Every finding on record at Avante at Mt Dora, Inc

Based on interview, observation, and record review, the facility failed to ensure wound care was provided in accordance with professional standards of practice and physician orders for 2 of 4 residents, Residents #1 and #3, reviewed for wound care services. Findings Include:1) During an observation on 06/09/2026 at 2:50 PM, Resident #1 was sitting up in bed on an air mattress. There was a rolled gauze dressing on the resident's left knee which was dated 06/08/2026 with the initials of Staff B.During an interview on 06/09/2026 at 2:50 PM, Resident #1 stated, The nurse did not do my wound care last night, and it has not been done today.Review of Resident #1's physician order dated 06/04/2026 read, Wound Care: Left lateral lower leg- cleanse with diluted betadine, pat dry. Apply calcium alginate silver, ABD [abdominal] pad and wrap with rolled gauze. Secure with ace wrap every day shift for Trauma Wound and as needed for soiled/displaced/wound rounds.Review of Resident #1's physician order dated 06/05/2026 read, Bacitracin External Ointment 500 Unit/GM [gram] apply to left knee topically every day and night shift for laceration apply xeroform [moist dressing] after and cover with abd and kerlix [rolled gauze] and apply to left knee topically as needed for soiled/displaced/wound rounds for 14 days.Review of Resident #1's TAR [treatment administration record] for June 2026 read, Bacitracin External Ointment 500 Unit/GM (Bacitracin (Topical)) Apply to left knee topically every day and night shift for laceration apply xeroform after and cover with abd and kerlix Start Date: 06/05/2026 2300.Review of Resident #1's TAR for June 2026 showed wound care was not documented on 06/08/2026 for night shift.During an interview on 06/09/2026 at 2:13 PM, Staff E, LPN [licensed practical nurse] stated, We used to have a wound care nurse, but now the nurse on the cart does the wound care. It is difficult because I have 28 residents today. I have not done [Resident #1's name]'s dressing change yet; I am planning to do it later before I leave.During an interview on 06/10/2026 at 8:50 AM, Staff A, LPN stated, I did not change [Resident #1's name]'s dressing the night before last because when [Staff E, LPN's name] gave me report, she told me she had just done it. I didn't think it would be good to do it right after [Staff E, LPN's name] had just done it.During an interview on 06/10/2026 9:30 AM the Director of Nursing stated, I got clarification from [Staff C, Advanced Practice Registered Nurse's [APRN] name], the wound care APRN on [Resident #1's name]'s orders. She said the Bacitracin order that was twice a day should have been discontinued and only kept the order for betadine with the calcium alginate once per day. She said it was an oversight on her part.During an interview on 06/10/2026 at 11:25 AM, Staff C, wound care APRN stated, The wound care orders come from [Resident #1's name]'s surgeon who repaired the flap that was there. At some point while I was seeing her, I called the plastic surgeon to update the wound care orders. The orders I received were betadine, calcium alginate with silver, abd pad and kerlix and ace wrap daily. I received that order on May 28th. Last time I saw her wound it had improved somewhat from the previous week. I don't know why the current order says twice a day. Whether or not they got updated orders after [Resident #1's name]'s follow-up appointment, I am unaware of.Review of Resident #1's physician order dated 05/28/2026 read, Wound care: Left lateral lower leg- cleanse with diluted betadine, pat dry. Apply calcium alginate, ABD pad and wrap with rolled gauze. Secure with ace wrap every day shift for trauma wound and as needed for soiled/displaced/wound rounds. The order was discontinued on 06/04/2026.During an interview on 06/10/2026 at 12:14 PM, the Director of Nursing stated, It looks like two different nurses put orders in for the same wound. [Staff C, APRN's name]'s orders were for once a day. [Staff C, APRN's name] is our wound care provider and based on our wound provider who oversees the wounds, it was supposed to be dressed once a day. The resident went to the plastic surgeon on June 5th for a follow up. [Resident #1's name] gave us the papers from the plastic surgeon from her purse today. Apparently, [Staff B, LPN's name] looked at the papers from the plastic surgeon and entered the orders for twice daily dressing changes and then gave the paper back to [Resident #1's name] instead of uploading it to the chart. What [Staff B, LPN's name] should have done is made a copy for medical records to put in the chart. The daily dressing order should not have been discontinued because we did not have an order to discontinue it. The nurses should have clarified the orders. I think it was a problem with communication and documentation. Now we have two orders from the provider for the same wound. We should have gotten clarification. Review of Resident #1 wound care note dated 06/04/2026, authored by Staff C, APRN read, Cleanse/Protect wound. Cleanse wound with diluted betadine. Wound Dressing: Apply Alginate with silver/silver alginate AG+ cover wound with ABD pad, Kerlix Ace Wrap change dressing daily. Change dressing as needed for soiling, saturation, or accidental removal. All orders will remain in effect until discontinued, revised, or replaced with additional orders.Review of the order from the plastic surgery follow up visit, provided by Resident #1, dated 06/05/2026 read, Dressing changes twice daily xeroform, bacitracin, ABD pad. Patient may shower. Patient may use scooter. Wound care doctor must call our doctor.During an interview on 06/10/2026 at 12:33 PM, Staff B, LPN stated, I remember updating the dressing change order after her plastic surgery appointment on June 5th to twice daily. The order was basically the same except for the frequency, so I just updated the frequency. She did not take the paperwork back from me. I put it in the scanner. My initials show up on the TAR as [Staff B, LPN's initials]. I changed her dressing on dayshift on Monday the 8th.During an interview on 06/10/2026 at 1:36 PM, Staff D, Medical Assistant for Resident #1's Plastic Surgeon stated, The doctor wants the wound care done twice a day with xeroform and bacitracin.Review of the policy and procedure titled, Consulting Physician/Practitioner Orders with a review date of 05/06/2026 read, 1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet.Review of policy and procedure titled, Physician Services review date 05/06/2026 read, Policy: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations. 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.2) During an observation on 06/09/2026 at 10:15 AM, Resident #3 was sitting in her wheelchair near a medication cart in the common area. There was a tan colored dressing to the resident's left posterior hand with no date on it.During an interview on 06/09/2026 at 10:15 AM, Resident #3 stated, I got this skin tear on my hand in the bathroom somehow. I just looked down and saw it was bleeding and I told the nurse. I am not sure when it was last changed, my memory is not so good.Review of Resident #3's current physician orders revealed no orders for wound care to the resident's left posterior hand.During an interview on 06/10/2026 at 9:30 AM, the Director of Nursing stated, I took the dressing off of [Resident #3's name]'s left hand, and it looked like a tiny, scabbed area. I asked if she had recently had labs drawn. She told me yes, she had a couple of days ago and that they stuck her in the back of her left hand. I called the lab and verified that they are the ones who placed the dressing on her hand. There was no skin tear there.During an observation on 06/10/2026 at 9:59 AM, Resident #3 was seated in a wheelchair in the common dining area of [Resident #3's unit]. There was a white, bordered dressing on the resident's left hand, which was not dated.During an interview on 06/10/2026 at 9:59 AM, Resident #3 stated, They had to change the dressing last night. I did have labs not too long ago, but they stuck me in my arm, not my hand [Resident pointed to her left arm]. I told you, I injured my hand in the bathroom, this one on my hand was not from a lab stick.Review of the policy and procedure titled, Wound Management review date 05/06/2026 read, Policy: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. Procedure: 1. The admitting nurse/nurse identifying a skin integrity issue, will then be responsible for initiating the appropriate interventions such as ensuring treatment order(s) are in place, pressure reduction devices are ordered and or requested, i.e. specialty mattress and wheelchair cushion, and that the interim care plan is initiated.

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 1 (Resident #29) of 1 resident reviewed for activities of daily living, 3 (Residents #36, #70, and #88) of 5 residents review for skin conditions and 5 (Resident #2, #3, #51, #70 and #105) of 10 residents reviewed for medication management.Findings include: 1) Review of Resident #29's care plan initiated on 7/10/2025 read, [Resident #29's name] is facing a significant shortfall in her self-care performance related to Activities of daily living (ADL), which is associated with the consequences of a terminal diagnosis in its end stage. Interventions: Dependent in toileting/always incontinent. Review of Resident #29's Functional Goals and Abilities Evaluation dated 9/29/2025 documented the resident was dependent on helper (staff) for toileting hygiene. Review of Resident #29's bladder continence documentation for the month of November 2025 revealed blank entries on day shift on 11/4/2025, 11/18/2025, 11/24/2025, and 11/25/2025. Evening shift revealed blank entries on 11/6/2025, and 11/16/2025, and night shift on 11/14/2025. Review of Resident #29's bowel continence documentation for the month of November 2025 revealed blank entries on day shift for 11/4/2025, 11/16/2025, 11/24/2025, and 11/25/2025, On evening shift for 11/6/2025, 11/12/2025, and 11/16/2025 and on night shift blank entries for 11/14/2025. During an interview on 12/4/2025 at 12:30 PM, the Director of Nursing stated, I have no other supporting documentation regarding care provided to [Resident #29's name]. I expect the staff to fill out accurately the task when providing care. 2) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed. Resident #88 right lower leg has a dressing dated 11/27/2025 [Staff F initials]. Review of Resident #88's physician order dated 11/20/2025 read, Wound Care: Right Heel-Skin prep, cover with ABD [abdominal] pad and wrap with kerlix. Secure with tape, every day shift for unstageable pressure injury and as needed for soiled/displaced/wound rounds. Review of Resident #88's Treatment Administration Record (TAR) for the month of November 2025 for wound care to the right heel documented wound care was completed on 11/28/2025, 11/29/2025 and 11/30/2025. During an interview on 12/3/2025 at 10:16 AM, Staff G, Licensed Practical Nurse (LPN), stated, I do not really recall. I remember doing something on Saturday [11/29/2025] with [Resident #88's name] right lower leg. I just cannot remember. If there is a check in the system it means it was completed. On Saturday [11/29/2025] that nurse who came in to do wound care had to take a cart and the nurses were helping to do the wound care. During an interview on 12/3/2025 at 12:56 PM, the Director of Nursing stated, Wound care should be documented accurately. 3) During an observation on12/01/2025 at 10:07 AM, Resident #36 was lying in bed right foot dressing dated 11/27 [Staff F initials]. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right heel-cleanse with Dakin's 1/2 str. Sol [strength solution] pat dry. Skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze secure with tape, every day shift for unstageable pressure ulcer. Review of Resident #36's TAR for the month of November 2025 for right heel wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's progress noted dated 11/29/2025 read, done by wound nurse. Review of Resident #36's physician order dated 10/17/2025 read, Wound care: Right lateral foot-skin prep, offload every day shift for arterial ulcer. Review of Resident #36 TAR for the month of November 2025 for right lateral foot skin prep documented treatment completed on 11/28/2025, 11/29/2025 and 11/30/2025. Review of Resident #36's physician order dated 10/31/2025 read, Wound Care: Right 2nd toe-cleanse with betadine, pat dry. Skin prep peri wound. Apply betadine -soaked gauze then wrap with rolled gauze and secure with tape, every day shift for DM Ulcer. Review of Resident #36 TAR for the month of November 2025 for Right 2nd toe cleanse with betadine documented blank entries on 11/7/2025, 11/11/2025, 11/12/2025, 11/14/2025, and 11/18/2025. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right 2nd toe-cleanse with Dakin's 1/2 str. Sol, pat dry. Skin prep peri wound, Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for DM Ulcer. Review of Resident #36's TAR for the month of November 2025 for Right second toe wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's physician order dated 10/31/2025, read, Wound Care: Right Lateral great toe Cleanse with betadine , pat dry skin prep peri wound. Apply betadine soaked gauze then wrap with rolled gauze and secure with tape ever day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral great toe documented blank entries on 11/7/2025, 11/11/2025, 11/12/2025, and 11/18/2025. Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right lateral great toe cleanse with Dakins 1/2 str. Sol pat dry. Skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right lateral great toe cleanse with Dakins wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right Lateral heel-cleanse with Dakin's 1/2 str. Sol, pat dry skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right lateral heel wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's physician order dated 10/31/2025, read, Wound Care: Right lateral second toe-cleanse with betadine, apply calcium alginate, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral second toe documented blank entries on 11/7/2025, 11/11/2025 and on 11/12/2025. Review of Resident #36's physician order dated 11/13/2025 read, Wound Care: Right Lateral second toe, cleanse with betadine , protect peri wound with skin prep, apply wet to dry betadine-soaked gauze, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral second toe documented a blank entry on 11/18/2025. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right lateral second toe-cleanse with Dakin's 1/2 str. Sol pat dry skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for right lateral second toe, cleanse with Dakins wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. During interview on 12/3/2025 at 10:16 AM, Staff G, LPN, stated, I might check off the wound care and sometimes you might forget. I am wondering if it was supposed to get done by the wound care nurse, so I checked it off and it didn't get done. During an interview on 12/4/2025 at 8:07 AM, Staff F, Wound Care Nurse, LPN, stated, On Friday I am not on the cart that is my documentation day. On 11/11/2025, I was training and was not on the wound care cart. I am not able to say what happened on 11/12/2025 or 11/18/2025. I know I had training two days, but I have no notes for those two days. I always do her wound care if I am here. I don't know why those days have blanks. Review of the facility policy and procedure titled, Documentation with a last review date of 1/28/2025, read, Policy: Each resident medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. Review of the facility policy and procedure titled, Clean Dressing Change with a last review date of 1/28/2025 read, 26. Document the completion of dressing change on the treatment record. 4) Review of Resident #2's physician order dated 10/6/2025 read, Lantus Subcutaneous Solution 100 Unit/ML [Unit per milliliter] (Insulin Glargine) Inject 10 unit subcutaneously one time a day for Hyperglycemia. Review of Resident #2's physician order dated 11/4/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (Insulin Glargine) Inject 12 unit subcutaneously one time a day for Hyperglycemia. Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 10 units documented on 11/2/2025 at bedtime coded 13 [Glucose out of Parameters]. Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 12 units documented at bedtime code 13 on 11/15/2025, 11/16/2025, 11/22/2025, and 11/24/2025. During an interview on 12/3/2025 at 11:59 AM Physician Assistant #1 stated, I have not gotten phone calls regarding staff holding [Resident #2's name] insulin. Communication and reporting is a big deal here. I have parameters in place for a reason. I want to be notified. I don't need a phone call every time but until we have trust and a pattern I want the staff to call me, but a lot of times they do not. [Resident #2's name] has not run into any danger, it is not a big issue. During an interview on 12/3/2025 at 12:57 PM, the Director of Nursing stated, I expect nurses to use their nursing judgment but always communicate with the provider and follow physician orders. If they are using their nursing judgment they should call the provider and get clarification. Review of the facility policy and procedure titled Physician Services with a last review date of 1/28/2025 read, 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. 5) Review of Resident #3's physician order dated 9/28/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 Unit/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously two times a day for Hyperglycemia (Before breakfast and bedtime). Review of Resident #3's physician order dated 11/30/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously one time a day for DM [Diabetes Mellitus]. Review of Resident #3's physician order dated 11/2/2025, read, Hold insulin if blood sugar is less than 90 every shift. Review of Resident #3's Medication Administration Record for the month of November 2025 for Insulin Lispro Protamine and Lispro documented at 2100 [9:00 PM] on 11/1/2025 blood sugar level 114 coded 13, on 11/16/2025 blood sugar level 112 coded 13, and on 11/22/2025 blood sugar level 138 coded 13 [Glucose out of Parameters]. During an interview on 12/3/2025 at 4:53 PM, Physician #1 stated, I don't recall notification from staff regarding [Resident #3's name]. Resident #3 has not had any medical emergencies regarding her diabetic management. 6) Review of Resident #105's admission data revealed that she was admitted to the facility on [DATE] with idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus with diabetic neuropathy, heart failure, major depressive disorder, chronic pain, essential hypertension, morbid obesity and nicotine dependence (not an inclusive list). Review of Resident #105's physician order dated 11/5/2025 read, Lantus SoloStar Subcutaneous Solution Pen-injector, 100 units/ ML (milliliters), inject 30 units subcutaneously one time a day for DM (diabetes mellitus). Review of Resident #105's November 2025's Medication Administration Record(MAR) revealed that there was nothing documented on the following days: 11/11/2025, 11/17/2025 and 11/18/2025 for Lantus Solostar Subcutaneous Solution Pen-injector. During an interview on 12/4/2025 at 8:45 AM, the DON stated that she reviewed Resident #105's November 2025 MAR for Lantus Solostar Subcutaneous Solution Pen-injector documentation for 11/11/2025, 11/17/2025 and 11/18/2025 and spoke to the nurses who were assigned to the resident on those days and stated that [Resident #105's Name] will be out on the smoking patio during the administration time and will not come in for administration of the medication. DON stated that her expectations should be that the nurse attempting to administer the medication should document as resident refusal instead of leaving it blank. 7) Review of Resident #51's admission Record documented an admission to the facility dated 5/26/2023 with medical diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; type 2 diabetes mellitus (DM) with diabetic polyneuropathy; and essential (primary) hypertension. Review of Resident #51's most recent Minimum Data Set comprehensive assessment documented the resident had a BIMS (brief interview for mental status) of 15/15, indicating intact cognition. Review of Resident #51's physician orders dated 10/16/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2 (type 2 diabetes mellitus). Review of Resident #51's physician orders dated 03/05/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 5 unit subcutaneously at bedtime for DM 2 (type 2 diabetes mellitus). This order was discontinued on 10/16/2025. Review of Resident #51's physician orders dated 05/26/2025 read, Humulin N Subcutaneous Suspension 100 unit/ML (Insulin NPH (Human) (Isophane)): Inject 18 unit subcutaneously two times a day for Type II DM. Hold for BG (blood glucose) <70. This order was discontinued on 10/16/2025. Review of Resident #51's physician orders dated 7/17/2023 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. Review of Resident #51's MAR (Medication Administration Record) for the month of September 2025 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. There was no documentation on 9/07/2025 at 6:30 AM; 9/12/2025 at 6:30 AM; 9/19/2025 at 4:30 PM; 9/20/2025 at 6:30 AM; and 9/21/2025 at 6:30 AM. Review of Resident #51's Progress Notes, including eMAR (electronic Medication Administration Record) notes for 9/01/2025 through 9/30/2025 revealed there were no notes regarding Resident #51's insulin. Review of Resident #51's MAR for the month of October 2025, read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. There was documentation on 10/18/2025 and 10/19/2025 that read code 9 – other/see nurse notes. Review of Resident #51's progress notes for 10/18/2025 and 10/19/2025 revealed an eMAR Medication Administration Note dated 10/19/2025 at 12:05 AM that read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. Refused. There was no documentation of physician or provider notification. There were no progress notes for 10/18/2025 related to insulin or blood glucose. Review of Resident #51's MAR for the month of October 2025, read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. There was documentation as follows: On 10/18/2025 at 10:00PM, 10/19/2025 and 10/202025 at 6:30 AM – NA (not applicable) for the blood sugar reading, and 9 (Other/See Nurse Notes) for the dosage of insulin administered; on 10/21/2025 at 4:30 PM, there was nothing documented for a blood sugar reading or dosage of insulin administered; and on 10/28/2025 at 11:30 AM – NA was documented for a blood sugar reading, and no dosage was documented for the amount of insulin administered. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 10/01/2025 through 10/31/2025 revealed no notes regarding provider notification for Resident #51's Humalog insulin and corresponding blood sugar monitoring. Review of Resident #51's MAR for the month of November read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. Code 9 (other/see nurse notes) was documented on 11/19/2025, 11/24/2025, 11/25/2025, 11/27/2025, 11/29/2025, and 11/30/2025. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 11/30/2025 revealed there were no notes regarding provider notification for Resident #51's Insulin Glargine. Review of Resident #51's MAR for November 2025 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. On 11/02/2025, 11/15/2025, 11/16/2025, 11/17/2025, 11/26/2025, and 11/28/2025 at 6:30 AM; 11/16/2025, 11/19/2025, 11/24/2025, 11/25/2025, 11/27/2025, 11/29/2025, and 11/30/2025 at 10:00 PM – NA was documented for the blood sugar reading, and 9 for the dosage of insulin administered. On 11/25/2025 at 6:30 AM – there was nothing documented for the blood sugar reading or the dosage of insulin administered. On 11/14/2025 and 11/18/2025 at 4:30 PM, and 11/18/2025 at 11:30 AM – NA for the blood sugar reading, and no dosage for the amount of insulin administered. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 11/30/2025 revealed no notes regarding provider notification for Resident #51's Humalog insulin and corresponding blood sugar monitoring. Review of Resident #51's MAR from 11/01/2025 through 12/03/2025, read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. On 12/01/2025 at 6:30 AM NA was documented for the blood sugar reading, and 9 for the dosage of insulin administered. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 12/03/2025 revealed no notes regarding provider notification for Resident #51's Insulin Glargine. During an interview on 12/03/2025 at 10:15 AM, Resident #51 stated that he did not refuse his accu checks (blood glucose monitoring test) or his insulin injections even late at night or early in the morning. During an interview on 12/03/2025 at 3:55 PM, the DON stated that the expectation was for the nurses to notify the provider if a resident refused their medications or treatments. During an interview on 12/03/2025 at 4:44 PM, Physician #1 stated, I receive so many calls from so many facilities. I may have received 1 or 2 calls [regarding Resident #51]. I tell them to just put in your notes that he refused and re-educate them. I did not say not to notify me. They should notify me. During an interview on 12/03/2025 at 5:47 PM, APRN #1 stated, I know him [Resident #51] from [name of another facility]. I get phone calls [from the facility], they can't give me names only room numbers, [Resident #51] has to give me permission to know his name. It [after-hours on-call] is only for emergencies. During an interview on 12/04/2025 at 8:55 AM, Staff C, LPN, stated that [Resident #51's Name] often refused his accu check and his medications. She always called the on-call provider [APRN #1], but she did not always remember to document that she notified the provider. During an interview on 12/04/2025 at 9:10 AM, Staff B, LPN, stated that [Resident #51's Name] did not refuse his medications for her. She thought it was weird that she had charted NA for his blood sugar on the MAR and did not document the amount of insulin she had given for the sliding scale order. She did work the 14th and the 18th [of November 2025]. She must have forgotten to chart some of the details. On the 21st [of October 2025] she stated she forgot to document checking his blood sugar and administering his insulin at 4:30 PM. 8) Review of Resident #70's admission record revealed she was admitted to the facility on [DATE] with medical diagnoses that included cerebrovascular disease, unspecified; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; chronic kidney disease, stage 3, unspecified; pressure ulcer of sacral region, stage 4; pressure ulcer of right buttock, stage 2; and a pressure ulcer of left buttock, stage 2. Review of Resident #70's physician orders dated 3/26/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (milliliter) (Insulin Glargine): Inject 36 unit subcutaneously two times a day for diabetic. Review of Resident #70's physician orders dated 12/26/2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified. Review of Resident #70's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2025 read, Lantus Subcutaneous Solution 100 Unit/ML (milliliter) (Insulin Glargine): Inject 36 unit subcutaneously two times a day for diabetic. On 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/22/2025, 11/23/2025, and 11/26/2025 at 9:00 AM, and 11/04/2025, 11/07/2025, 11/13/2025, 11/16/2025, 11/18/2025, 11/19/2025, 11/22/2025, and 11/26/2025 at 9:00 PM, there was documentation of 2 – Drug refused. Review of Resident #70's progress notes, including eMAR (electronic Medication Administration) notes revealed there was no documentation of physician/provider notification regarding Resident #70's refusal of Insulin Glargine. Review of Resident #70's MAR/TAR for November 2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified. On 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/22/2025, 11/23/2025, 11/25/2025, 11/26/2025 at 8:00 AM; 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/21/2025, 11/22/2025, 11/25/2025, 11/26/2025 at 12:00 PM, and 11/03/2025. 11/04/2025, 11/05/2025, 11/09/2025, 11/11/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/21/2025, 11/22/2025, 11/25/2025, and 11/26/2025 at 5:00 PM, there was documentation of 2 – Drug refused. Review of Resident #70's MAR/TAR for November 2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously three times a day for Diabetes. On 11/30/2025 at 5:00 PM, there was documentation of 2 – Drug refused. Review of Resident #70's progress notes, including eMAR notes for November 2025 revealed no documentation of physician/provider notification regarding Resident #70's refusal of Insulin Aspart. Review of Resident #70 physician orders dated 11/01/2025, read, Wound care: coccyx cleanse with wound cleanser, pat dry period skin prep peri [around] wound. Apply calcium alginate and cover with silicone super absorbent dressing, every day shift for stage 3 pressure ulcer. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: coccyx cleanse with wound cleanser, pat dry period skin prep peri wound. Apply calcium alginate and cover with silicone super absorbent dressing, every day shift for stage 3 pressure ulcer. There was no documentation on 11/07/2025, 11/09/2025, 11/11/2025, 11/21/2025, and 11/22/2025. Review of Resident #70 physician orders dated 11/01/2025 read, Wound care: left lateral sacrum cleanse with wound cleanser, pat dry, protect peri wound with skin prep, apply calcium alginate, cover with silicone super absorbent every day shift for shear. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left lateral sacrum cleanse with wound cleanser, pat dry, protect peri wound with skin prep, apply calcium alginate, cover with silicone super absorbent every day shift for shear. There was no documentation on 11/01/2025, 11/02/2025, 11/03/2025, and 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Left lateral sacrum skin prep, every day shift for shear. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Left lateral sacrum skin prep, every day shift for shear. There was no documentation on 11/21/2025. Review of Resident #70 physician orders dated 2/12/2024 read, Heel protector boots to bilateral heels, while in bed every shift for pressure. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Heel protector boots to bilateral heels, while in bed every shift for pressure. There was no documentation on 11/07/2025 for the second entry/second shift of the day (7:00 PM – 7:00 AM). Review of Resident #70 physician orders dated 10/31/2025 read, Ketoconazole External Cream 2% (Ketoconazole (Topical)): Apply to R&L buttock topically every day and night shift for MASD for 21 days. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Ketoconazole External Cream 2% (Ketoconazole (Topical)): Apply to R&L buttock topically every day and night shift for MASD for 21 days. There was no documentation on either shift on 11/07/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: left buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD (moisture-associated skin damage). This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: left buttock apply zinc paste every day and evening shift for MASD. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left buttock apply zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/21/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Left groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Left groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. There was no documentation for day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Left lower leg apply lac hydrin lotion every day and night shift for xerosis, it was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2025 revealed the following: An entry read, Wound care: Left lower leg apply Lac-Hydrin lotion every day and night shift for xerosis. There was documentation for day or night shift on 11/07/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Right buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Right buttock apply zinc paste every day and evening shift for MASD. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right buttock apply zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/21/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Right groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. There was no docume

Based on record review and interview the facility failed to ensure that residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for pre-admission screening and resident review (PASARR) level II for 1 (Resident #74) of 3 residents reviewed for PASARR. Findings include:Review of Resident #74's admission record documented the resident was admitted on [DATE] with a readmission date of 3/13/2025 with a diagnoses that included brief psychotic disorder [onset date 8/19/2024]. Review of Resident #74 State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 7/20/2023 did not include brief psychotic disorder.Review of Resident #74 psychiatric subsequent note dated 3/17/2025 read, Chief Complaint: Depression, anxiety, insomnia, bipolar disorder, psychosis, and alcohol abuse. Rationale behind diagnoses: Brief Psychosis: The history suggest that this patient suffers from psychotic symptoms that are not consistent and long lasting. The disturbance is not attributed to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.During an interview on 12/4/2025 at 7:30 AM, the Director of Nursing stated, We do not have an updated PASSAR for Resident #74. we will have to update it. Review of the facility policy and procedure titled Coordination Pre-admission Screening and Resident Review (PASRR) Program with a last review date of 1/28/2025 read, Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations.

Based on record review and staff interviews, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 1 (Resident #27) of 4 residents reviewed for comprehensive care planning. Findings include:Record review of Resident #27's November 2025 Medication Administration Record (MAR) revealed 28 documented refusals of physician-ordered medications.Record review of Resident #27's December 2025 MAR revealed an additional 28 documented refusals of physician-ordered medications.Review of the resident's care plan revealed no problem statement, goals, or individualized interventions addressing repeated refusal of medications, despite the ongoing pattern of refusals across two consecutive months.During an interview with the Director of Nursing (DON) on 12/4/2025 at 9:50 AM, she stated that Resident #27 should be care planned for refusal of medications, confirming that the care plan did not reflect this clinically relevant issue.

Based on interview and record review the facility failed to administer insulin as ordered for 2 (Resident #2 and Resident #3) of 7 residents reviewed for medication administration and failed to provide wound care as ordered for 2 (Resident #36 and Resident #88) of 4 residents reviewed for pressure ulcers.Findings include:1) Review of Resident #2's physician order dated 10/6/2025 read, Lantus Subcutaneous Solution 100 Unit/ML [Unit per milliliter] (Insulin Glargine) Inject 10 unit subcutaneously one time a day for Hyperglycemia.Review of Resident #2's physician order dated 11/4/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (Insulin Glargine) Inject 12 unit subcutaneously one time a day for Hyperglycemia.Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 10 units documented on 11/2/2025 at bedtime coded 13 [Glucose out of Parameters].Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 12 units documented at bedtime code 13 on 11/15/2025, 11/16/2025, 11/22/2025, and 11/24/2025.During an interview on 12/3/2025 at 11:59 AM Physician Assistant #1 stated, I have not gotten phone calls regarding staff holding [Resident #2's name] insulin. Communication and reporting is a big deal here. I have parameters in place for a reason. I want to be notified. I don't need a phone call every time but until we have trust and a pattern I want the staff to call me, but a lot of times they do not. [Resident #2's name] has not run into any danger, it is not a big issue.During an interview on 12/3/2025 at 12:57 PM, the Director of Nursing stated, I expect nurses to use their nursing judgment but always communicate with the provider and follow physician orders. If they are using their nursing judgment they should call the provider and get clarification.Review of the facility policy and procedure titled Physician Services with a last review date of 1/28/2025 read, 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.2) Review of Resident #3's physician order dated 9/28/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 Unit/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously two times a day for Hyperglycemia (Before breakfast and bedtime).Review of Resident #3's physician order dated 11/30/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously one time a day for DM [Diabetes Mellitus].Review of Resident #3's physician order dated 11/2/2025, read, Hold insulin if blood sugar is less than 90 every shift.Review of Resident #3's Medication Administration Record for the month of November 2025 for Insulin Lispro Protamine and Lispro documented at 2100 [9:00 PM] on 11/1/2025 blood sugar level 114 coded 13, on 11/16/2025 blood sugar level 112 coded 13, and on 11/22/2025 blood sugar level 138 coded 13 [Glucose out of Parameters].During an interview on 12/3/2025 at 4:53 PM, Physician #1 stated, I don't recall notification from staff regarding [Resident #3's name]. Resident #3 has not had any medical emergencies regarding her diabetic management.3) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed. Resident #88 right lower foot was wrapped with Kerlix Gauze secured with tape dated 11/27/2025 [Staff F initials]. [photographic evidence obtained]Review of Resident #88's physician order dated 11/20/2025 read, Wound Care: Right Heel-Skin prep, cover with ABD [abdominal] pad and wrap with kerlix. Secure with tape every day shift for unstageable pressure injury and as needed for soiled /displaced/wound rounds.During an interview on 12/3/2025 at 10:16 AM, Staff G, Licensed Practical Nurse, stated, I do not really recall. I remember doing something on Saturday [11/29/2025] with [Resident #88's name] right lower leg. I just cannot remember. If there is a check in the system it means it was completed.During an interview on 12/3/2025 at 12:56 PM, the Director of Nursing stated, Wound care should be done as per physician orders.Review of the facility policy and procedure titled Wound Management with a last review date of 1/28/2025 read, Policy: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds.4) During an observation on 12/01/2025 at 10:07 AM, Resident #36 was lying in bed, right foot was wrapped with gauze secured by tape dated 11/27 [Staff F initials]. Dressing was loosened in the heel area and soiled.Review of Resident #36's physician order dated 11/20/2025,, read, Wound Care: Right heel-cleanse with Dakin's 1/2 str. Sol [strength solution]. pat dry. Skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze secure with tape every day shift for unstageable pressure ulcer.Review of Resident #36's physician order dated 10/17/2025 read, Wound care: Right lateral foot-skin prep, offload every day shift for arterial ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right 2nd toe-cleanse with Dakin's 1/2 str. Sol, pat dry. Skin prep peri wound, apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape every day shift for DM [Diabetic] Ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right lateral great toe cleanse with Dakins 1/2 str. Sol pat dry. Skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure tape every day shift for arterial ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right Lateral heel-cleanse with Dakin's 1/2 str. Sol, pat dry skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape every day shift for arterial ulcer.During interview on 12/3/2025 at 10:16 AM, Staff G, LPN, stated, I might have check off the wound care and sometimes you might forget. I am wondering if it was supposed to get done by the wound care nurse, so I checked it off and it didn't get done.During an interview on 12/4/2025 at 6:54 AM with the DON stated, I spoke to the nurses, and they stated they had checked it off [wound care] and would do the wound care later and they forgot. I expect them to check off on a treatment once it is completed.During an interview on 12/4/2025 at 11:50 AM with Staff H, LPN, stated I don't remember without looking at the record. If the nurse assigned to wound care is not able to do the wound care they will let the nurses on the cart know to do the wounds. I don't remember what happened.Review of the facility policy and procedure titled Clean Dressing Change with a last review date of 1/28/2025 read, Policy: It is the policy of the facility to ensure change dressings in accordance with the state and federal regulations, and national guidelines.

Based on observation, interview, and record review facility failed to safely use a mechanical lift for 1 (Resident #99) of 2 residents reviewed for accidents.Findings include:During an observation on 12/01/2025 at 9:40 AM, Staff E, Certified Nursing Assistant (CNA) entered Resident #99's room with a Hoyer lift. Resident #99 was observed on the Hoyer lift with only Staff E in the room. Resident #99 was hanging in the Hoyer lift completely off bed on left side parallel to the bed with the floor beneath resident's bottom and legs. Staff E was making the residents bed standing next to Resident #99.Review of Resident #99's care plan initiated on 10/4/2021, read, [Resident #99's name] has a chronic ADL [activities of daily living] self-care performance deficit resulting from the physical effects of muscle weakness, impaired balance /coordination and historical expressions of pain with non-ambulatory status. Interventions: is dependent upon staff for transfers with 2 person via HOYER lift.During an interview on 12/1/2025 at 9:49 AM, Staff E, CNA, stated, I know the Hoyer lift should be used with two people at all times. I was trying to change the linen on her [Resident #99] bed. I was not going to transfer her. Staff E confirm resident was hanging on the Hoyer lift off the bed with the floor underneath the resident. Staff E stated, I am sorry.During an interview on 12/3/2025 at 10:31 AM, the Director of Nursing stated, A Hoyer lift should be used with two staff members at all times.During an interview on 12/3/2025 at 11:10 AM, the Director of Therapy and Rehabilitation stated, The protocol to use a Hoyer is 2 person at all times. Upon hire, staff are trained using videos that are sent by the company that makes the Hoyer. It is important to always have two person assist when using the Hoyer in case something goes wrong you have an extra set of hands. Let's say the Hoyer fails or a strap is not on correctly, something could happen. By having two people you will not be by yourself. Review of the facility policy and procedure titled Safe Resident Handling /Transfers with a review date of 1/28/2025 read, Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: 10. Two staff members must utilize when transferring resident with a mechanical lift.

Based on interview and record review the facility failed to provide nutritional services for 2 (Resident #30 and Resident #66) of 5 resident review for dietary services.Findings include:1) Review of Resident #30's weights documented on 07/15/2025, the resident weighed 189 lbs [pounds]. On 11/04/2025, the resident weighed 164 lbs, which is a -13.23% Loss.Review of Resident #30 dietary progress note dated 11/18/2025 read, Summary: Resident show fair appetite. Weight on downward trend stabilizing with fortified foods with meals and shakes. Resident is on medication that cause edema. Liberalized diet intervention in place to promote po [by mouth] intakes nutrition interventions in place to avoid significant wt [weight] loss. Goals: avoid significant wt changes, po intake >76% as tolerated, 100% supplements, skin remains intact. Recommend: continue fortified foods with meals and health shakes x 30 days. Continue to monitor wt, skin labs, and po intakes as appropriate.Review of Resident #30's physician orders did not document an active order for health shakes after 11/23/2025.Review of Resident #30's Medication Administration Record for the month of November 2025 did not document health shakes after 11/23/2025.Review of Resident #30's Medication Administration Record for the month of December 2025 did not document health shakes administration.During an interview on 12/3/2025 at 1:05 PM, the Registered Dietician stated, [Resident #30's name] is receiving palliative care and weight loss is unavoidable. She is receiving house shakes and not improving. I would consider comfort measures for her. I send an email to the Director of Nursing at an end of day and then the recommendations get approved. I don't see the health shakes in her record; they should have been added. I thought she was receiving them. I believe her weight loss is due to the condition of her health because health shakes are only once a day and only provide 200 calories which would not be substantial. I am not sure how the health shakes didn't get put on there.During an interview on 12/3/2025 at 3:15 PM, the Director of Nursing stated, The Registered Dietitian puts in here own orders into the system. She does send an email, but she is the one putting the orders in herself.During an interview on 12/4/2025 at 9:54 AM, Physician #1 stated, I don't remember if they notified me about [Resident #30's name] weight loss. The registered dietitian is able to put in her own hers into the system if she has any recommendations. 2) Review of Resident #66's weights on 08/01/2025, the resident weighed 171 lbs [pounds]. On 11/04/2025, the resident weighed 156 lbs which is a -8.77% Loss.Review of Resident #66's weights on 5/3/2025, the resident weighed 174 lbs. On 11/04/2025, the resident weighed 156 lbs which is a -10.34% Loss.Review of Resident #66 progress note did not reveal any dietary notes.During an interview on 12/3/2025 at 1:12 PM, the Registered Dietician stated, There aren't any progress notes in the system. Last nutritional comprehensive was done in August 2023. We have a list of high-risk patients to see. Usually, I will review weights to see who has had significant weight loss and they will be included in my list to see them. I am not sure how we missed that. She [Resident #66] is not on my list. She should have been seen on November (2025) and October (2025). I am not sure why this happened.During an interview on 12/3/2025 at 2:43 PM, the Registered Dietician (RD)stated, I reviewed her record and she is trending down. Currently, resident is on palliative care due to Cancer, COPD [Chronic Obstructive Pulmonary Disease], and CKD [Chronic Kidney Disease]. She has had past weight fluctuations. He BMI Body mass index] is with in normal limits.During an interview on 12/3/2025 at 3:15 PM, the Director of Nursing stated, Registered Dietitian has a tracking log, and she has access to PCC [point click care]. We do not tell them who to see normally. We have clinical meetings were we will review weight loss and nine out of ten she always has them on her list to see them. She [Resident #66] fell through the cracks, she should have been seen by the RD. [Resident #66's name] was reweighed and gain weight almost makes me feel like the November [2025] weight was incorrect. A nutritional assessment should be done quarterly or when a significant change occurs. My regional nurse is getting more clarification.During an interview on 12/4/2025 at 12:42 PM, Physician Assistant #1 stated, I want to say yes, the facility notified me of her [Resident #66] weight loss. Her boyfriend was telling her she was overweight. I believe I spoke to the unit manager, and we had a discussion about protein drinks. I believe that the registered dietitian can put her own orders in if she feels that the resident needs anything she will go ahead and communicate to tell me, but she can put in her orders.During an interview on 12/3/2025 at 1:43 PM, Certified Dietary Manager stated, [Resident #66's name] is a vegetarian per se [latin for 'in itself'] she eats dairy, chicken and seafood. No beef or pork products. She eats quite well and submits special orders often. The RD has not communicated any weight loss to me regarding [Resident #66's name]. The RD is the only one looking at weights. I look at the ideal body weight and BMI and recommendations made.Review of the facility policy and procedure titled Nutritional Management with a last review date of 1/28/2025 read, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance Guidelines: C. Comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow up assessments will be completed as needed.

Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the correct flow rate for 1 (Resident #88) of 3 residents and failed to change the nebulizer treatment bag 1 (Resident #50) of 3 reviewed for respiratory services.Findings include: 1) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed with oxygen being administered at 4 liters of oxygen per minute via nasal cannula. [photographic evidence obtained] During an observation on 12/02/2025 at 8:22 AM, Resident #88 was sitting up in bed eating breakfast. Oxygen was being administered via nasal cannula at 4 liters per minute. Review of Resident #88's physician order dated 6/28/2025 read, Oxygen continuous at 3 lpn [sic] liters/ min [liters per minute] via nasal cannula medical DX [diagnosis]: CHF [congestive heart failure] every shift for CHF. During an observation on 12/3/2025 at 10:10 AM, Staff G, Licensed Practical Nurse (LPN) entered Resident #88's room. Resident #88 was lying in bed with oxygen being administered via nasal cannula at 4 liters per minute. During an interview on 12/3/2025 at 10:11 AM, Staff G, LPN, stated, [Resident #88's name] oxygen was running at 4 liters per minute, and she has orders for 3 liters per minute I will have to readjust her oxygen. During an interview on 12/3/2025 at 10:24 AM, the Director of Nursing stated, Nursing staff should check the oxygen flow rate for accuracy every shift. We have some residents that will adjust the oxygen themselves. [Resident #88's name] is not one of them. Review of the facility policy and procedure titled, Tracheostomy Care and Suctioning/Oxygen with a last review date of 1/28/2025 read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standard s of practice, the comprehensive person-center care plan and resident goals and preferences. Procedures: 2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by physician, treatments, mechanical ventilation, tracheostomy care and /or suctioning. 2) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; paroxysmal atrial fibrillation; and essential (primary) hypertension. During an observation on 12/01/2025 at 11:05 AM, Resident #50's nebulizer supply bag, containing the tubing and the face mask was dated 11/22/25. (photographic evidence)During an interview on 12/01/2025 at 11:15 AM, Resident #50 stated that her nebulizer treatments were as needed because she had a history of bronchitis and asthma. During an observation on 12/03/2025 at approximately 9:30 AM, Resident #50's supply bag for her nebulizer, that contained the tubing and the face mask was dated 11/22/2025. (photographic evidence) Review of Resident #50's physician orders revealed an order dated 10/25/2025 that read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/ML (milligrams per milliliter) (Ipratropium-Albuterol): 3 ml inhale orally every 6 hours as needed for wheezing/cough. Review of Resident #50's MAR (Medication Administration Record) for November 2025 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/ML (milligrams per milliliter) (Ipratropium-Albuterol): 3 ml inhale orally every 6 hours as needed for wheezing/cough There was documentation of administration on 11/23/2025. During an interview on 12/03/2025 at 9:49 AM, the DON (Director of Nursing) stated that the expectation was that oxygen, nebulizer and other respiratory equipment was supposed to have the tubing and masks changed every week. The supplies were to be kept in the plastic bag when not in use, and the tubing and bag were supposed to have the date when they were changed.

Based on record review and interview the facility failed to ensure the physician provided a documented rationale for no action taken following the pharmacist's recommendation for 2 residents, Resident #10 and Resident #50, of 5 residents sampled for unnecessary medications.Findings include:1) Review of Resident #10's pharmacy consultation reports dated 3/18/2025, 4/28/2025 and 5/28/2025 revealed the pharmacist noted Resident #10's prescribed as needed medication, Midodrine, had not been used within the previous 60 days and recommended, Please consider discontinuing due to lack of use. Review of Resident #10's physician progress note dated 3/28/2025 revealed the Advanced Registered Nurse Practitioner had documented, Continue Midodrine but failed to document the rationale for no action taken following the pharmacist's recommendation to discontinue use of the medication. Review of Resident #10's physician orders showed an active physician order dated 10/31/2024 that read, Midodrine HCl [hydrochloride] oral tablet 5 mg [milligrams], Give 1 tablet by mouth every 8 hours as needed for SBP [systolic blood pressure] < [less than] 100. During interview on 12/3/2025 at 12:27 PM, the Director of Nursing confirmed there was no record to show the physician provided a documented rationale for no action taken following the pharmacist's recommendation. 2) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; long term (current) use of anticoagulants; paroxysmal atrial fibrillation; and essential (primary) hypertension. Review of the Consultation Report with the Pharmacist recommendations dated 7/30/2025 read, Comment: Issued on 7/30/2025. Clinical Priority Recommendation: Prompt Response Requested. [Resident #50's Name] receives Eliquis (apixaban) [anticoagulant (blood thinner) medication used to prevent and treat blood clots] 5 mg BID [twice daily]. Recommendation: Please decrease to Eliquis 2.5 mg twice daily. There was a hand-written note that read, Disagree, it was not signed or dated. Review of Resident #50's progress notes from 7/01/2025 through 12/01/2025 revealed no mention of Eliquis or declination of pharmacy recommendation. Review of Resident #50's Medication Administration Record (MAR) for July 2025 and August 2025 revealed an entry that read, Apixaban Oral Tablet 5 MG (Apixaban): Give 1 tablet by mouth two times a day related to Paroxysmal Atrial Fibrillation [an irregular heartbeat that starts and stops on its own, with episodes lasting less than a week and often resolving within 24 hours]. There was documentation of administration twice daily from 7/01/2025 through 8/31/2025. A Consultation Report for Resident #50 with Pharmacist's recommendation dated 10/27/2025 read, Comment: [Resident #50's Name] receives lidocaine patch [a medicated, adhesive transdermal (method of administering a medication or drug through the skin) patch that delivers the local anesthetic lidocaine through the skin to provide localized pain relief]. Recommendation: Please ensure that the following administration recommendations are followed: Order should include instructions to remove after 12 hours. The Director of Nursing Comments documented the signature of the DON; it was dated 10/29/2025. Review of Resident #50's Physician's Orders revealed an order dated 10/25/2024 that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's MAR for October 2025 revealed an entry that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's MAR for November 2025 revealed an entry that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's physician progress note, dated 10/31/2025, from the PA #1 (Physician's Assistant from the Primary Care Physician's group for Resident #50). It read, . Meds [medications] were reviewed . There was no mention of her Lidocaine patch or altering the order to include instructions for removal after 12 hours. During an interview on 12/03/2025 at approximately 3:00 PM, the DON (Director of Nursing) stated that she had reviewed Resident #50's medical record pertaining the pharmacist recommendations and did not find any progress notes or other documentation addressing the reasons the pharmacist's recommendations had not been followed. During an interview on 12/04/2025 at 12:48 PM, PA #1 stated that he was aware of the process regarding the pharmacy recommendations, and that they were supposed to mark agree or disagree and that there was a section to write in the reason for disagreeing with a recommendation. He did not recall a conversation at the end of October [2025] with the DON regarding a removal order for Resident #50's Lidocaine patch. Review of the policy and procedure titled, Medication Regimen Review, with the last review date of 1/28/2025, read, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR [Medication Regimen Review] and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendation contained in the MRR and provide explanations as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Review of the policy and procedure titled, Physician Services, with an issued date of 3/29/2025, with last revision date of 1/28/2025, read, Policy: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations. Procedure: . 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residents medical record during that shift.

Based on interview and record review, the facility failed to ensure that residents' medication regimens were free from unnecessary medications, including excessive doses/dosages for 3 (Resident #50, Resident #22 and Resident #71) of 5 residents reviewed for unnecessary medications.Findings include:1) Review of Resident #22's admission data revealed that she was admitted to the facility on [DATE] with medical diagnosis that include Alzheimer's Disease with late onset, acute chronic combined systolic heart failure, difficulty walking, major depressive disorder, anemia, essential (primary) hypertension, paroxysmal atrial fibrillation, cardiomegaly, unspecified dementia, type 2 diabetes mellitus and anxiety disorder (not an inclusive list). Review of Resident #22's physician orders revealed an order dated 10/29/2025 read, DIL-XR Oral Capsule Extended Release 24 hours 120 milligrams (mg), give 2 capsules by mouth one time a day for hypertension, hold for systolic blood pressure (SBP) below 160. Review of Resident #22's physician orders revealed an order dated 10/29/2025 read, Metoprolol Succinate ER Oral Tablet Extended Release 24 hours, 25 MG, give 3 tablets by mouth one time a day for hypertension, total 75 mg, hold for SBP below 160. Review of Resident #22's Medication Administration Record (MAR) for November 2025 revealed DIL-XR Oral Capsule was administered on 11/10/2025 at 10:00 AM for a blood pressure of 131/74. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/14/2025 at 10:00 AM for a blood pressure of 123/83. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/17/2025 at 10:00 AM for a blood pressure of 129/80. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/24/2025 at 10:00 AM for a blood pressure of 131/65. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/28/2025 at 10:00 AM for a blood pressure of 131/76. Review of Resident #22's MAR for November 2025 revealed Metoprolol ER oral tablet was administered on 11/24/2025 at 8:00 AM for a blood pressure of 123/68. 2) Review of Resident #71's admission data revealed that she was admitted to the facility on [DATE] with medical diagnosis that include heart failure, muscle weakness, malignant neoplasm of the cecum, hypotension, anemia, chronic kidney disease, anxiety disorder, major depressive disorder and essential hypertension (not an inclusive list). Review of Resident #71's physician orders revealed an order dated 8/21/2023 read, Lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, give 1 tablet by mouth one time a day for hypertension, hold is SBP is less than 110. Review of Resident #71's physician orders revealed an order dated 11/7/2023 read, Midodrine oral tablet 5 mg, give 1 tablet by mouth one time a day for hypotension, give if BP (blood pressure) is below 100/60. Review of Resident #71's MAR for November 2025 revealed Lisinopril-hydrochlorothiazide oral tablet was administered on 11/10/2025 at 9:00 AM for a blood pressure of 103/62. Review of Resident #71's MAR for November 2025 revealed Midodrine oral tablet was administered on 11/11/2025 at 9:00 AM for a blood pressure of 105/58. Review of Resident #71's MAR for November 2025 revealed Midodrine oral tablet was administered on 11/25/2025 at 9:00 AM for a blood pressure of 109/59. During an interview on 12/2/2025 at 4:40 PM, Staff B stated that she misinterpreted the order and did administer the medications on those dates. During an interview on 12/3/2025 at 3:35 PM, the DON (Director of Nursing) stated that her expectations would be that the physician orders would be read complete, administered as order and if there were any concerns with clarification of the order the nurse would contact the physician or her. 3) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; long term (current) use of anticoagulants; paroxysmal atrial fibrillation; and essential (primary) hypertension. The Pharmacist recommendation dated 1/21/2025 read, Please reduce Methocarbamol to 750 mg QD with the end goal of discontinuation. It was accepted and signed by Resident #50's primary care physician. Review of Resident #50's physician orders revealed an order dated 11/30/2024 that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. Review of Resident #50's physician orders revealed an order dated 10/25/2025 that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. Review of Resident #50's MAR (Medication Administration Record) for January 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily from 1/01/2025 through 1/31/2025. Review of Resident #50's MAR for February 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily from 2/01/2025 through 2/28/2025. Review of Resident #50's MAR for November 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily for 55 out of 60 scheduled doses from 11/01/2025 through 11/30/2025. During an interview on 12/02/2025 at 5:00 PM, the DON (Director of Nursing) stated that she was aware that they had problems with getting the changes and orders from the pharmacist recommendations entered and carried out. During an interview on 12/03/2025 at 3:00 PM, the DON stated that she had reviewed Resident #50's medical record pertaining the pharmacist recommendations and did not find any progress notes or other documentation addressing the reasons the recommendations had not been followed. Review of the Policy and Procedure titled Physician Services, with an issued date of 3/29/2025 and last revision date of 1/28/2025, read, Policy: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations. Procedure: . 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residence medical record during that shift. Review of the Policy and Procedure titled General Dose Preparation and Medication Administration, with an effective date 12/01/2007 and last revision date of 1/28/2025, read, Applicability: This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications.

Based on observation, interview, and record review, the facility failed to maintain infection control and prevention measures related to medication handling and the use of personal protective equipment (PPE) for three residents (Resident #101, Resident #120, and Resident #121) out of five residents observed for medication administration.Findings include:During an observation on 12/03/2025 at 8:19 AM while Staff A, RN (Registered Nurse) was expelling amlodipine 5 MG (milligrams) Oral Tablet out of the package, it dropped onto the medication cart. Staff A, RN picked up the tablet without donning gloves, placed the pill in the medication cup with several other medications, and administered the medications to Resident #101.During an observation on 12/03/2025 at 8:34 AM Staff A, RN opened a capsule of Lactobacillus acidophilus 10 MG Oral Capsule without wearing gloves and added the contents to a medication cup prior to adding pudding for administration to Resident #120.During an observation on 12/03/2025 at 8:59 AM Staff A, RN donned gloves and administered six medications to Resident #121 via G-Tube (A gastrostomy tube is a tube placed through the abdomen directly into the stomach, used for feeding, administering medication, and draining air or fluid). Staff A, RN failed to don a gown prior to administering medications via Resident #121's G-tube.During an interview on 12/03/2025 at 9:30 AM Staff A, RN stated that she had overlooked wearing a gown while administering medications to Resident #121 via her G-Tube. Staff A. RN should not have picked up Resident #101's amlodipine tablet from the top of the medication cart, especially without wearing gloves, and then administer it to the resident. Staff A, RN was not sure if she should have opened Resident #120's capsule without wearing gloves, but she would wear gloves in the future.During an interview on 12/03/2025 at 9:49 AM the DON stated that residents were on EBP (Enhanced Barrier Precautions) for [intravenous (IV)] lines, G-tubes, and Foleys, PPE (personal protective equipment) was to be worn, including gloves and gowns when in close contact or providing care. A nurse should wear a gown and gloves when administering medications through a peg (Percutaneous Endoscopic Gastrostomy tube, which is a feeding tube inserted through the abdominal wall directly into the stomach) or G-tube. A nurse should not touch pills with their hands. If a resident has an order to open a capsule for administration, the nurse should wear gloves to open or touch the capsule.Review of the policy and procedure, with an issue date of 3/29/2019 and last reviewed date of 1/28/2025, titled Infection prevention and control and surveillance program, read, Policy: It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulations, and national guidelines. Procedure: . 7. The facility will provide infection prevention and control training upon hire and ongoing throughout the year as needed in the following areas: d. personal protective equipment.Review of the policy and procedure, with an issue date of 4/01/2024 and last review date of 1/28/2025, titled Enhanced Barrier Precautions, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Policy explanation and compliance guidelines: 2. Initiation of enhanced barrier precautions:. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism) . 4. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Table 1: Implementing Contact versus Enhanced Barrier Precautions:. Resident Status: Has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. Use EBP: Yes.Review of the policy and procedure, with an effective date of 12/01/2007 and last review date of 1/28/2025, titled General Dose Preparation and Medication Administration, read, Applicability: This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. Procedure: 1. Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications. 2. Prior to preparing or administering medications, authorized and competent facility staff should follow facilities infection control policy.

Based on record review and interview, the facility failed to report the laboratory results to the physician in a timely manner in accordance with professional standards of practice for 1 of 3 residents reviewed for hospital transfers (Resident 1).Findings include:Review of Resident #1's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including right dominant side hemiplegia, acute kidney failure, dementia, cognitive communication deficit, type 2 diabetes mellitus, pulmonary fibrosis, edema, and failure to thrive.Review of Resident #1's laboratory results showed the first partial result on 7/2/2025 at 1:17 PM and the second partial result on 7/2/2025 at 1:37 PM, and the final result on 7/2/2025 at 1:42 PM. The reports showed abnormal BUN (Blood Urea Nitrogen; a blood test that measures the amount of urea in the blood, primarily to assess kidney function) result of 90 H (high), with the normal range being 8-27 mg/dL (milligram/deciliter); abnormal Creatinine (waste product from normal muscle and protein breakdown, released into the bloodstream and filtered by the kidneys into urine.) result of 3.9 H, with normal range being 0.5-0.9 mg/dL.Review of Resident #1's daily progress notes for 7/2/2025, 7/3/2025, and 7/4/2025 showed no documentation of laboratory results being reported to physician.Review of Resident #1's physician progress note dated 7/2/2025 showed it read, History of Present Illness: General: 74 yo [years old] with medical h/o [history of] DM2 [type 2 diabetes mellitus]/Neuropathy, Fibromyalgia, HTN [hypertension], HLD [hyperlipidemia], CVA [cerebrovascular accident] with residual hemiplegia, cognitive communication deficient, was recently hospitalized due to AKI [Acute Kidney Injury], Weakness, FIT [Failure to Thrive]. Treated and stabilized at hospital. Transferred to this facility to continue medical treatment and skilled rehabilitation. Patient is being seen today for follow up and review management. At evaluation, pt [patient] is alert and oriented in person, in no distress. Denies chest pain, no SOB [Shortness of Breath], no nausea or vomiting, no abdominal pain. No pain at evaluation. Generalized weakness more left side hemibody. PT/OT/ST [Physical Therapy/ Occupational Therapy/ Speech Therapy] to evaluate and treat. Assist with ADLs [Activities of Daily Living]. Falls precautions.During a telephone interview on 9/10/2025 at 3:00 PM, the Physician stated, I do not recall a call for her [Resident #1] results. I saw the patient that day and only that day. As per my routine when in the facility, I visit new admission first thing in the morning, then continue to see others in the facility. Lab result from any day will start coming in around 2 PM. The result should have been reported to me that day.During an interview on 9/10/2025 at 2:13 PM, the Director of Nursing (DON) stated, The labs results should have been reported to the physician immediately.Review of the facility policy and procedure titled Diagnostic Services revised on 3/2/2019 showed it read, Policy: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Procedure: 4. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference ranges in accordance with the facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 1 of 3 residents, Resident #97, reviewed for respiratory care. Findings include: During an observation on 07/08/2024 at 10:53 AM, Resident #97 was lying in bed with a nasal cannula intact in their nares and the oxygen concentrator was administering oxygen at 2 liters per minute (L/min.). (Photographic evidence obtained) During an observation on 07/09/2024 at 8:51 AM, Resident #97 was lying in bed with a nasal cannula intact in his nares and the oxygen concentrator was administering oxygen at 2 L/min. During an observation on 07/09/2024 at 12:40 PM, Resident #97 was lying in bed. The nasal cannula was intact in his nares and the oxygen concentrator was administering oxygen at 2 L/min. Review of the medical record showed that Resident #97 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), pleural effusion, kidney failure, and chronic kidney disease Stage 3B. Review of the physician's order dated 06/07/2024, read, Oxygen continuous at 3 liters/min [liters per minute] via NC [nasal cannula]. Medical Diagnosis: RF [respiratory failure]. Every shift. Review of the care plan dated 06/07/2024, read, [Resident #97's name] is ordered oxygen therapy associated with a diagnosis of COPD. Give medications (oxygen) as ordered by physician. During an interview on 07/07/2024 at 1:22 PM, Staff A, Licensed Practical Nurse (LPN) Unit Coordinator confirmed the oxygen concentrator was not administering oxygen at 3 L/min, stating, It's not set at 3 L/min. Staff A, LPN verified the physician's order dated 06/07/2024 read, Oxygen continuous at 3 liters/min via NC. During an interview on 07/09/2024 at 1:52 PM the Director of Nursing (DON) stated, The nurse should check the oxygen settings on the concentrator at the beginning of her shift. The setting should be checked every couple of hours, because they should be checking on the resident every two hours, at maximum they should check the oxygen settings 3-4 times a shift. Review of the policy and procedure titled, Tracheostomy Care and Suctioning/Oxygen, last reviewed on 01/25/2024 read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident care goals and preferences. Procedures: 2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by physician, treatments, mechanical ventilation, tracheostomy care and/or suctioning.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff information was posted daily at the beginning of each shift. Findings include: During an observation on 7/8/24 at 9:00 AM of the Nursing Staffing data, located on the wall in the main lobby was dated July 4, 2024. (Photographic evidence obtained) During an interview on 7/9/24 at 1:06 PM the Director of Nursing stated, It's the staffing coordinator's job to post the federal staffing schedule between 6:00 AM -7:00 AM Monday through Friday and on the weekends it's the supervisors responsibility. Review of the of policy and procedure titled Nursing Staffing Information, last reviewed on 3/2/19, read, Policy: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. Procedure: 1. The facility will post the following information on a daily basis: a. Facility name b. The current date c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses or licensed vocational nurses (as defined under state law). iii. Certified nurse's aides 2. The facility will post the nurse staffing data on a daily basis at the beginning of each shift. 3. Data must be posted as follows: a. Clear and readable format b. In a prominent place readily accessible to residents and visitors.

Based on observation, interview, and policy and procedure review, the facility failed to ensure food and dishes were properly stored, covered, labeled, and dated in the areas of the kitchen's reach-in and walk-in coolers, and walk-in freezer. Findings include: An initial walk-through of the kitchen was conducted on 7/08/24 beginning at 9:10 AM with the Regional Culinary Director (RCD) and the Dietary Manager (DM.) At 9:13 AM there was an observation made of numerous boxes of food on the floor in the walk-in freezer. At 9:17 AM two cases of raw shell eggs were observed stored on the top shelf of the walk-in cooler over a box of produce and a box of opened ready-to-use chocolate chips, there were two large containers of a liquid substance with a clear plastic cover with no identifying label or date, and a large stainless-steel bowl containing a white diced product covered in clear plastic with no label or date. An observation was made in a reach-in cooler of an opened package of what appeared to be butter or margarine lying on the top shelf with the contents exposed. (Photographic evidence obtained). During an interview on 7/08/2024 at 9:25 AM the DM confirmed there were two cases containing 15 dozen eggs in each case on the top shelf of the walk-in cooler directly over produce and a case of chocolate chips. The DM stated the eggs should have been on the bottom shelf under the produce and other products. The DM confirmed there were two large containers of liquid that did not have identifying labels or dates and stated there should have been labels and dates on each of the containers. The DM stated the diced white product was diced pears and should have been labeled and dated, the large clear containers were lemonade and fruit punch and should have identifying labels and dates, the boxes of food in the walk-in freezer remained on the floor and had not been properly stored since the last week's delivery date, the reach-in cooler had a package of margarine that was left opened and exposed and should have been securely wrapped and properly stored and labeled. During an observation on 7/09/2024 at 7:35 AM of the kitchen with the RCD there were numerous dishes to include scooped and regular plates, ramekins, soup and fruit bowls all stored on a shelf that had visible spills and debris without being covered or inverted. (Photographic evidence obtained) During an interview on 7/09/2024 at 9:19 AM the RCD stated his expectations are for the covering, labeling, dating, and storing of food items and dishes, these items are to be stored according to the policy for food safety. Review of the policy and procedure titled Food Safety read, Policy: Dry Storage rooms 1d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2d. Refrigerated items: d. Should be properly dated, stored, labeled. g. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat food. 3c. Freezer: Store all foods on racks or shelves off the floor.

Based on observation, interview, and record review the facility failed to ensure personal protective equipment was used while caring for 1 of 12 residents, Resident #310, on enhanced barrier precautions; failed to clean and sanitize the multi-use blood pressure cuff and monitor during medication administration for 2 of 6 residents, Residents #72 and #92; and failed to perform proper hand hygiene according to the standards of professional practice for 4 residents, Resident #48, #72, #92, and #153, to prevent the possible spread of infection. Findings include: During an observation on 07/08/2024 at 09:50 AM, there was a sign on the door of Resident #310's room that read, Enhanced Barrier Precautions in addition to standard precautions: STOP. Everyone MUST: Wear gown and gloves for the following high-contact resident care activities: Changing briefs/assisting with toileting . (Photographic evidence obtained) During an observation on 07/08/2024 at 09:50 AM, Staff B, Certified Nursing Assistant (CNA), entered Resident #310's room. The CNA donned gloves but no gown. The CNA then pulled the privacy curtain back at the resident's bedside while holding onto a clean incontinence brief with one hand, and without wearing a gown, initiated incontinence care and changed the soiled incontinence brief for Resident #310. During an observation on 07/08/2024 at 11:25 AM, Staff B, CNA, entered the room for Resident #310. The CNA donned gloves but no gown. The CNA again pulled the privacy curtain back at the resident's bedside and without wearing a gown, initiated incontinence care and changed the soiled incontinence brief for Resident #310. Review of the medical record for Resident #310 documented the resident was admitted on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), bacteremia (presence of bacteria in the blood), cellulitis (a deep infection of the skin caused by bacteria) of the left lower limb, acquired absence of the right toe, brief psychotic disorder, major depressive disorder, and bipolar disorder. Review of the comprehensive care plan dated 6/9/2024 documented Resident #310 has a Stage 3 pressure ulcer to the coccyx area, a Stage 2 pressure ulcer to the right buttock, and a Stage 3 pressure ulcer to the left and right heels. Review of the physician's order dated 07/10/2024 reads, Enhanced Barrier Precautions: Chronic Wound, every shift for wound. During an interview on 07/09/2024 at 1:40 PM Staff B, CNA stated, I've taken care of this resident before. She's on enhanced barrier precautions [EBP]; she has wounds on her butt and feet. I really don't know what I am supposed to be wearing for PPE [Personal Protective Equipment] for EBP residents. I wore gloves and washed my hands before and after caring for [Resident #310's name]. I didn't wear a gown when I changed her brief. I asked the nurse later if I was supposed to wear a gown while I was doing that. She didn't seem to know either. I didn't get any real training on it. I guess I'm supposed to look at the sign. Staff B, CNA confirmed the Enhanced Barrier Precautions sign posted on Resident #310's door read, Wear gown and gloves for the following high contact activities: Changing briefs/assisting with toileting. During an interview on 07/09/2024 at 1:52 PM, the Director of Nursing (DON) stated, The staff should be wearing a gown and gloves when doing any type of care with resident's on EBP, direct care or touching their things, and performing hand hygiene before and after care. Review of the policy and procedure titled, Enhanced Barrier Precautions, issued 4/1/2024 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wound such as pressure ulcers, diabetic foot wounds .3. Implementation of Enhanced Barrier Precautions: a. Make gown and gloves available immediately near or outside the resident's room. 4. High-contact resident care activities include .f. Changing briefs or assisting with toileting. During an observation on 07/09/2024 at 07:54 AM, Staff D, Certified Nursing Assistant (CNA), exited a resident's room wearing gloves and carrying a closed bag of linen. The CNA discarded the bag of linen in the covered bin, removed her gloves, and without performing hand hygiene, proceeded to the soiled utility room and grabbed a roll of clear bags. Without performing hand hygiene, Staff D, CNA proceeded to the clean linen cart, and without performing hand hygiene, grabbed a clean blanket and put it in a clear bag. Staff D, CNA then proceeded to Resident #153's room. The CNA entered the room, and without performing hand hygiene, set up towels and a basin full of water on Resident #153's bedside table for the resident to do personal hygiene care. Staff D, CNA then exited the resident's room, and without performing hand hygiene entered Resident #48's room. Without performing hand hygiene, Staff D, CNA donned gloves, pulled Resident #48's privacy curtain back, and proceeded to provide incontinence care. During an observation on 7/9/2024 at 08:21 AM, Staff C, Licensed Practical Nurse (LPN) pushed Resident #72 in his wheelchair from the common area to his room and administered medications to the resident. Without washing her hands, Staff C, LPN unlocked the medication cart, removed an automatic blood pressure cuff monitor from the drawer, entered Resident #72's room, and without washing her hands, placed the cuff on his arm. Staff C, LPN then removed the cuff, placed it on top of the medication cart, wrote the results on a piece of paper, put the cuff back in the drawer without cleaning or disinfecting the shared equipment after use, and proceeded with preparing the medications. After placing the medications in a cup, without washing her hands, Staff C, LPN entered the room and completed the medication administration with Resident #72. The LPN then returned to the medication cart, and without washing her hands, wheeled the cart down to Resident #92's room. Staff C, LPN unlocked the cart, grabbed the same automatic blood pressure cuff from the drawer, and without washing her hands, entered Resident #92's room. The LPN placed the blood pressure cuff on Resident #92's arm, took the reading, removed the blood pressure cuff from the resident's arm, returned to the medication cart, set the cuff on top of the cart and without washing her hands, proceeded with preparing the medications for administration to Resident #92. After preparing the medications for administration in a medicine cup, the nurse entered Resident #92's room, and without performing hand hygiene, donned a pair of gloves and completed the medication administration. Staff C, LPN then returned to the cart, without performing hand hygiene, put the blood pressure cuff back in the drawer without cleaning or disinfecting the equipment after use, and proceeded down the hall with the medication cart to another resident's room. During an interview on 7/9/2024 at 09:34 AM Staff C, LPN confirmed that she did not clean the blood pressure monitor between resident use and did not perform hand hygiene during care for Residents #72 or Resident #92 and did not perform hand hygiene after providing care to the residents. Staff C, LPN stated, I should have cleaned and disinfected the equipment between each resident and washed my hands before and after medication administration to each resident. During an interview on 7/9/2024 at 1:08 PM Staff D, CNA confirmed she did not perform hand hygiene after discarding the soiled linen bag and removing her gloves this morning and did not perform hand hygiene before or after care for Resident #153 and Resident #48. Staff D, CNA stated, I should have washed my hands before and after care for [Resident #153's name] before I took care of [Resident #48's name]. I didn't wash my hands before putting on gloves to care for [Resident #48's name] either. I should wash my hands before and after care and before and after wearing gloves. During an interview on 7/9/2024 at 1:52 PM, the Director of Nursing (DON) stated, The staff should be performing hand hygiene before and after care and between residents. The nursing staff should be cleaning and disinfecting the blood pressure cuff monitor between each resident using the cleaning wipes. They need to follow the manufactures' instructions on the wipes for cleaning, disinfecting, and dry times. During an interview on 7/11/2024 at 07:55 AM the Director of Nursing (DON) stated, The facility policies for Infection Control need to follow the State and Federal regulations and National guidelines. We cannot override the regulations with our own policy rules. Review of the policy and procedure titled, Infection Control - Cleaning and Disinfection/Non-Critical Care and Shared Equipment, last reviewed on 1/25/2024 read, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Review of the policy and procedure titled, Infection Control - Hand Hygiene, last reviewed 1/25/2024, read, Policy: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: e. Before and after assisting a resident with personal care; i. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident); j. Before and after assisting a resident with toileting; m. After handing soiled or used linens, dressings, bedpans, catheters, and urinals . Review of the U.S. Centers for Disease Control and Prevention (CDC) website document titled, CDC Environmental Cleaning Procedures, last updated March 19, 2024, read, Section 4.7 Noncritical patient care equipment: Portable or stationary noncritical patient care equipment includes IV poles, commode chairs, blood pressure cuffs, and stethoscopes. These high-touch items are: Often shared by patients. Table 26. Recommended Selection and Care of Noncritical Patient Care Equipment. Type of Equipment: Shared (e.g., general inpatient wards). Frequency: Before and after each use. Method: Clean and disinfect.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 4 of 4 medication carts and Wing 1 Medication Room. Findings include: On [DATE] at 9:10 AM, during an observation of Unit 1 Medication Cart 1 with Staff B, Licensed Practical Nurse (LPN), there was an opened Insulin Glargine Pen with no opened date documented. During an interview on [DATE] at 9:10 AM, Staff B, LPN, stated, Yes it should be dated once opened. On [DATE] at 9:19 AM, during an observation of Unit 1 Medication Cart 2 with Staff C, LPN, there was an unopened Insulin Glargine Pen in the cart with a label to refrigerate until opened. During an interview on [DATE] at 9:19 AM, Staff C, LPN, stated, I don't know how long it has been there. I don't use that insulin. That is a night time medication. On [DATE] at 9:30 AM, during an observation of the refrigerator of Unit 1 Medication Room with Staff D, LPN, there were one syringe of Aplisol 0.1 milliliter (ml) labeled as expired on [DATE] and one bottle of Omeprazole 2 milligram (mg)/ml labeled as expired on [DATE]. During an interview on [DATE] at 9:30 AM, Staff D, LPN, stated, These medications should have been removed from the refrigerator. On [DATE] at 9:45 AM, during an observation of Unit 2 Rehab Cart 2 with Staff E, LPN, there was one Saline Nasal Spray dated [DATE] with no resident identifier and one Thiamin vial with no security tab. During an interview on [DATE] at 9:45 AM, Staff E, LPN, stated, The nasal spray should have a resident name on the bottle and the Thiamine should have the cap. On [DATE] at 9:58 AM, during an observation of Unit 2 Rehab Cart 1 with Staff F, Registered Nurse (RN), there was one Insulin Aspart ,d+[DATE] Pen with three different dates of [DATE], [DATE] and [DATE]. During an interview on [DATE] at 9:58 AM, Staff F, RN, stated she could not be sure on which day the insulin pen was opened. During an interview on [DATE] at 11:25 AM, the Director of Nursing (DON) stated her expectation was for the nurses to keep the medications labeled properly and insulin to be refrigerated until opened. Review of the facility policy and procedure titled Pharmacy Services revised on [DATE] reads, Policy: It is the policy of the facility to provide care and services related to Pharmacy Services in accordance to State and Federal regulation. Procedures . 10. Drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided in accordance with professional standards for 1 of 2 residents reviewed for respiratory care, Resident #45. Findings include: During an observation on 2/26/2023 at 9:33 AM, Resident #45 was in his room seated in a wheelchair, receiving oxygen at 2.5 liters via nasal cannula. During an observation on 2/28/2023 at 8:58 AM, Resident #45 was seated in a wheelchair in his room beside his bed. The oxygen concentrator beside Resident #45's bed was running at 2 liters but was not in use by Resident #45. During an interview on 2/28/2023 at 9:30 AM, after observing Resident #45's room, Staff A, Licensed Practical Nurse (LPN), confirmed that there was an oxygen concentrator in Resident #45's room at his bed side for use by Resident #45. Review of Admission Plan of Care note dated 1/20/2023 for Resident #45 reads, The resident has respiratory failure. The resident's lungs are clear. The resident is not receiving oxygen. Review of Daily Skilled Note dated 2/1/2023 for Resident #45 documented that the resident was on oxygen. Review of Resident #45's physician's orders, active orders as of 2/28/2023, showed Resident #45's physician's order for oxygen via nasal cannula had a start date of 2/28/2023. The physician's order for Resident #45 to receive oxygen via nasal cannula was obtained 27 days after the facility documented oxygen therapy had started for Resident #45. During an interview on 2/28/2023 at 9:20 AM, Staff A, LPN, confirmed Resident #45 did not have an active physician's order to be administered oxygen. During an interview on 2/28/2023 at 9:37 AM, the Director of Nursing confirmed Resident #45 did not have an active physician's order or a discontinued physician's order to be administered oxygen. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration last revised on 1/1/2022 and last reviewed on 1/19/2023, reads, Procedure . 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. 4.1.2 Confirm that the MAR Medication Administration Record] reflects the most recent medication order.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation on 2/26/2023 at 8:55 AM, the nurse staffing information posted on the wall behind the desk in the front lobby was dated 2/24/2023. During an interview on 2/26/2023 at 10:55 AM, the Director of Nursing stated, It is her expectation to have the staffing information posted and readily available with the correct information at the beginning of each shift, by the front desk receptionist. Review of the facility policy and procedures titled Nursing Services- Nurse Staffing Information revised on 3/2/2019 reads, Policy: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. Procedure: 1. The facility will post the following information on a daily basis: a. Facility name b. The current date . 2. The facility will post the nurse staffing data on a daily basis at the beginning of each shift.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided in accordance with professional standards of practice and the resident's centered comprehensive care plan for 1 of 3 residents, Resident #62, reviewed for respiratory care, in a total sample of 36 residents. Findings: Review of the Admission Record for Resident #62 revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order dated 4/7/2021 for Resident #62 reads, apply oxygen at 3 liters per minute via nasal cannula. Resident #62 was observed on 8/30/2021 at 9:58 AM. The resident was being administered oxygen via nasal cannula at 2.5 liters per minute (Photographic evidence obtained). Resident #62 was observed on 8/31/2021 at 8:06 AM. The resident was being administered oxygen via nasal cannula at 2.5 liters per minute (Photographic evidence obtained). Resident #62 was observed on 9/1/2021 at 9:17 AM. The resident was being administered oxygen via nasal cannula at 2.5 liters per minute. Resident #62 was observed on 9/1/2021 at 2:00 PM with Staff A, Registered Nurse (RN). The resident was being administered oxygen via a nasal cannula at 2.5 liters per minute. During an interview on 9/1/2021 at 2:02 PM, Staff A, RN confirmed Resident #62 was being administered oxygen at 2.5 liters per minute instead of the prescribed 3 liters per minute. She stated she is supposed to check oxygen administration when she comes into the residents' rooms to administer medications. During an interview on 9/1/2021 at 2:10 PM the Staff B, Unit Manager, RN confirmed the physician's order for Resident #62 was for oxygen to be administered at three liters per minute via nasal cannula. She reported her expectation is that the nurse checks oxygen administration when they go in to render any care to the resident. Review of the resident centered care plan dated 4/9/2021 for Resident #62 read the resident now requires continuous oxygen therapy at 3 LPM (liters per minute) via N/C [nasal cannula] with indications of use related to shortness of breath with a goal to have no signs or symptoms of poor oxygen absorption. Interventions include give medications as ordered by physician. Review of the facility policy and procedure titled Respiratory/[CONDITION(S)] Care and Suctioning, revised on 3/26/2021, reads, Policy. The facility will ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and residents goals and preferences. Procedures: . 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, [CONDITION(S)] care and/or suctioning.