and procedures (P&P) titled, Nutritional Adequacy of Menu and Approval, dated 1/15/2026, the P&P indicated, The menu will be based upon the most recent publication of the Dietary Reference Intake of the National Research Council, National Academy of Sciences adjusted for the average area of the residents. The menu will promote good nutrition among the residents. During a review of the facility's P&P titled, Standardized Recipes, dated 1/15/2026, the P&P indicated, A standardized recipe adjusted to appropriate yield is available for each menu item and is used in the preparation of each. Procedure: 1. Each recipe shall include the following: a. All ingredients in order of introduction to the recipe. b. Amount of each ingredient required to achieve the desired yield c. Preparation method, including Critical Control Point (CCP) d. Total yield e. Standard serving size. f. Equipment needed g. Extensions to meet the census of diets. 1. Each recipe shall be adjusted to be exact for every ingredient. a. Use weights for greatest accuracy. 2. During a review of the facility's menu spreadsheet titled Summer 2026, dated 8/11/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray: - Lemon baked chicken 2 oz - Au gratin potatoes 1/2 c - Peas and red pepper 1/2 c - Roll and margarine 1 each - Strawberry and pear cup 1/2 c During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 8/11/2026 at 12:38 p.m. with the DM, observed the strawberry and pear cup only had one thin slice of strawberry. The DM stated the presentation of the strawberry and pear cup is not good as it has no color contrast and there was only one sliced thin strawberry in it. The DM stated their strawberry and pear cup are missing strawberries and the residents could complain about it as a potential outcome. During a review of the facility's P&P titled, Production, dated 1/15/2026, the P&P indicated, The preparation of food will be done following standard food handling techniques. Standardized recipes, quantity cookbooks, safe handling procedures and an approved diet manual will be made available to assist Food and Nutrition Services employees. Use of standardized recipes, census sheets, diet board, and production sheets will help avoid over or under production of food. During a review of the facility's standardized recipe titled, Strawberry Pear Cup, dated 1/15/2026, the recipe indicated that 140 servings would need the following recipes: - Diced pear halves 2 gallon plus 3/4 quart - Sliced strawberries 20 pounds plus 6 oz.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance when the puree beans were flat on the plate for minced and moist diet (soft, tender foods chopped or ground into small sizes of four [4] millimeters or smaller) and puree diet residents. This failure had potential to result in 52 of 208 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Cross-reference F805. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Summer 2026, dated 8/10/2026, the spreadsheet indicated residents on puree diet/ International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: - Pureed pork chop 1/2 cup (c, household measurement) - Pureed seas beans 1/2 c - Pureed smothered cabbage 1/4 c - Pureed cornbread/margarine c - Pureed mandarin oranges c - Beverage eight (8) fluid ounces (oz, a unit of measurement) During a review of the facility's spreadsheet titled, Summer 2026, dated 8/10/2026, the spreadsheet indicated residents on minced and moist diet would include foods on the tray: - Minced and moist pork chop/ gravy one (1) each - Pureed seas beans 1/2 c - Pureed smothered cabbage 1/4 c - Pureed cornbread/margarine c - Pureed mandarin oranges c - Beverage 8 fluid oz During an observation on 8/10/2026 at 11:57 a.m., of lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates), observed the Dietary Manager (DM) performing a spoon tilt test using the ice cream scoop and told the Registered Dietitian (RD) the puree food needed more thickener. During an observation on 8/10/2026 at 12:00 p.m., of the puree food, observed puree food items were served flat on the plate and the puree seas beans were also for residents for minced and moist diet. During an interview on 8/10/2026 at 12:37 p.m. with the DM and the RD, the DM stated they used IDDSI standards and puree diet should be formed, not drippy, not runny. The RD stated the puree foods should hold its form and shape. The RD stated [NAME] 1 prepared the puree food. During an interview on 8/10/2026 at 12:53 p.m. with the RD, the RD stated it was important to follow the menu and standardized recipes for resident's safety and to meet their dietary needs and restrictions. During a concurrent test tray (process of tasting, temping, and evaluating the quality of food) observation and interview on 8/10/2026 at 1:07 p.m., of the pureed seas beans with the RD, observed the pureed seas beans were flat on the plate touching other food items. The RD stated the pureed seas beans were flat on the plate, and it needed to hold its shape so that the presentation is not affected. The RD stated they need to investigate the recipe more so it could hold its shape. During an interview on 8/10/2026 at 1:10 p.m. with the DM, the DM stated if the presentation of food is not good there could be decrease in resident's appetite because people eat with their eyes. The DM further stated low food intake led to possible weight loss. During a review of the facility's policies and procedures (P&P) titled, Food Preparation, dated 1/15/2026, the P&P indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance. (4) Poorly prepared food will not be served, such as food is to either be improved, prepared again, or replaced with an appropriate substitution. During a review of the facility's P&P titled, Diet Manual, dated 1/15/2026, the P&P indicated, The community designates a current diet manual, which is available for all Medical, Nursing and Food & Nutrition Services Department staff to use as a reference for normal and therapeutic nutrition. The diet manual contains description, rationale, and description of dietary deficiencies and the appropriate title for all diets served in the community. During a review of the facility's diet manual titled, Dysphagia Diets, Puree IDDSI Level 4, dated 1/15/2026, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on the plate. The diet requires no biting or chewing. Any liquids must not separate from the food, and the food can fall off a spoon intact. All prepared pureed recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines. They should pass a fork drip test and the spoon tilt test. During a review of the facility's standardized recipe titled, Smothered Cabbage, dated 2026, the recipe indicated, Puree: drain portions needed from regular recipe. Place into a food processor. Process to a fine texture. For every 5 portions needed, add 3 tablespoons thickener and process until smooth. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds. Reheat to 165 F and service with a number 16 scoop. CCP: All IDDSI texture modifications need to pass their established testing methods at the start and every 15 minutes for the duration of the service. During a review of the facility's standardized recipe titled, Seas Beans (Legumes) Method, dated 2026, the P&P indicated, All IDDSI texture modification need to pass their established testing methods at the start and every 15 minutes for duration of service. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

Based on observation and interview, the facility failed to ensure to provide the name of medications and their indications (reason for the use of the medication) prior to administration of the medications, affecting one (1) of four (4) residents observed for medication administration (Resident 65.) This failure violated Resident 65's rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial harm. Findings: During an observation on 8/11/2026 at 10:15 a.m., Licensed Vocational Nurse (LVN) 2 was observed handing Resident 65 a medication cup containing midodrine (a medication for low blood pressure,) pioglitazone (a medication to regulate blood sugar levels,) lubiprostone (a medication for bowel discomfort,) aspirin (a medication for thinning the blood,) escitalopram (a medication for depression,) finasteride (a medication for enlarged prostate [small gland found only in people with male reproductive anatomy,]) gabapentin (a medication for nerve pain,) and furosemide (a medication for relieving swelling,) and stating that these are the morning medications. Resident 65 was observed swallowing the medications with a glass of water. LVN 2 was observed not informing Resident 65 the name of midodrine, pioglitazone, lubiprostone, aspirin, escitalopram, finasteride, gabapentin and furosemide and their indications during administration of the medications. LVN 2 was then observed handing Resident 65 a medication cup containing multivitamin with minerals (a supplement,) vitamin D3 (a supplement,) and ferrous sulfate (a supplement,) and stating these were the morning supplements. Resident 65 was observed swallowing the supplements with a glass of water. LVN 2 was then observed handing Resident 65 a glass of water containing polyethylene glycol (a medication for constipation) and stating the medication was for constipation. Resident 65 was observed refusing to drink the polyethylene glycol stating that he had a bowel movement and was not constipated. During an interview on 8/11/2026 at 10:20 a.m., with LVN 2, LVN 2 stated during the medication administration LVN 2 administered midodrine, pioglitazone, lubiprostone, aspirin, escitalopram, finasteride, gabapentin and furosemide orally to Resident 65 and failed to inform Resident 65 the names of midodrine, pioglitazone, lubiprostone, aspirin, escitalopram, finasteride, gabapentin and furosemide and their indications prior to the resident swallowing them. LVN 2 stated that LVN 2 usually informs the residents of each medication and the indication prior to administration but did not do so earlier with midodrine, pioglitazone, lubiprostone, aspirin, escitalopram, finasteride, gabapentin and furosemide. LVN 2 stated according to facility policy and procedures (P&P) LVN 2 needed to inform Resident 65 the name and indication of all the medications administered, to give Resident 65 the right to be involved in their care and treatment and be able to make choices such as refusing a specific medication. LVN 2 stated not providing that information during medication administrations restricted Resident 65 from their rights. During a review of the facility's P&P, titled Resident Rights, last reviewed 1/15/2026, the P&P indicated: Be fully informed and participate in their treatment in a language that they can understand. During a review of the facility's P&P, titled Guidelines for Medication Administration, last reviewed 1/15/2026, the P&P indicated Properly identify the Resident/Patient and explain the type pf medication to be administered. During a review of the facility's P&P, titled Medication- Administration, last reviewed 1/15/2026, the P&P indicated: A. The resident has the right to know what the medication does. B. The resident has the right to refuse the medication.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who returned to the facility after a hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) treatment on [DATE], at approximately 7:10 p.m., received necessary care and monitoring in accordance with professional standards of practice. Resident 1, who had anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen [a colorless, odorless reactive gas and the life-supporting component of the air] to the body) and was receiving Eliquis (a medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding), had a history of removing the pressure dressing (specialized bandage applied to access site to provide firm, consistent pressure after dialysis to stop bleeding) from her (Resident 1) left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be drawn, cleaned, and returned to the body) after a hemodialysis treatment, which had previously resulted in bleeding. The facility failed to: 1. Conduct a post-dialysis assessment (a crucial clinical evaluation after a hemodialysis treatment to check for complications and access site issues like bleeding) and ensure Resident 1 was not bleeding from the left upper arm AV fistula site when Resident 1 returned to the facility after a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 2. Monitor Resident 1's left upper arm AV fistula site for bleeding and other complications upon return from a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 3. Ensure a clearly documented communication process was in place and followed when Resident 1 returned to the facility from a hemodialysis treatment on [DATE], at approximately 7:10 p.m. 4. Follow the facility's policy and procedure (P&P) titled, Dialysis Care, last reviewed on [DATE], indicating, The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident . after the completion of each dialysis treatment. 5. Follow the facility's P&P titled, End-Stage Renal Disease (ESRD - the final stage of chronic kidney disease [CKD] where kidneys fail permanently, requiring hemodialysis or a kidney transplant for survival), Care of a Resident with, last reviewed on [DATE], indicating, Residents with ESRD will be cared for according to currently recognized standards of care. As a result, on [DATE], at approximately 7:50 p.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 bleeding from the AV fistula site. Resident 1 was found, unresponsive, in a sitting position at the edge of the bed, with upper body leaning on the bed, without the pressure dressing in place at the AV fistula site, and with blood all over the bed and floor in Resident 1's room. On [DATE] at 8:15 p.m., the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1 deceased in the facility. On [DATE] at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Staffing Department (DSD), the Infection Preventionist (IP), and the Administrator (through telephone), due to the facility's failure to ensure a resident who required hemodialysis treatment received care and services consistent with professional standards of practice under S483.25(l) Dialysis, by not providing the necessary care and monitoring to Resident 1, which resulted in Resident 1's death on [DATE] at 8:18 p.m. (the Certificate of Death dated [DATE] indicated a time of death of 8:18 p.m., while the facility's Progress Note dated [DATE] indicated the time of death as 8:15 p.m.). On [DATE] at 5:08 p.m., the Administrator provided an acceptable IJ removal plan (a detailed plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to provide necessary care and monitoring to Resident 1, resulting in Resident 1's death on [DATE] at 8:15 p.m. On [DATE] at 6:27 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to provide necessary care and monitoring to Resident 1, resulting in Resident 1's death on [DATE] at 8:15 p.m., was no longer present. The SSA removed the IJ situation, while onsite, on [DATE] at 6:27 p.m. in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE] at 4 p.m., the DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment on [DATE]. The DON conducted interviews with Registered Nurse 1 (RN 1), and Licensed Vocational Nurse 1 (LVN 1), who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift (scheduled work period). The DON reviewed the facility's P&P on Dialysis Care,, forms used for dialysis care (Nursing Facility Pre and Post Dialysis Assessment forms), nurses progress notes, and communication related to Resident 1's return from the dialysis treatment. The DON identified failures related to post-dialysis assessment, monitoring, communication, and documentation. 2. Effective [DATE], at 2 p.m., all residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse (an LVN coordinating care for the assigned residents) and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs (measurements of your body's most basic functions, including temperature, heart rate, respiratory rate, and blood pressure), bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN. 3. On [DATE] at 2:05 p.m., the DON and Medical Records staff conducted an audit (review of records, processes, or systems to assess accuracy and compliance) on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1. 4. On [DATE] at 3 p.m., the Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. On [DATE] at 10 a.m., the Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care. The updated policy became effective [DATE] at 3 p.m. and will be presented to the Quality Assurance Committee at the next monthly meeting in 1/2026. 5. On [DATE] at 4 p.m., the DON provided one-on-one (1:1) in-service (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 and LVN 1, who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident. 6. The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs), and the residents' goals and preferences. 7. On [DATE] at 2:10 p.m. and 5:25 p.m., and [DATE] at 12 p.m., the DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on the following: a. Comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment. b. Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility. 8. On [DATE] at 3:30 p.m., the DON performed a competency check (an evaluation of the necessary skills, knowledge, and behaviors for a specific task) of RN 1 regarding dialysis care, including monitoring, documentation, and communication. 9. On [DATE] at 3:30 p.m., the DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation. 10. On [DATE] at 3:30 p.m., the DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations. 11. On [DATE] at 4 pm., the DON conducted an audit on residents who returned from hemodialysis on [DATE] (Residents 2, 4, 7, and 8). Audit findings showed all requirements were completed and in place for each of the reviewed residents. The review showed that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient (a resident who receives care and treatment at a hospital or clinic but does not stay overnight) hemodialysis. Cross reference F656.Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including ESRD, anemia, unspecified atrial fibrillation (a-fib - an irregular and often very rapid heart rhythm), and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump [systolic] and relax/fill [diastolic], leading to fluid buildup and inefficient blood flow). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - [DATE]: Hemodialysis every Tuesday, Thursday, and Saturday. - [DATE]: Monitor left arm AV shunt dialysis access for bruit (sound of turbulent blood flow heard with a stethoscope [a medical instrument for listening to the action of someone's heart or breathing]) and thrill (the palpable vibration felt by hand over a turbulent blood flow), swelling, bleeding, and signs of infection every shift. - [DATE]: Eliquis oral tablet 2.5 milligram (mg - unit of measurement) to give one tablet by mouth two times a day for a-fib. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was intact. The MDS indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing, and lower body dressing. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from the facility staff to propel (move) a wheelchair (a chair with wheels used in order to move around) at least 150 feet (ft - unit of length). During a review of Resident 1's Change in Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) Evaluation form, dated [DATE], timed at 11:21 p.m., the COC form indicated that on [DATE], in the afternoon (time not specified), Resident 1 removed the AV shunt pressure dressing prior to the allotted time (not specified) and bled for over one hour. During a review of Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], the Care Plan indicated Resident 1 was a hemodialysis resident with AV fistula in her (Resident 1) left arm. The Care Plan indicated Resident 1 had episodes of prematurely (before the recommended time) removing the pressure dressing, resulting in bleeding from the fistula site. The Care Plan interventions indicated to check bandage and leave in place for at least 4 hours after hemodialysis treatment or longer if the needle site continued to ooze. The Care Plan interventions also indicated to monitor the dialysis access site upon return from the dialysis for bleeding, redness, swelling, pain, and notify the physician as needed. During a review of Resident 1's Progress Note, dated [DATE], the Progress Notes indicated that on [DATE], at approximately 7:50 p.m., CNA 1 informed RN 1 that Resident 1 was bleeding from her (Resident 1) AV fistula site. The Progress Note indicated Resident 1 was found in a sitting position (at the edge of the bed) with her (Resident 1) upper body lying in bed without the pressure dressing on the fistula site and with blood all over the bed and floor. The Progress Note indicated RN 1 applied pressure to the AV fistula site and placed Resident 1 in bed. The Progress Note further indicated that paramedics arrived at the facility on [DATE] at 8:15 p.m. The Progress Note indicated Resident 1 was noted with cardiac (relating to the heart) activity, however respirations (action of breathing) were not observed, and vital signs were unobtainable. The Progress Note indicated the paramedics pronounced Resident 1 deceased on [DATE] at 8:15 p.m. (The Certificate of Death indicated Resident 1's time of death as 8:18 p.m. on [DATE]). During a review of Resident 1's Nursing Facility Pre-Dialysis Assessment (to be completed by the facility staff) form, dated [DATE], the Pre-Dialysis Assessment form indicated that LVN 5 completed Resident 1's pre-dialysis assessment. However, the lower portion of the form titled, Nursing Facility Post-Dialysis Assessment (to be completed by the facility staff) was blank and not completed, indicating that a post-dialysis assessment was not conducted by the facility staff after Resident 1 returned from hemodialysis treatment on [DATE]. During a review of Resident 1's Certificate of Death, dated [DATE], the Certificate of Death indicated Resident 1 died at the facility on [DATE] at 8:18 p.m. During an interview on [DATE] at 3:44 p.m. with CNA 1, CNA 1 stated that on [DATE] during the 3 p.m. to 11 p.m. shift, she (CNA 1) was the assigned CNA for Resident 1. CNA 1 stated that on [DATE], at the start of her (CNA 1) shift, Resident 1 was outside the facility receiving hemodialysis treatment. CNA 1 stated that she did not observe Resident 1's return to the facility prior to going on her lunch break at approximately 7:20 p.m. and did not check Resident 1's room before leaving for her (CNA 1) lunch break. CNA 1 further stated that on [DATE], at approximately 7:50 p.m., upon returning from her (CNA 1) lunch break, she (CNA 1) entered Resident 1's room and found Resident 1 sitting on the side of the bed with her (Resident 1) feet on the floor and her (Resident 1) upper body leaning onto the bed. CNA 1 stated there was a puddle of blood on the floor and Resident 1's hemodialysis access site was actively bleeding, like a running faucet, like if you cut yourself with a kitchen knife. CNA 1 stated that she (CNA 1) immediately exited the room and notified RN 1 of Resident 1's condition. During an interview on [DATE] at 5:01 p.m. with LVN 1, LVN 1 stated that she was the LVN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. LVN 1 stated that at the start of her (LVN 1) shift, Resident 1 had already left the facility for outpatient hemodialysis treatment. LVN 1 stated that Resident 1 would usually return from the hemodialysis treatment between 7 p.m. and 7:30 p.m., depending on the duration of the treatment. LVN 1 stated that on [DATE] at approximately 7:30 p.m., she (LVN 1) went on her (LVN 1) lunch break. LVN 1 stated that prior to leaving for her (LVN 1) lunch break, she (LVN 1) could not recall checking Resident 1's room to determine whether Resident 1 had returned to the facility. LVN 1 stated she (LVN 1) was not informed by another facility staff when Resident 1 returned from hemodialysis treatment. LVN 1 further stated that upon returning from her (LVN 1) lunch break, RN 1 gestured for her (LVN 1) to follow her (RN 1) to Resident 1's room. LVN 1 stated that when she (LVN 1) entered Resident 1's room, at approximately 8 p.m., Resident 1 was lying on her (Resident 1) back, in bed with her (Resident 1's) eyes open and fixed upward. LVN 1 stated that Resident 1's AV fistula dressing was no longer in place and was located on the bed next to Resident 1's left arm. LVN 1 stated there was blood on the AV fistula dressing, on the bed, and everywhere. LVN 1 stated there was a pool of blood near Resident 1's left arm. LVN 1 stated CNA 1 and RN 1 were present in Resident 1's room. LVN 1 stated that facility staff attempted to arouse Resident 1 and assess Resident 1's pulse to determine if Resident 1 was responsive, however, Resident 1 did not respond. LVN 1 stated she (LVN 1) felt Resident 1's thready (very weak, barely perceptible, often fading in and out) pulse, but since Resident 1 was not responding, she (LVN 1) was unsure whether Resident 1 had a pulse. LVN 1 stated a few minutes after she (LVN 1) entered Resident 1's room (cannot recall the exact time), paramedics arrived, at which point she (LVN 1) stepped out of the room. During a concurrent interview and record review on [DATE] at 11:19 p.m. with Registered Nurse 2 (RN 2), Resident 1's Progress Notes dated [DATE] and Nursing Facility Post-Dialysis Assessment form dated [DATE], were reviewed. RN 2 stated there was no record in Resident 1's progress notes indicating the time Resident left the facility for hemodialysis and the time she (Resident 1) returned to the facility on [DATE]. RN 2 further stated Resident 1's Nursing Facility Post-Dialysis Assessment portion of Resident 1's post-dialysis assessment form was not completed, indicating that facility staff did not perform and document Resident 1's post hemodialysis assessment when Resident 1 returned to the facility on [DATE]. RN 2 stated per facility policy and protocol when residents return to the facility after a hemodialysis treatment, an LVN or the RN is required to complete a post-hemodialysis assessment and document the resident's return in the progress notes. RN 2 stated that on [DATE], facility staff did not follow the facility's policies and protocols for the care of dialysis residents and failed to assess Resident 1 upon her (Resident 1) return from hemodialysis treatment. RN 2 further stated that there was no record or documentation identifying which facility staff member received Resident 1 upon return from hemodialysis treatment and there was no documentation indicating that Resident 1's AV fistula site was assessed or monitored following Resident 1's return. RN 2 stated that a prompt post-hemodialysis assessment upon Resident 1's return could have identified potential issues, including the status of the AV fistula dressing, and could have prevented Resident 1 from removing the AV fistula dressing and experiencing subsequent bleeding, which could have potentially altered the outcome of the incident. During an interview on [DATE] at 2:28 p.m. with RN 1, RN 1 stated that she was the RN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. RN 1 stated that on [DATE], at approximately 7:10 p.m., she (RN 1) observed transportation staff with Resident 1 seated in a wheelchair outside the facility near the locked emergency exit door. RN 1 stated that she (RN 1) was the only staff member present near the nursing station at that time. RN 1 stated she (RN 1) opened the door and wheeled Resident 1 to her (Resident 1) room. RN 1 stated Resident 1 remained seated in the wheelchair, and she (RN 1) assisted Resident 1 back into bed by holding Resident 1's left arm and guiding Resident 1 to the bed. RN 1 stated Resident 1 sat on the edge of the bed. RN 1 stated she (RN 1) connected Resident 1 to oxygen at two liters (L - unit of measurement) per minute via nasal cannula (clear tube with two prongs that sit in the nostrils to deliver supplemental oxygen). RN 1 stated Resident 1 did not complain of pain. RN 1 stated Resident 1 was wearing a cardigan and that she (RN 1) did not see the left upper arm AV fistula dressing. RN 1 stated that because Resident 1's cardigan near the left upper arm was not wet, she (RN 1) assumed Resident 1's left upper arm AV fistula site was not bleeding. RN 1 stated she (RN 1) did not check Resident 1's vital signs and did not visually inspect Resident 1's left upper arm AV fistula site. RN 1 stated Resident 1 looked stable and that when she (RN 1) was paged to answer a phone call (cannot recall the details of the phone call), she (RN 1) left Resident 1's room after spending approximately 10 minutes in Resident 1's room. RN 1 further stated she did not inform LVN 1, CNA 1, or any other facility staff that Resident 1 had returned to the facility. RN 1 stated she (RN 1) assumed that both LVN 1 and CNA 1 were on their lunch breaks but did not confirm with them (LVN 1 and CNA 1). RN 1 stated after answering the phone call, she (RN 1) returned to the nursing station. RN 1 stated that at 7:50 p.m. (approximately 30 minutes after RN 1 left Resident 1's room), CNA 1 informed her (RN 1) that Resident 1 was bleeding. RN 1 stated she (RN 1) immediately went to Resident 1's room. RN 1 stated there was blood all over Resident 1's bed and on the floor. RN 1 stated Resident 1's legs were near the edge of the bed with her (Resident 1) feet touching the floor, while her (Resident 1) upper body was leaning back towards the right side with her (Resident 1) eyes closed. RN 1 stated that Resident 1 opened her eyes when her (Resident 1) name was called but did not verbally respond. RN 1 stated Resident 1's cardigan was off, and that the left upper arm AV fistula dressing made of gauze and tape, was off and no longer in place and was next to the left arm. RN 1 stated blood was actively squirting from Resident 1's left upper arm AV fistula site. RN 1 stated blood was all over Resident 1's clothing and bed. RN 1 stated Resident 1's abdominal area, pants and the left side of the bed linens were saturated with blood. RN 1 stated that there was blood on the floor, approximately equal to the size of a bedside table. RN 1 stated she (RN 1) immediately used gauze to put pressure on Resident 1's left upper arm AV fistula site to stop the bleeding. RN 1 stated Resident 1 had a weak pulse, and she (RN 1) was unable to obtain a blood pressure reading. RN 1 stated that paramedics arrived at approximately 8:05 p.m. and that Resident 1 was pronounced deceased at approximately 8:15 p.m. (The Certificate of Death indicated the time of death as 8:18 p.m. on [DATE].). RN 1 stated she (RN 1) should have assessed Resident 1's vital signs and inspected the AV fistula site for bleeding upon Resident 1's return from hemodialysis treatment. RN 1 stated that she (RN 1) should have documented Resident 1's return and notified other facility staff. RN 1 further stated Resident 1's Care Plan interventions (such as monitoring access site upon return from hemodialysis for bleeding) were not implemented, and that Resident 1 was not assessed and monitored upon return from hemodialysis. RN 1 stated Resident 1's incident on [DATE] could have been avoided if Resident 1 had been assessed and monitored following her (Resident 1) return to the facility from hemodialysis treatment. During an interview on [DATE] at 4:13 p.m. with the DON, the DON stated residents who receive hemodialysis should be assessed prior to leaving the facility and upon return following hemodialysis treatment. The DON stated the Nursing Facility Pre and Post Dialysis Assessment form must be completed by the Charge Nurse (LVN), RN, or another licensed nurse on the floor who accepts the resident upon return from the outpatient hemodialysis center. The DON further stated that facility staff should document in the progress notes the time residents leave the facility and the time they return from outpatient treatments such as hemodialysis. The DON stated Resident 1, who had anemia, heart failure, was receiving Eliquis, and had a documented history of prematurely removing her (Resident 1) AV fistula dressing, was not assessed and monitored on [DATE] after returning to the facility from the hemodialysis treatment. The DON stated facility staff failed to document when Resident 1 left and returned to the facility, failed to obtain vital signs, and failed to assess Resident 1's AV fistula site for bleeding upon her (Resident 1) return. The DON stated there was no documented evidence to indicate that Resident 1 was monitored after returning to the facility on [DATE]. The DON stated facility staff did not follow the facility's policies and protocol related to the care and monitoring of a resident receiving hemodialysis and failed to implement Resident 1's Care Plan interventions for AV fistula care and monitoring following her (Resident 1) return from hemodialysis treatment. The DON stated, as a result, on [DATE], Resident 1 experienced a hemorrhage (excessive bleeding) from the AV fistula site and passed away at 8:15 p.m. The DON stated the incident on [DATE] could have been avoided if facility staff followed the facility's P&P for the care and monitoring of hemodialysis residents and implemented Resident 1's Care Plan (initiated on [DATE]) interventions. During a concurrent interview and record review on [DATE] at 3:08 p.m. with the DON, the facility's P&P tiled, Dialysis Care, dated [DATE] was reviewed. The P&P indicated, The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment and providing for all non-dialysis needs of the resident including during the time period when the resident is receiving dialysis. V. Documentation: A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. B. Documentation may include NP-225-Form A-Pre/Post Dialysis Assessment, Form-225-Form-B-Dialysis Flow Sheet-Return Assessment. The DON stated the facility's P&P for Dialysis Care did not clearly define the pre- and post-dialysis responsibilities of licensed nurses, the required monitoring of the residents before and after dialysis treatment, and the care and monitoring of dialysis access sites. The DON stated that this lack of clarity resulted in confusion among facility staff regarding pre- and post-dialysis assessments, the care of residents receiving hemodialysis, and the proper implementation of care plan interventions. The DON further stated there was a systemic failure in the facility's processes for providing care to residents before and after hemodialysis treatment. During a review of the current facility-provided P&P titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on [DATE], the P&P indicated, Residents with (ESRD) will be cared for according to currently recognized standards of care. 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: . b. the type of assessment data that is to be gathered about the residents' condition on a daily or per shift basis; . g. the care of grafts (is a surgically implanted, soft, synthetic tube used to connect an artery and a vein, typically in the arm) and fistulas. 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a review of the current facility-provided P&P titled, Documentation-Nursing, last reviewed on [DATE], the P&P indicated, To provide documentation of resident status and care given by nursing staff. Nursing documentation will be concise, clear, pertinent, and accurate. G. Nurse's notes addressing the resident leaving the facility will document when and with whom, and time of return, along with any medications sent.

Based on interview and record review, the facility failed to: 1. Implement the care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs) for one of four sampled residents (Resident 1) which included interventions related to hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) care that required monitoring of Resident 1's left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be drawn, cleaned, and returned to the body) for bleeding upon return to the facility following hemodialysis treatment. On [DATE], at approximately 7:10 p.m., the facility failed to monitor Resident 1's AV Fistula site as indicated in the care plan. Resident 1, who had a diagnosis of anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen [a colorless, odorless reactive gas and the life-supporting component of the air] to the body), was receiving Eliquis (a medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding), and had a known history of removing the pressure dressing (specialized bandage applied to access site to provide firm, consistent pressure after dialysis to stop bleeding) from her (Resident 1) left upper arm AV fistula after a hemodialysis treatment, which had previously resulted in bleeding. As a result, on [DATE], at approximately 7:50 p.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 bleeding from the AV fistula site. Resident 1 was found, unresponsive, in a sitting position at the edge of the bed, with upper body leaning on the bed, without the pressure dressing in place at the AV fistula site and with blood all over the bed and floor in Resident 1's room. On [DATE] at 8:18 p.m., the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1 deceased in the facility. 2. Develop and implement a person-centered care plan for one of three sampled residents (Resident 5) to address Resident 5's admission to hospice (compassionate care for people who are near the end of life). This failure had the potential for delays in the delivery of necessary care and services to Resident 5. On [DATE] at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Staffing Department (DSD), the Infection Preventionist (IP), and the Administrator (through telephone), due to the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following hemodialysis treatment on [DATE] under S483.21(b) Comprehensive Care Plans, which resulted in Resident 1's death on [DATE] at 8:18 p.m. (The Certificate of Death dated [DATE] indicated a time of death of 8:18 p.m., while the facility's Progress Note dated [DATE] indicated the time of death as 8:15 p.m.) On [DATE] at 5:22 p.m., the Administrator provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following hemodialysis treatment on [DATE], which resulted in Resident 1's death on [DATE] at 8:18 p.m. On [DATE] at 6:27 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to implement Resident 1's care plan related to hemodialysis care that required monitoring of Resident 1's left upper arm AV fistula for bleeding upon return to the facility following hemodialysis treatment on [DATE], which resulted in Resident 1's death on [DATE] at 8:18 p.m. was no longer present. The SSA removed the IJ situation, while onsite, on [DATE] at 6:27 p.m. in the presence of the Administrator and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE] at 4 p.m., the DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment on [DATE]. The DON conducted interviews with Registered Nurse 1 (RN 1), and Licensed Vocational Nurse 1 (LVN 1), who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift (scheduled work period). The DON reviewed the facility's policy and procedure (P&P) on Dialysis Care, forms used for dialysis care (Nursing Facility Pre (before) and Post (after) Dialysis Assessment forms - a crucial clinical evaluation after a hemodialysis treatment to check for complications and access site issues like bleeding), nurses progress notes, and communication related to Resident 1's return from the dialysis treatment. The DON identified failures related to post-dialysis assessment, monitoring, communication, and documentation. 2. Effective [DATE], at 2 p.m., all residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse (an LVN coordinating care for the assigned residents) and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs (measurements of your body's most basic functions, including temperature, heart rate, respiratory rate, and blood pressure), bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN. 3. On [DATE] at 2 p.m., the RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their (Residents 2, 3, 4, 5, 6, 7, 8, and 9) dialysis access sites.4. On [DATE] at 2:05 p.m., the DON and Medical Records staff conducted an audit (review of records, processes, or systems to assess accuracy, compliance) on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1. 5. On [DATE], at 2:05 p.m., the DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9. 6. On [DATE] at 2:10 p.m. and 5:25 p.m., and on [DATE] at 12 p.m., the DON and DSD provided in-service (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) training to nursing staff regarding care planning, with emphasis on the following: a. Implementation of residents' individualized hemodialysis care plans. b. Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment. c. Comprehensive assessment and monitoring of residents by LVNs or RNs following dialysis treatment. 7. On [DATE] at 4 p.m., the DON provided a one on one (1:1) in-service to RN 1 and LVN 1, who were assigned to Resident 1 on [DATE] during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident. Cross reference with F698. Findings: 1. During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including End-Stage Renal Disease (ESRD - the final stage of chronic kidney disease [CKD] where kidneys fail permanently, requiring hemodialysis or a kidney transplant for survival), anemia, unspecified atrial fibrillation (a-fib - an irregular and often very rapid heart rhythm), and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump [systolic] and relax/fill [diastolic], leading to fluid buildup and inefficient blood flow). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - [DATE]: Hemodialysis every Tuesday, Thursday, and Saturday. - [DATE]: Monitor left arm AV shunt dialysis access for bruit (sound of turbulent blood flow heard with a stethoscope [a medical instrument for listening to the action of someone's heart or breathing]) and thrill (the palpable vibration felt by hand over a turbulent blood flow), swelling, bleeding, and signs of infection every shift. - [DATE]: Eliquis oral tablet 2.5 milligram (mg - unit of measurement) to give one tablet by mouth two times a day for a-fib. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was intact. The MDS indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing, and lower body dressing. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from the facility staff to propel (move) a wheelchair (a chair with wheels used in order to move around) at least 150 feet (ft - unit of length). During a review of Resident 1's Change in Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) Evaluation form, dated [DATE], timed at 11:21 p.m., the COC form indicated on [DATE], during the afternoon hours (time not specified), Resident 1 removed the AV shunt pressure dressing prior to the allotted time (not specified) and bled for over one hour. During a review of Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], the Care Plan indicated Resident 1 was a hemodialysis resident with AV fistula in her (Resident 1) left arm. The Care Plan indicated Resident 1 had episodes of prematurely (before the recommended time) removing the pressure dressing, resulting in bleeding from the fistula site. The Care Plan interventions indicated to check bandage and leave in place for at least 4 hours after hemodialysis treatment or longer if the needle site continued to ooze. The Care Plan interventions also indicated to monitor the dialysis access site upon return from the dialysis for bleeding, redness, swelling, pain, and notify the physician as needed. During a review of Resident 1's Progress Note, dated [DATE], the Progress Notes indicated that on [DATE], at approximately 7:50 p.m., CNA 1 informed RN 1 that Resident 1 was bleeding from her (Resident 1) AV fistula site. The Progress Note indicated Resident 1 was found in a sitting position (at the edge of the bed) with her (Resident 1) upper body lying in bed without the pressure dressing on the fistula site and with blood all over the bed and floor. The Progress Note indicated RN 1 applied pressure to the AV fistula site and placed Resident 1 in bed. The Progress Note further indicated that paramedics arrived at the facility on [DATE] at 8:15 p.m. The Progress Note indicated Resident 1 was noted with cardiac (relating to the heart) activity, however respirations (action of breathing) were not observed, and vital signs were unobtainable. The Progress Note indicated the paramedics pronounced Resident 1 deceased on [DATE] at 8:15 p.m. (The Certificate of Death indicated Resident 1's time of death as 8:18 p.m. on [DATE].) During a review of Resident 1's Nursing Facility Pre-Dialysis Assessment (to be completed by the facility staff) form, dated [DATE], the pre-dialysis assessment form indicated LVN 5 completed Resident 1's pre-dialysis assessment. However, the lower portion of the form titled, Nursing Facility Post-Dialysis Assessment (to be completed by the facility staff) was blank and not completed indicating that a post-dialysis assessment was not conducted by the facility staff after Resident 1 returned from the hemodialysis treatment on [DATE]. During a review of Resident 1's Certificate of Death, dated [DATE], the Certificate of Death indicated Resident 1 died at the facility on [DATE] at 8:18 p.m. The Certificate of Death indicated ESRD as the immediate cause of death and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [colorless, odorless gas] from the body, making it hard to breathe and function) as a significant condition contributing to death but not resulting in the underlying cause. During an interview on [DATE] at 3:44 p.m. with CNA 1, CNA 1 stated that on [DATE] during the 3 p.m. to 11 p.m. shift, she (CNA 1) was the assigned CNA for Resident 1. CNA 1 stated that on [DATE], at the start of her (CNA 1) shift, Resident 1 was outside the facility receiving hemodialysis treatment. CNA 1 stated that she did not observe Resident 1's return to the facility prior to going on her lunch break at approximately 7:20 p.m. and did not check Resident 1's room before leaving for her (CNA 1) lunch break. CNA 1 further stated that on [DATE], at approximately 7:50 p.m., upon returning from her (CNA 1) lunch break, she (CNA 1) entered Resident 1's room and found Resident 1 sitting on the side of the bed with her (Resident 1) feet on the floor and her (Resident 1) upper body leaning onto the bed. CNA 1 stated there was a puddle of blood on the floor and Resident 1's hemodialysis access site was actively bleeding, like a running faucet, like if you cut yourself with a kitchen knife. CNA 1 stated that she (CNA 1) immediately exited the room and notified RN 1 of Resident 1's condition. During an interview on [DATE] at 5:01 p.m. with LVN 1, LVN 1 stated that she was the LVN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. LVN 1 stated that at the start of her (LVN 1) shift, Resident 1 had already left the facility for outpatient hemodialysis treatment. LVN 1 stated that Resident 1 would usually return from the hemodialysis treatment between 7 p.m. and 7:30 p.m., depending on the duration of the treatment. LVN 1 stated that on [DATE] at approximately 7:30 p.m., she (LVN 1) went on her (LVN 1) lunch break. LVN 1 stated that prior to leaving for her (LVN 1) lunch break, she (LVN 1) could not recall checking Resident 1's room to determine whether Resident 1 had returned to the facility. LVN 1 stated she (LVN 1) was not informed by another facility staff when Resident 1 returned from hemodialysis treatment. LVN 1 further stated that upon returning from her (LVN 1) lunch break, RN 1 gestured for her (LVN 1) to follow her (RN 1) to Resident 1's room. LVN 1 stated that when she (LVN 1) entered Resident 1's room, at approximately 8 p.m., Resident 1 was lying on her (Resident 1) back, in bed with her (Resident 1's) eyes open and fixed upward. LVN 1 stated that Resident 1's AV fistula dressing was no longer in place and was located on the bed next to Resident 1's left arm. LVN 1 stated there was blood on the AV fistula dressing, on the bed, and everywhere. LVN 1 stated there was a pool of blood near Resident 1's left arm. LVN 1 stated CNA 1 and RN 1 were present in Resident 1's room. LVN 1 stated that facility staff attempted to arouse Resident 1 and assess Resident 1's pulse to determine if Resident 1 was responsive, however, Resident 1 did not respond. LVN 1 stated she (LVN 1) felt Resident 1's thready (very weak, barely perceptible, often fading in and out) pulse, but since Resident 1 was not responding, she (LVN 1) was unsure whether Resident 1 had a pulse. LVN 1 stated a few minutes after she (LVN 1) entered Resident 1's room (cannot recall the exact time), paramedics arrived, at which point she (LVN 1) stepped out of the room. During a concurrent interview and record review on [DATE] at 11:19 a.m. with RN 2, Resident 1's Care Plan regarding hemodialysis, initiated on [DATE], indicating to monitor the dialysis access site upon return from the dialysis for bleeding, was reviewed. RN 2 stated there was no documented evidence in Resident 1's medical record to indicate that Resident 1 was assessed and monitored upon return to the facility following hemodialysis treatment. RN 2 further stated there was no documentation showing that the AV fistula dressing was assessed or indicating when the dressing was removed. RN 2 stated the facility staff failed to implement Resident 1's Care Plan interventions related to monitoring and managing Resident 1's AV fistula site and failed to complete post-dialysis assessments upon Resident 1's return to the facility. RN 2 stated that the facility's failure to conduct post-dialysis assessments could potentially result in adverse (harmful or undesired) outcomes, including bleeding. RN 2 stated prompt assessment and monitoring of Resident 1 after returning from hemodialysis could have prevented Resident 1 from removing the AV fistula dressing and experiencing subsequent bleeding, potentially altering the outcome of the incident. During an interview on [DATE] at 2:28 p.m. with RN 1, RN 1 stated that she was the RN assigned to Resident 1 during the 3 p.m. to 11 p.m. shift on [DATE]. RN 1 stated that on [DATE], at approximately 7:10 p.m., she (RN 1) observed transportation staff with Resident 1 seated in a wheelchair outside the facility near the locked emergency exit door. RN 1 stated that she (RN 1) was the only staff member present near the nursing station at that time. RN 1 stated she (RN 1) opened the door and wheeled Resident 1 to her (Resident 1) room. RN 1 stated Resident 1 remained seated in the wheelchair, and she (RN 1) assisted Resident 1 back into bed by holding Resident 1's left arm and guiding Resident 1 to the bed. RN 1 stated Resident 1 sat on the edge of the bed. RN 1 stated she (RN 1) connected Resident 1 to oxygen at two liters (L - unit of measurement) per minute via nasal cannula (clear tube with two prongs that sit in the nostrils to deliver supplemental oxygen). RN 1 stated Resident 1 did not complain of pain. RN 1 stated Resident 1 was wearing a cardigan and that she (RN 1) did not see the left upper arm AV fistula dressing. RN 1 stated that because Resident 1's cardigan near the left upper arm was not wet, she (RN 1) assumed Resident 1's left upper arm AV fistula site was not bleeding. RN 1 stated she (RN 1) did not check Resident 1's vital signs and did not visually inspect Resident 1's left upper arm AV fistula site. RN 1 stated Resident 1 looked stable and that when she (RN 1) was paged to answer a phone call (cannot recall the details of the phone call), she (RN 1) left Resident 1's room after spending approximately 10 minutes in Resident 1's room. RN 1 further stated she did not inform LVN 1, CNA 1, or any other facility staff that Resident 1 had returned to the facility. RN 1 stated she (RN 1) assumed that both LVN 1 and CNA 1 were on their lunch breaks but did not confirm with them (LVN 1 and CNA 1). RN 1 stated after answering the phone call, she (RN 1) returned to the nursing station. RN 1 stated that at 7:50 p.m. (approximately 30 minutes after RN 1 left Resident 1's room), CNA 1 informed her (RN 1) that Resident 1 was bleeding. RN 1 stated she (RN 1) immediately went to Resident 1's room. RN 1 stated there was blood all over Resident 1's bed and on the floor. RN 1 stated Resident 1's legs were near the edge of the bed with her (Resident 1) feet touching the floor, while her (Resident 1) upper body was leaning back towards the right side with her (Resident 1) eyes closed. RN 1 stated that Resident 1 opened her eyes when her (Resident 1) name was called but did not verbally respond. RN 1 stated Resident 1's cardigan was off, and that the left upper arm AV fistula dressing made of gauze and tape, was off and no longer in place and was next to the left arm. RN 1 stated blood was actively squirting from Resident 1's left upper arm AV fistula site. RN 1 stated blood was all over Resident 1's clothing and bed. RN 1 stated Resident 1's abdominal area, pants and the left side of the bed linens were saturated with blood. RN 1 stated that there was blood on the floor, approximately equal to the size of a bedside table. RN 1 stated she (RN 1) immediately used gauze to put pressure on Resident 1's left upper arm AV fistula site to stop the bleeding. RN 1 stated Resident 1 had a weak pulse, and she (RN 1) was unable to obtain a blood pressure reading. RN 1 stated that paramedics arrived at approximately 8:05 p.m. and that Resident 1 was pronounced deceased at approximately 8:15 p.m. (The Certificate of Death indicated the time of death as 8:18 p.m. on [DATE].). RN 1 stated she (RN 1) should have assessed Resident 1's vital signs and inspected the AV fistula site for bleeding upon Resident 1's return from hemodialysis treatment. RN 1 stated that she (RN 1) should have documented Resident 1's return and notified other facility staff. RN 1 further stated Resident 1's Care Plan interventions (such as checking the bandage and monitoring the access site upon return from hemodialysis for bleeding) were not implemented, and that Resident 1 was not assessed and monitored upon return from hemodialysis. RN 1 stated Resident 1's incident on [DATE] could have been avoided if Resident 1 had been assessed and monitored following her (Resident 1) return to the facility from hemodialysis treatment. During a concurrent interview and record review on [DATE] at 12:14 p.m. with the DON, Resident 1's Care Plan regarding ESRD - hemodialysis, initiated on [DATE], and Care Plan regarding hemodialysis, initiated on [DATE] were reviewed. The Care Plan initiated on [DATE] indicated Resident 1 needed hemodialysis. The Care Plan interventions included checking the dressing on Resident 1's left upper arm AV fistula, changing the dressing daily, and documenting the care provided. The Care Plan interventions further indicated to monitor and document, as needed, for signs and symptoms of bleeding or hemorrhage (loss of blood from a damaged blood vessel). The DON stated there was no documented monitoring system in place beyond assessing Resident 1's AV fistula site every shift for bleeding or other complications. The DON stated monitoring was primarily based on visual observation by facility staff. The DON further stated that the Nursing Facility Pre and Post Assessment form did not include documentation of the time the hemodialysis access site dressing was removed and Resident 1's response to the removal. The DON stated facility staff should document when the dressing is removed and how the resident tolerates the process. The DON stated there was no record indicating that Resident 1 was assessed and monitored following hemodialysis treatment on [DATE]. The DON further stated that Resident 1's dialysis-related Care Plan interventions were not implemented by the facility staff. The DON stated that the Care Plan serves as a guiding process for providing appropriate and accurate care to residents. The DON stated that prior to the incident on [DATE] when Resident 1 removed her (Resident 1) AV fistula dressing and experienced bleeding, Resident 1's Care Plan did not adequately address care of the left upper arm AV fistula. The DON stated that a specific Care Plan addressing AV fistula site care was necessary to ensure staff understood how to appropriately monitor and manage the fistula site. The DON stated it is the responsibility of LVNs and RNs to ensure that a resident's care plan is complete, accurate, and that all interventions are implemented. The DON stated facility staff failed to implement Resident 1's Care Plan interventions related to hemodialysis and AV fistula assessment and monitoring following Resident 1's return from hemodialysis treatment on [DATE]. During an interview on [DATE] at 2:31 p.m. with the DON, the DON stated Resident 1's death could have been avoided had Resident 1's Care Plan addressing hemodialysis and AV fistula site care been fully developed and Care Plan interventions implemented. The DON further stated the facility did not have a policy addressing Care Plan intervention implementations. During a review of the current facility-provided P&P titled, Care Planning, last reviewed on [DATE], the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team (IDT - a group of various skilled healthcare professionals who collaborate to create a comprehensive, person-centered care plan for a resident, coordinating services, setting goals, and addressing complex needs) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the current facility-provided P&P titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on [DATE], the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. 2. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on [DATE], with diagnoses that included unspecified (unconfirmed) encephalopathy (any disease, disorder, or damage that changes the way your brain works), late onset Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and history of falling. During a review of Resident 5's H&P, dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 5 was always incontinent (unable to control) of bowel and bladder functions. During a review of Resident 5's Physician Order, dated [DATE], the Physician Order indicated admitting Resident 5 to hospice with routine level of care. During a review of Resident 5's Care Plan, dated [DATE], the Care Plan indicated Resident 5's admission to hospice. During a concurrent interview, and record review on [DATE], at 10:30 a.m., with the MDS Nurse Coordinator (MDSC), Resident 5's Care Plan, dated [DATE] was reviewed. The MDSC stated Resident 5 was admitted to hospice on [DATE]. The MDSC stated Care Plan on hospice should have been created on [DATE] when Resident 5 was admitted to hospice and not on [DATE]. The MDSC stated the nurse who received the order on [DATE], for admission to hospice should have created a care plan on [DATE]. The MDSC stated delays in care plan can cause a delay in care. During an interview on [DATE], at 1:40 p.m., with the Director of Nursing (DON), the DON stated care plan should have been created on [DATE] when Resident 5 was admitted to hospice to prevent delay in care. During a review of facility's P&P titled, Care Planning, dated [DATE], and last reviewed on [DATE], the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial. A Licensed Nurse will initiate the Care Plan . and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. VIII. A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to prevent physical and verbal abuse for two of three sampled residents (Resident 1 and Resident 2). On 12/3/2023 at around 7 p.m. Resident 2 bumped his wheelchair into Resident 1 ' s wheelchair, subsequently Resident 1 and Resident 2 got into an exchange of verbal profanity against each other and punched each other ' s face with close fist several times. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical and verbal abuse by one another while under the care of the facility. Resident 1 sustained redness to the left check and Resident 2 had swelling to the left cheek (inflammation) needing cold compress (chilled or frozen object, often a piece of cloth to relieve pain / swelling). Resident 2 stated feeling defenseless during the assault and was not able to protect himself due to his limited mobility of his left arm. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 11/9/2023, with diagnoses including essential (primary) hypertension (when the pressure in the blood vessels is too high), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/15/2023, indicated Resident 1 had the ability to understand and be understood, make his needs known, and had some memory problem. The MDS indicated Resident 1 required limited to extensive assistance with toileting hygiene and shower and / or bathing and partial assistance with upper body dressing and personal hygiene. Resident 1 used a wheelchair and a walker as mobility devices. A review of Resident 1 ' s Situational Background Assessment Recommendations (SBAR - (communication form between members of the health care team caring for a resident about his / her condition), dated 12/3/2023, indicated that around 7 p.m. Certified Nursing Assistant (CNA 1) informed supervisor about a verbal and physical altercation between Residents 1 and 2. Resident 1 stated he was chatting with CNA 1 in hallway when Resident 2 pushed Resident 1from behind and then, Resident 1 hit Resident 2 hit him. Resident 1 was assessed and was found to have redness on the left cheek. A review of Resident 1 ' s Psychiatric Examination, dated 12/5/2023, indicated the chief complaint was the physical fight with another resident (12/3/2023) with no injuries. Resident 1 denied any pain or concerns. A review of Resident 2's Admission Record indicated the facility admitted the resident on 2/17/2023, with diagnoses including left hemiplegia (severe or complete loss of strength on one side of the body) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply), abnormalities o(manner of walking) and mobility, and essential hypertension. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand and be understood and had some memory problems. The MDS indicated Resident 2 required substantial assistance with toileting hygiene and shower and / or bathing and partial assistance with upper body dressing and personal hygiene. Resident 2 use a walker and a wheelchair for mobility. A review of Resident 2 ' s SBAR, dated 12/3/2023, indicated that around 7 p.m., CNA 1 informed the supervisor that Residents 1 and 2 were exchanging words. Resident 2 stated he was trying to wheel himself through the hallway and he accidentally pushed (or bumped) Resident 1 ' s wheelchair and Resident 1 started hitting him (Resident 2). Resident 2 stated he hit Resident 1 back defending himself (Resident 2). Resident 2 was noted with swelling to the left cheek and was treated with cold compress. A review of Resident 2 ' s Skin and Body Assessment, dated 12/3/2023, indicated physical altercation with another resident and slight swelling to the left cheek. A review of Resident 2 ' s Psychiatric Examination, dated 12/5/2023, indicated the chief complaint was the physical fight with another resident (12/3/2023) with no injuries. Resident 1 denied any pain or concerns. During an interview on 12/12/2023 at 10:25 a.m., Resident 2 stated he could not recall when incident occurred, but it was in the evening he was looking for assistance to get back into bed. Resident 2 stated he was in his wheelchair in hallway and Resident 1 was in hallway speaking to CNA 1 blocking the hallway with his wheelchair. Resident 2 stated he tried to get around Resident 1 but Resident 1 jerked his wheelchair and both wheelchairs made contact. Resident 2 stated that Resident 1 turned around and with a closed fist punched him (Resident 2) on the left eye and pulled on his bag he had around his neck. Resident 2 denied hitting Resident 1 back and stated he only put his right arm up in attempt to protect himself. Resident 2 stated he was given an ice pack, Resident 2 stated he felt defenseless during the assault, he was not able to protect himself due to his stroke and limited mobility of his left arm and leg. During an interview on 12/12/2023 at 11 a.m., Resident 1 stated he did not recall date of incident, but he remembered being outside of his room sitting in the wheelchair and another resident (Resident 2) hit his wheelchair from behind so hard he (Resident 1) almost fell out of his wheelchair. Resident 1 stated he asked Resident 2 what was happening, and Resident 2 replied with profanity, and he (Resident 1) responded back with profanity. Resident 1 stated that Resident 2 then backhanded him in the mouth, and he reacted by smacking Resident 2 back. Resident 1 stated staff (did not identify the staff) separated both. Resident 1 stated he was offered an ice pack for his cheek which was red, but he refused. Resident 1 denied pain or feeling scared. During an interview on 12/12/2023 at 12:33 p.m., CNA 1 stated that on 12/3/2023 around 7 p.m. she was speaking to Resident 1 in hallway and Resident 2 came into hallway in his wheelchair and hit Resident 1 on his wheelchair from behind. CNA 1 stated Resident 1 asked Resident 2 why he pushed him and to say, excuse me. Both residents got into an exchange of foul language, cussing at each other then they started punching each other in the face. CNA 1 stated she tried to separate them but was unable and called for help while staying with Residents 1 and 2. CN 1 stated Licensed Vocational Nurse 1 (LVN 1) and other staff came to help. CNA 1 stated Resident 1 had a red mark on his face but did not complaint of pain. CNA 1 stated the incident was both physical and verbal abuse, it was unpredictable and occurred fast. During a telephone interview on 12/12/2023 at 1:10 p.m., LVN 1 stated that on 12/3/2023 around 7:30 p.m., he was walking out of a resident room when he heard CNA 1 calling for help. LVN 1 stated he saw Resident 1 and Resident 2 both in wheelchairs punching and yelling at each other. LVN 1 stated he assisted with separating both residents. Resident 1 had redness to the left cheek without complaint of pain, refused first aid, and was mad. LVN 1 stated Resident 2 was upset had redness to left cheek and was provided with cold compress. LVN 1 stated he witnessed both verbal and physical abuse but mostly physical abuse. LVN 1 stated he could not tell how many times they hit each other, and both were punching each other with close fists. During an interview on 12/12/2023 at 2:58 p.m., the Director of Nursing (DON) stated was made aware of incident between Residents 1 and 2 on 12/3/2023 around 7:30 p.m. to 8 p.m. and was told it was a physical altercation. A review of facility's policy and procedures titled, Abuse Prevention Program, last revised on 8/2006 indicated resident have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone.

Based on interview, and record review, each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 sampled residents (Resident 36, 133) reviewed for accidents by: 1. Failing to ensure a resident who had histories of getting out of bed and wheelchair unassisted was fully assessed and identified through the facility Incident Reports the probable cause of the resident's falls, in order to develop interventions likely to minimize the chance for additional falls for Resident 36. These deficient practices resulted in Resident 36, having five falls within three months that included a fall on (MONTH) 15, 2019, where the resident sustained [REDACTED]. 2. Failing to ensure that a resident was deemed safe to smoke as per the facility's Resident Smoking Assessment by not having a physician's orders [REDACTED]. This deficient practice had the potential to create an unsafe environment. Findings: a. A review of Resident 36's Admission Record indicated the resident was originally admitted to the facility on (MONTH) 11, (YEAR), and readmitted to the facility on (MONTH) 18, 2019, with [DIAGNOSES REDACTED]. (the ball-and-socket hip joint) fracture (a broken bone). A review of Resident 36's Fall Risk assessment dated (MONTH) 4, (YEAR), indicated the resident was alert, had a history of [REDACTED]. Resident 36's Fall Risk Assessment Form, indicated Resident 36, had a fall risk score of 14. The Fall Risk Assessment indicated that a score of 14 or above represents a high risk for falls. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated (MONTH) 19, (YEAR), indicated Resident 36's Brief Interview for Mental Status (BIMS) score was 14. A BIMS score of 14 indicates the resident is cognitively (mental processes of thinking and understanding) intact for daily living decisions. Resident 36 required extensive assistance by staff with activities of daily living (ADLs) such as transfers, toilet use, and walking in his room with one person physical assistance to provide weight-bearing, support. A review of Resident 36's Quarterly Minimum Data Set (MDS) dated (MONTH) 19, 2019, indicated Resident 36 had a decline in his cognition from (MONTH) 19, when he had a BIMS score of 14, to (MONTH) 19, 2019, when his Brief Interview for Mental Status (BIMS) score was 9. A BIMS score of 9 indicates the resident has moderately impaired cognition for daily living decisions. The MDS indicated Resident 36 continued to require extensive assistance on staff with activities of daily living (ADLs) such as transfers, toilet use, walking in his room. The MDS indicated Resident 36 was not steady, for moving from seated to standing position, walking, and turning around. The MDS indicated the resident had functional limitation in range of motion with impairment on one side of his upper extremities (shoulder, elbow, wrist or hand), and normally used a walker and wheelchair. A review of the facility's Incident Reports indicated Resident 36 had the following fall incidents: 1. On (MONTH) 10, 2019, at 5:10 p.m., Resident 36, had a fall to the floor (first fall). Resident 36 was found by the certified nursing assistant lying on his back on the floor, between the wheelchair and bed. Resident 36 stated, I was trying to sit in my chair. Upon assessment, Resident 36 had a bump to the left side of his head. Injuries: Bump on left side of head 3 centimeters (cm's) in length and 2 cm's width. Care planning or Interdisciplinary Team (IDT- a group of health care professionals from diverse fields) was not documented. MD (medical doctor) Notified: MD notified at 5:30 p.m., and ordered that Resident 36, was transferred to the GACH ER (emergency room )Department for evaluation of bump to left side of his head. The (MONTH) 10, 2019, incident report did not indicate how the nursing staff would be alerted when the resident was attempting to stand from his wheelchair or specify the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. 2. On (MONTH) 17, 2019, at 10 p.m., indicated Resident 36, was found on the floor, (second fall) on his left side. The (MONTH) 17, 2019, incident report did not address the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. 3. On (MONTH) 27, 2019, at 2 p.m., Resident 36 had an unwitnessed fall to the floor, (third fall) on his way to the bathroom. Resident 36 complained of right hip pain at a pain rating of 4 of 10, (on a pain rating level of zero being no pain, and 10 being the worst possible pain). Pain medication given. The incident report did not address provision of routine toileting, or ongoing supervision of the resident to decrease the resident's attempts to go to the bathroom without assistance. 4. On (MONTH) 12, 2019, at 4:55 p.m., Resident 36 had an unwitnessed fall to the floor (fourth fall). The resident's account of the fall indicated he went to the bathroom and his feet felt weak so he sat down on the floor. Nursing Interventions indicated to provide a toileting schedule time for 30 days. The incident report did not include the use of a wheelchair alarm as a possible fall prevention intervention to remind the resident to call for assistance, and or to alert the staff when the resident was attempting to stand or walk without assistance, and did not address ongoing supervision of the resident to prevent falls. 5. On (MONTH) 15, 2019, at around 8:45 a.m., a licensed nurse (Licensed Nurse 10) heard Resident 36 calling for help inside his room. Resident 36 was found at the foot of his bed (5th fall). Resident 36 stated he wanted to go to the bathroom, and stood up from the wheelchair and lost his balance and fell to the floor. A review of Resident 36's Post Fall Assessment/Rehab Team, dated (MONTH) 15, 2019, at 8:45 a.m., indicated the resident has a change in functional status unable to do range of motion (ROM-joint movement) on bilateral (both) lower extremities (legs) due to pain. Resident 36 complained of pain in both hips, knee, and thigh. Pain medication given. The documentation indicated Resident 36 will be transferred to GACH emergency room (ER) per physician order. A review of Resident 36's Diagnostic Radiology result, dated (MONTH) 15, 2019, at 12:23 p.m., indicated mildly impacted (the ends of the fractured bone are wedged together) fracture involving the right femoral (thigh bone) neck (socket joint of the hip) with minimal displacement (out of place): A review of Resident 36's physician order [REDACTED]. A review of Resident 36's, GACH Orders and Discharge Summary dated (MONTH) 17, 2019, at 2:15 p.m., indicated Resident 36 underwent an operation/procedure: Hip pinning cannulated (to insert) screws, percutaneous (through the skin, to fix the fracture). Resident 36 was admitted for physical therapy evaluation, pain control and wound evaluation. Resident 36 progressed slowly with physical therapy and required further treatments. After Resident 36's pain was controlled with oral (by mouth) pain medications, the resident was medically stable, and ready to be transferred back to the skilled nursing facility (SNF) for continued rehabilitation. A review of Resident 36's Care Area Assessment (CAA) dated (MONTH) 19, 2019, triggered for fall. The CAA was not completed as follows: there was no analysis of the assessment findings to include causes and contributing factors for each of the resident's falls. A review of Resident 36's care plan dated (MONTH) 7, (YEAR), titled Fall Risk, indicated the resident required extensive assistance from staff with walking. There were no revisions made to the care plan after the resident's falls of (MONTH) 10, 17, 27, 2019, but was updated on (MONTH) 12, 2019, and (MONTH) 27, 2019, after the resident's fifth fall. The care plan goal: Will reduce/minimize risk of injury/potential injuries from falls time 90 days. related to partial loss of ability to balance, moving from seated to standing position, unsteadiness on feet. The care plan Approaches/Interventions included the following: -Encourage resident to move to a room closer to the nurses' station -Toileting schedule for 30 days -Nurses would walk the resident ad/lib (as desired) with or without an assistive device -One person assist with transfers -One person assist with walking The care plan did not include how the nursing staff would be alerted when Resident 36 was attempting to stand or walk from a wheelchair, or specify the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. The care plan did not include the need for a wheelchair pad alarm and or not specify when, or how, the resident would be assisted with walking, or with toileting to ensure the resident was safe during walking and toileting activities. A review of Resident 36 physician order [REDACTED]. On (MONTH) 5, 2019, at 10:52 a.m., during an interview and concurrent record review of Resident 36's care plan, the Director of Nursing (DON) was unable to provide documentation that the facility analyzed the cause of Resident 36's five falls within three months and identified measure to prevent Resident 36 from falls. A review of the facility's undated policy and procedures titled, Fall/Accident Mitigation and Intervention, indicated under Policy: It is the policy of this facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with falls or accidents. Procedure: - Residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. - After proper assessment of the resident, notification of the appropriate persons, and after the resident is stable, the facility staff member in charge will complete a report and forward to management as per the facility policy. - The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrence of a fall or other event. A review of the facility's policy and procedures titled, Fall Prevention, dated (MONTH) 2013, indicated to reduce the number of fall incident and to help minimize the risk of injuries from falls. The policy indicated, a fall prevention program will be developed for each patient that will provide patient care staff with creative functional strategies to minimize falls. - The Falls/Risk Committee members meet to analyze interdisciplinary data related to the fall incident/injury and recommend an appropriate intervention to minimize the patient's risk for fall or injury. - The MDS/Care planning Interdisciplinary Team updates the resident's plan of care to include the additional recommendation(s) made by the Falls/Risk committee. b. A review of Resident 133's Face Sheet (admission record) indicated the resident was admitted to the facility on (MONTH) 16, (YEAR), and with a readmission on (MONTH) 22, 2019. The resident's [DIAGNOSES REDACTED]. A review of Resident 133's Minimum Data Set (MDS- an assessment and care screening tool) dated (MONTH) 5, 2019, indicated the resident has a Brief Interview for Mental Status (BIMS- a screening tool to determine cognitive impairment) score of 15 (a score of 13-15 indicates the resident has intact cognition) and has the ability to make self-understood and the ability to understand others. A review of Resident 133's Resident Smoking Assessment Form dated (MONTH) 19, (YEAR), indicated that Resident 133 does not have a physician's orders [REDACTED]. The form indicated, Note: if a resident smokes they must be supervised and the physician's orders [REDACTED]. During a concurrent interview and record review on (MONTH) 6, 2019, at 3:15 p.m., Social Service 2 (SS2) stated she completed the Resident Smoking Assessment Form and confirmed that Resident 133 does not have a physician's orders [REDACTED]. SSD 2 also stated that she had not marked the outcome of the assessment indicating if the resident is considered a safe smoker or unsafe smoker. During a concurrent interview and record review on (MONTH) 6, 2019, at 4:17 p.m., the Director of Nursing (DON) stated that according to the Resident Smoking Assessment Form, residents who wish to smoke at the facility would need a physician's orders [REDACTED]. The DON confirmed that Resident 133 does not have a physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 16), who was recently admitted to the facility with a broken collar bone was free of neglect (means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness) by failing to: 1. Failure to handle Resident 16 gently during care. 2. Failure to honor Resident 16 request for Certified Nursing Assistant 3 (CNA 3) to stop given care because of pain. 3. Failure to ensure Resident 16 condition was communicated to CNA 3. These deficient practices resulted in Resident 16 experiencing unnecessary pain during care, mental anguish and had a potential to result in further injury of the resident's shoulder. Findings: According to the admission record, Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's History and Physical report dated May 20, 2017, indicated the resident was admitted to the facility for rehabilitation trial due to fall and weakness. The report also indicated the resident had a left distal clavicle fracture. A review of Resident 16's admission nurse notes dated May 19, 2017, indicated the resident had left shoulder discoloration. A review of Resident 16's care plan dated May 19, 2017, indicated the resident had a left clavicle fracture and had a history of [REDACTED]. A review of Resident 16's care plan dated May 22, 2017, indicated the resident had a sling on the left upper extremity. The care plan interventions included to provide therapy exercises, safety training, and cognitive training. A review of Resident 16's nurses' notes from May 20, 2017 to May 22, 2017, indicated the resident was awake, alert, and able to follow directions. On May 23, 2017 at 8:48 a.m., during an observation, Resident 16's room door was closed. Resident 16 was heard yelling and screaming from the room. Resident 16 was saying I have broken arms, stop, you are hurting me. From 8:48 a.m. till 8:51 a.m., Resident 16 was continuously yelling and screaming (pausing 10 to 15 seconds at times) repeating more than once Stop, you are hurting me, my arms hurt. On May 23, 2017 at 8:51 a.m., during an observation, Resident 16 was lying in bed on her right side, her knees were bent and drawn up to her abdomen, and her back was curved. Resident 16 was crying. During a concurrent interview, Resident 16 stated that CNA 3 rough handled her about five minutes ago. Resident 16 also stated she had two broken arms, and told CNA 3 to stop because her arms were hurting. On May 23, 2017 at 8:51 a.m., during a concurrent interview, CNA 3 stated there was no issue; she was just changing the resident. At the time of the interview, Resident 16 was heard saying CNA 3 was lying. Resident 16 stated CNA 3 Roughed her up. On May 23, 2017 at 8:53 a.m., during an interview, CNA 3 stated she touched Resident 16's arm while attempting to put the resident's arms into the long sleeves of her blouse. CNA 3 also stated that she did not stop after the resident verbalized more than once her arms were hurting. CNA 3 stated she was supposed to stop and ask if the resident was in pain. On May 23, 2017 at 12 p.m., during a follow up interview, CNA 3 stated she did not know Resident 16 had a clavicle fracture. CNA 3 also stated while providing care earlier in the morning, Resident 16 was telling her she had broken bones and kept trying to push her away. CNA 3 stated she assumed the resident was confused about the broken bones. CNA 3 stated she was assigned to the resident on May 22, 2017 and the licensed nursing staff did not notify her of the resident's broken clavicle. On May 23, 2017 at 2:29 p.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated she did not notify CNA 3 of Resident 16's fractured clavicle on May 22, 2017 and May 23, 2017. LVN 6 stated she assumed CNA 3 knew about the resident's fractured clavicle, because the resident was wearing a sling on May 22, 2017. LVN 6 also stated she should have notified CNA 3 to be extra careful with Resident 16 while providing care, because the resident had a broken bone. On May 23, 2017 at 2:43 p.m., during an interview, Occupational Therapist 1 (OT 1) stated a clavicle fracture could be painful during upper body dressing. OT 1 stated a resident who was screaming, yelling, and complaining of pain during upper body dressing was not normal. On May 24, 2017 at 7:43 a.m., during an interview, the DSD stated if Resident 16 was complaining of pain during care and was asking CNA 3 not to touch her, CNA 3 should have stopped providing care and notified the charge nurse because the resident might have been in pain. CROSS REFERENCE F226.

Based on observation, interview, and record review, the facility failed use bilateral hand mittens in a safe manner for 1of 4 residents who required the use of physical restraints in a sample of 30 residents (6) and failed to discontinue the use of a physical hand mitten restraint of a resident when the restraint was no longer necessary for 1of 4 residents in a sample of 30 residents, (17) by failing to: 1. Follow the physician order [REDACTED]. 2. Follow the manufacturer's directions by altering the mitten restraints by wrapping tape over the Velcro fasteners on a resident's hand mitten restraints and following directions for safe use of mitten restraints, including removal of the physical restraint mitten to check circulation frequently, and monitor for skin discoloration and provide range of motion at regular intervals (6). 3. Follow the resident's care plan to ensure the resident's physical mitten restraints were released at least every two hours to assess skin condition and circulation of the wrists and hands (6). 4. Follow the facility's policy and procedure for the use of physical hand mitten restraints to ensure the resident did not develop complications due to the use of physical mitten restraint, such as severe emotional, psychological, and physical problems that may occur if a resident ' s movement is severely limited (6). 5. Discontinue the use of a physical hand mitten restraint when the resident no longer required the use of a hand mitten restraint (17). 6. Fully document the use of physical mitten restraints as indicated in the facility policy in order to determine when the when the physical hand mitten was last removed. As a result, Resident 6 had physical hand mittens applied to both of her hands for over 10 consecutive hours, without release, exercise or range of motion, checking for circulation or assessment of skin. Resident 6 developed redness to the left wrist from the pressure of the Velcro mitt strap that was placed tightly around the resident's wrist and from the tape that was tightly wrapped around the top of the Velco mitt strap. This had the potential to result in serious harm or impairment including decubitus ulcers, impaired muscle strength, impaired circulation, and increased agitation. Resident 17 had a hand mitten restraint intermittently applied to her right hand for over 10 months after the hand restraint was no longer required. Findings: a. A review of the admission record indicated Resident 6 is an [AGE] year old who was admitted to the facility with a medical history of [REDACTED]. A review of Resident 6's Minimum Data Set (MDS- an assessment and care screening tool), dated November 5, 2015, and February 16, 2016, indicated Resident 6 had severe cognitive (mental) impairment, was totally dependent for all activities of daily living and did not use physical restraints. A review of Resident 6's physician order [REDACTED]. A review of Resident 6's Care Plan dated February 12, 2016, for Devices indicated apply both hand mittens to prevent resident from pulling out GT ([DEVICE], a tube that is surgically placed through the skin of the abdomen that goes directly in the stomach to provide nutrition and/or medications). Release Q2H (every two hours) for circulation. Interventions included to make sure device is applied properly and in comfortable position, release and reposition at least every two hours/PRN (as needed). The care plan dated November 12, 2015, indicated Resident 6 was at risk for an alteration in skin integrity (skin breakdown or other problems with her skin). Risk factors identified on Resident 6's care plan for skin integrity impairment included having a history of skin alterations, reduced mobility, fragile skin, impaired cognitive status, and the aging process. The goal was to minimize the risk of skin breakdown/bruising/pressure sore daily. During the initial tour on April 11, 2016, at 3:20 PM, Resident 6 was observed lying in bed on her back. She was observed wearing hand mitten restraints (a device that limits the ability to grab tubes) over both of her hands at this time. Each hand mitten restraint had tape wrapped around the wrists over the Velcro fasteners of the restraint. Registered Nurse (RN) 2 who was guiding the initial tour, after being asked if the mitt restraints were readily/easily removable and releasable, attempted to remove the restraints. RN 2 was asked when the restraint was applied but, RN 2 stated she did not know when the mitts were applied. RN 2 was not able to readily or easily remove the mitt restraints because tape was stuck covering the Velcro (a fastener for clothes or other items) fasteners of the restraint. RN 2 pulled, tugged, and attempted to tear the tape to remove it from the mitt restraint in order to release the mitt from Resident 6's hands. Resident 6 had redness to her left wrist after the restraint was removed, where the Velcro and the tape were tight around the resident's wrist. RN 2 after showing Resident 6's wrists attempted to place the mitt restraints back onto Resident 6. Resident 6 was agitated and did not want the mitt restraints on again. Resident 6 pulled her hands away from RN 2. Resident 6 was confused and speaking with a mixture of non-understandable random words. During a staff interview on April 11, 2016 at 3:50 PM, LVN 6, the Rehabilitation Nursing Assistants' (RNA) Supervisor, stated that RNAs are supposed to remove Resident 6's hand mittens every day for 15 minutes during therapy. LVN 6 also stated that all CNAs who are assigned to care for the resident are supposed to give care for restraints and to release them every two hours. LVN 6 was asked where this care would be documented; LVN 6 replied actually, we don't have that documentation. LVN 6 also stated that he checks to make sure that the residents have the correct restraint in place as ordered. LVN 6 stated he checked to make sure Resident 6 had the right restraint, but did not check the proper application of the restraint, release or remove the restraint. LVN 6 stated restraints should be easily removed by staff. CNA 5 was interviewed at 4:15 PM on April 11, 2016. CNA 5, who works the 3 pm to 11 pm shift, stated that she did not receive report from the day shift CNA (CNA 4). CNA 5 did not know when the restraints were initially applied, did not know who placed the tape on the restraint around the resident's wrist, or when it was last applied, as she observed the tape on Resident 6's mitt restraints. CNA 5 also confirmed that there was no documentation for the release of and the care of Resident 6's hand mitten restraints or the care provided for the resident's use of wrist and hand restraints. RNA 1 was interviewed at 4:26 PM on April 11, 2016. RNA 1 stated that she provides passive range of motion (exercise) to Resident 6 during therapy, but did not remove Resident 6's mittens during her shift, because the resident resisted. RNA 1 stated we do not document restraints at all when asked where restraint documentation was completed. CNA 4 was interviewed at 4:30 PM on April 11, 2016 and was the day shift CNA for Resident 6. CNA 4 stated that she received a report from CNA 7 but she did not know when CNA 7 applied the mitt restraints to Resident 6. CNA 4 stated she did not take off Resident 6's mitt restraints during her shift, from 7 am to 3 pm on April 11, 2016. CNA 4 also stated that CNA 6 who is actively involved in caring for Resident 6 is afraid to remove the mitten restraints as she is concerned the resident will pull out her [DEVICE]. CNA 6 was interviewed at 4:45 PM on April 11, 2016, regarding Resident 6's hand mitt restraints. CNA 6 stated I did not take off the resident's hand mitts or put them on today. I do not know who put them on last when asked if she had removed the restraints or knew when they were last removed/applied. CNA 7 was interviewed on April 12, 2016 at 8:40 AM. CNA 7 stated that she was the person who applied the tape to the mitt restraints of Resident 6, during the night shift starting at 11 PM on April 10, 2016 and ending at 7:30 AM on April 11, 2016. It was clarified with CNA 7 that she placed the tape over the Velcro fasteners of the mitten restraint, because the resident was removing the hand mitten using her teeth. CNA 7 stated yeah, on the top of the Velcro. CNA 7 was asked if she had anything documented in her charting to show that CNAs were monitoring Resident 6's care for her restraints. CNA 7 stated I didn't write it down we don't have a paper to monitor. CNA stated sometimes Resident 6's restraints would come off and stated noone directed her to apply tape over the Velcro fasteners of the restraints. CNA 7 stated I told my supervisor and she didn't know what to do when CNA 7 stated she went to her supervisor to inform her that Resident 6 was not wearing her restraints. CNA 7 indicated that her supervisor did not know what to do to make sure that the restraints did not come off of Resident 6. CNA 7 then stated that she applied tape over the Velcro to keep the restraints on. CNA 7 stated she told her supervisor she put the tape on top of the restraint. CNA 7 indicated that she had been applying tape over the Velcro of the restraints for a month. CNA 7 stated I check the circulation when she wakes up. CNA 7 then stated I don't wake her up. CNA 7 agreed the restraints should be easily removable, when asked. CNA 7 stated that she last applied the restraints to Resident 6's hands at 4:30 AM or 5 AM on April 11, 2016. A review of Resident 6's nurses notes and nursing assistant notes, on April 11, 2016 at 4:30 PM, indicated no documentation of the date and time the restraints were applied, the name and title of the individual/s who applied the restraint, the type of restraint applied, the specific reason the restraint was applied, the length of time the restraint will be used, each time the device is released for resident exercise, toileting, and position change, each time the resident is monitored, There was no documentation in the Weekly Summaries for Resident 6 regarding her restraints since the restraints were ordered on February 12, 2016. The Medication Administration Record [REDACTED]. According to LVN 6's interview, CNAs were primarily responsible for releasing restraints and providing care to the resident at least every two hours. A review of the facility's policy and procedure for physical restraint application revised October 2010, indicated the purpose of the procedure is to prevent injury to the resident when the resident has medical symptoms that warrant the use of restraints. The preparation includes; verify the physician's orders [REDACTED]. The steps in the procedure include; apply the ordered restraint using the appropriate procedure, follow the instruction provided by the manufacturer of the restraint. The following information should be documented in the resident ' s medical record and/or on the device/physical restraint monitoring flowsheet; the date and time the restraint was applied, the name and title of the individuals) who applied the restraint, the type of restraint applied, the specific reason the restraint was applied, the length of time the restraint will be used, each time the device is released for resident exercise, toileting, and position change, each time the resident is monitored, per facility policy, if the resident refused the treatment and the reason why, the signature and title of the person recording the data, and to notify the supervisor if the resident refuses the procedure. b. A review of the admission Face Sheet, indicated Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), an assessment and care screening tool, dated February 11, 2016, indicated Resident 17 was unable to answer questions. The MDS indicated Resident 17 was totally dependent on staff and required one person assistance for care and used a limb restraint. A review of Resident 17's physician order [REDACTED]. A review of the care plan dated August 21, 2014, indicated Resident 17 used a right hand mitten to prevent her from pulling out the [DEVICE]. The interventions included review the need for restraints for possible discontinuation, reduction, less restrictive measures or continuation of use regularly, notify the physician for any changes. During the initial tour on April 11, 2016 at 2:21 p.m., Resident 17 was observed to have a mitten to her right hand. In an interview with Registered Nurse (RN 1) at the same time, she stated the mitten was on to prevent the resident from removing her [DEVICE]. In an interview and record review with RN 1 on April 13, 2016, at 8:27 a.m., she stated that the quarterly review for physical restraints dated May 19, 2015, November 5, 2015, and March 5, 2016 indicated Resident 17 had not required restraints for 10 months. RN 1 stated a hand mitten restraint should not have been applied to the resident's hand. In an interview and record review with director of nursing (DON) on April 13, 2016, at 8:43 a.m., she stated Resident 17 has not required a mitten restraint since May 19, 2015. She stated the physician was not notified after the interdisciplinary team indicated Resident 17 no longer required the mitten restraint. A review of the Interdisciplinary Team Restraint Recommendations dated February 18, 2015, indicated Resident 17 did not require a hand mitten restraint. A review of the weekly summaries from May 2015 to February 2016 indicated staff had continued to apply the hand mitten restraint to Resident 17's hand, even after there was no need. The facility's policy and procedure titled, Use of Restraint, revised December 2008, indicated Treatment restraints shall be applied for no longer than the time required to complete the treatment.