Every finding on record at Beach Creek Post-Acute

Based on interview, medical record review, and facility P&P review, the facility failed to protect the residents' right to be free from physical abuse for one of three sampled residents (Resident 2). * Resident 1 was waiting in line at the nursing station for medication when Resident 2 stepped in front of Resident 1. A verbal altercation occurred between Residents 1 and 2, after which Resident 2 struck Resident 1 on the left side of his face. This failure to prevent physical abuse had the potential to result in serious injury and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse Reporting and Investigating dated 1/10/24, showed the facility is to ensure residents' safety and well-being once admitted to the facility, and to keep residents safe an prevent future or recurrent potential abuse. Review of the facility's SOC 341 dated 8/6/26, showed an incident of verbal and physical altercation between Residents 1 and 2 while waiting in line at the nurses' station during the medication pass. The staff witnessed Resident 2 hit Resident 1 in the face with a closed fist. a. Medical record review for Resident 1 was initiated on 8/18/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/8/26, showed the resident was cognitively intact with a diagnosis of schizoaffective disorder. Review of Resident 1's Behavioral Note dated 8/6/26 at 2055 hours, showed a physical altercation between Residents 1 and 2. The staff observed Resident 2 strike Resident 1's jaw area with a swinging motion. Resident 1 stated being confused when other residents moved ahead in the medication line, and stated Resident 2 became confrontational, swore, entered personal space, and struck Resident 1. b. Medical record review for Resident 2 was initiated on 8/18/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 1/21/26, showed the resident was cognitively intact. Resident 2 had a diagnosis of schizoaffective disorder. Review of Resident 2's Care Plan Report showed a care plan problem initiated on 1/19/26, addressing a history of aggressive behavior towards others. The interventions included removing the resident from others when combative and monitoring episodes of danger to other behavior. Review of Resident 2's Behavioral Note dated 8/6/26 at 2031 hours, showed Resident 2 was involved in a physical altercation with another male resident during afternoon medication administration, where the staff witnessed Resident 2 striking the male resident in the face twice. Review of Resident 2's Behavioral Note dated 8/7/26 at 1423 hours, showed MHW 3 followed up with Resident 2 regarding the resident's thoughts, feelings, and concerns about the altercation that occurred on 8/6/26. The progress note showed Resident 2 stated He was all up in my face and I tried to tell him politely to not. But eventually I ended up hitting him. It's that prison mentality. I know I messed up. Review of Resident 2's IDT notes dated 8/7/26, showed Resident 2 hit a male another resident on the left side of the face, near the jaw area twice. On 8/11/26 at 0902 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed sitting on his bed reading. Resident 2 stated a nurse told him to get in front of Resident 1 during medication pass. Resident 2 stated Resident 1 began yelling and cursing at him, but Resident 2 could not understand the words. Resident 2 stated Resident 1 stepped toward him, and he believed Resident 1 was entering his personal space, triggering what he described as a prison mentality. Resident 2 stated he then struck Resident 1. On 8/18/26 at 1030 hours, an interview was conducted with Resident 3. Resident 3 stated witnessing the verbal and physical altercation between Residents 1 and 2. Resident 3 observed Resident 2 turn toward Resident 1 and punch Resident 1 in the face. On 8/18/26 at 1050 hours, an interview was conducted with Resident 1. Resident 1 stated waiting in line for medication when two residents stepped in front. Resident 1 stated expressing confusion by saying, wait, I thought I was next. Resident 1 stated Resident 2 confronted Resident 1 by stating, what are you going to do about it, are you going to run and tell staff? Resident 1 stated after telling Resident 2 what the fuck are you going to do about it Resident 2 punched Resident 1 in the face. On 8/18/26 at 1116 hours, an interview was conducted with CNA 1. CNA 1 stated medication pass was underway, and the residents were lining up. CNA 1 was trying to get the other residents to line up for their medication administration when CNA 1 observed Resident 2 punch Resident 1 and immediately intervened. On 8/18/26 at 1200 hours, an interview was conducted with MHW 2. MHW 2 stated observing Resident 2 strike Resident 1 on the left jaw area and witnessing the nursing staff attempting to separate the residents. MHW 2 stated Resident 1 reported confusion regarding the medication line order and stated Resident 2 challenged Resident 1 verbally by asking what are you going to do about it, are you going to tell staff? MHW 2 stated Resident 1 reported both residents started cursing at each other followed by Resident 2 striking Resident 1 in the face. MHW 2 stated Resident 1 reported being tired of Resident 2 and stated Resident 2 doesn't belong here. On 8/18/26 at 1338 hours, a telephone interview was conducted with LVN 2. LVN 2 stated Resident 1 was standing in line waiting for the medication when Resident 2 moved ahead of Resident 1. LVN 2 stated Resident 1 tried setting boundaries by asking Resident 2, what the fuck are you doing? LVN 2 stated hearing Resident 2 state to Resident 1, what are you going to do about it followed by Resident 2 striking Resident 1 twice on the left side of the face. LVN 2 stated both residents were separated and assessed for injuries. On 8/18/26 at 1645 hours, an interview was conducted with the Administrator, Program Director and Clinical Lead. The Administrator, Program Director and Clinal Lea were informed and acknowledged the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident's physician and resident's representative of a change in condition for one of six sampled residents (Resident 4). * The facility failed to notify Resident 4's physician and resident's representative of the resident's unwitnessed fall timely. This failure had the potential to result in Resident 4 not receiving timely and appropriate care.Findings: Review of the facility's P&P titled Fall Prevention and Response dated 7/2025 showed following a fall accident, a licensed nurse shall promptly respond and take actions, which may include:a. Evaluating for signs of physical injury or trauma prior to moving the Resident;b. Addressing emergency condition or fist-aid needs;c. Assisting Resident to a safe and comfortable position;d. Obtaining vital signs and conduct a physical assessment;e. Implementing neurological checks for known, reasonably suspected, or verbalized head injury;f. Notifying Physician and Resident Representative;g. Attempting to determine precipitating or contributing factors (when possible);h. Documenting assessment findings and actions;i. Reviewing care plan and updated (as indicated) to address immediate safety needs;j. Monitoring Resident's condition for at least 72 hours for post fall complications.Medical record review for Resident 4 was initiated on 5/28/26. Resident 4 was admitted to the facility on [DATE].Review of Resident 4's H&P examination dated 3/5/26, showed Resident 4 had the capacity to understand and make decisions. Review of Resident 4's SBAR Fall Report dated 5/4/26, showed the resident had a fall incident on 5/3/26 at 2330 hours. However, further review of Resident 4's SBAR report showed documentation the resident's physician and resident representative were notified on 5/4/26 at 0744 hours. On 5/28/26 at 1343 hours, a telephone interview was conducted with LVN 1. LVN 1 stated Resident 4 had a fall incident on 5/3/26 at 2330 hours and was monitored closely following the fall incident. LVN 1 further stated the physician and resident's representative were not notified immediately after the incident because to resident did not exhibit any change in condition. LVN 1 stated she notified the physician and resident's representative the following morning at approximately 0745 hours. On 5/29/26 at 1615 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 4 had a fall incident on 5/3/26 at 2330 hours. RN 1 stated the licensed nurse should notify the physician and resident's representative immediately after assessing the resident, rather than waiting until the following morning when the notification occurred at 0744 hours. On 5/29/26 at 1715 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of six of final sampled (Residents 1, 2, 6, 9, 121, and 131) and five non-sampled residents (Residents 24, 26, 52, 66, 115) reviewed for respiratory care. * The facility failed to administer oxygen to Resident 24 per the physician's order. * The facility failed to administer oxygen to Resident 66 per the physician's order. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 66 was changed every seven days. * The facility failed to ensure the nasal cannula tubing and oxygen concentrator near Resident 2's bed was hers and not her roommate's. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 2 was changed every seven days. * The facility failed to ensure the nasal cannula tubing for Resident 26 was labeled and dated. * The facility failed to ensure there was a physician's order to administer oxygen to Resident 6. In addition, the facility failed to ensure the nasal cannula tubing for Resident 6 was stored inside a set-up bag when not in use. * The facility failed to ensure the nebulizer mask and set-up bag were changed every seven days for Resident 1. The set-up bag was dated 12/3/25. * The facility failed to ensure the set-up bag to which the nebulizer mask was stored in was changed for Resident 52. The nebulizer mask was dated 1/13/25, however, the set-up bag was observed worn and brownish in color. * The facility failed to administer oxygen Residents 9 and 115 according to the physician's orders. * The facility failed to ensure Resident 131's suction machine tubing were dated and bagged when not in use. * The facility failed to administer oxygen to Resident 121 per the physician's order. These failures had the potential for these residents not to receive the appropriate respiratory care, for increased risks of infection, and potential to affect the residents' well-being.Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for this procedure. 1. On 1/20/26 at 0859 hours, during the initial tour of the facility, Resident 24 was observed in bed with nasal cannula tubing connected to an oxygen concentrator and turned on at three LPM of oxygen. However, the nasal cannula tubing was not properly placed in the resident's nostrils. Medical record review for Resident 24 was initiated on 1/20/26. Resident 24 was readmitted to the facility on [DATE]. Review of Resident 24's Order Summary Report showed a physician's order dated 10/23/25, to administer oxygen at two LPM via nasal cannula continuously to keep oxygen above 92%. On 1/20/26 at 0945 hours, an observation for Resident 24, interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 24's nasal cannula prongs were not properly placed in the resident's nose. RN 1 placed Resident 24's nasal cannula prongs into the resident's nostrils. RN 1 verified Resident 24 was receiving oxygen at three LPM. RN 1 stated Resident 24 should have received oxygen at two LPM as per the physician's order. 2. On 1/20/26 at 0815 hours, during the initial tour of the facility, Resident 66 was observed in bed receiving four LPM of oxygen. The set-up bag for the nasal cannula tubing was dated 1/12/26. Medical record review for Resident 66 was initiated on 1/20/26. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's Order Summary Report showed the following physician's order dated 1/2/26: - to administer oxygen at three LPM via nasal cannula, may titrate up to four LPM to maintain oxygen saturation between 88 to 92%; and - to change the nasal cannula and oxygen tubing every seven days. Review of Resident 66's MAR for January 2026 showed Resident 66's oxygen saturation ranged from 93 to 96% from 1/1 to 1/21/26. Further review of Resident 66's medical record did not show Resident 66 had any episodes of desaturation to warrant the titration of oxygen to four LPM. On 1/20/26 at 1000 hours, an observation for Resident 66, interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 66 was receiving oxygen at four liters minute. RN 1 stated Resident 66's oxygen could be titrated to four LPM to keep oxygen at 88 to 92% per the physician's order. However, RN 1 could not provide any documented evidence to show Resident 66 had any episodes of desaturation. RN 1 also verified the set-up bag for the nasal cannula was dated 1/12/26, and not changed every seven days. 3. On 1/20/26 at 0820 hours, during the initial tour of the facility, Resident 2 was observed in bed. An oxygen concentrator was observed by the resident's bed. The set-up bag for the nasal cannula was dated 1/12/26, and labeled for Resident 2's roommate (Resident 51). a. Medical record review for Resident 2 was initiated on 1/20/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 1/26/26, did not show any physician's order to administer oxygen to the resident. Further review of Resident 2's medical record did not show any physician's order to administer oxygen to Resident 2. b. Medical record review for Resident 51 was initiated on 1/20/26. Resident 51 was readmitted to the facility on [DATE]. Review of Resident 51's Order Summary Report showed the following physician's orders dated 1/2/26: - to administer oxygen at two LPM via nasal cannula as needed for shortness of breath; and - to change the nasal cannula and oxygen tubing every seven days. On 1/20/26 at 0956 hours, an observation for Resident 2, interview and concurrent medical record review was conducted with RN 1. RN 1 verified an oxygen concentrator was beside Resident 2's bed. RN 1 also verified the set-up bag for the nasal cannula was labeled for Resident 2's roommate, and dated 1/12/26, and not changed every seven days. 4. On 1/20/26 at 0910 hours, during the initial tour of the facility, Resident 26 was observed in bed receiving three LPM of oxygen. The nasal cannula tubing was observed undated, and no set-up bag was observed. Medical record review for Resident 26 was initiated on 1/20/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed the following physician's orders dated 1/7/26: - to administer oxygen at three LPM via nasal cannula continuously to keep oxygen above 92%; and - to change the nasal cannula every fourteen days. On 1/20/26 at 0940 hours, an observation for Resident 26 interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 26 was receiving oxygen at three LPM. RN 1 also verified the nasal cannula tubing was undated and there was no set-up bag provided for the nasal cannula. RN 1 stated when the NOC shift licensed nurses changed the nasal cannula tubing, it should be dated, and a set-up bag, which is also dated and labeled with the resident's name should be provided. On 1/26/26 at 1047 hours, an interview for Resident 26 was conducted with Nurse Consultant 1. When asked about the facility's policy for changing the nasal cannula tubing, Nurse Consultant 1 stated the nasal cannula tubing should be changed every seven days and provide a set-up bag dated and labeled with the resident's name, by the NOC shift RN or LVN. 5. On 1/20/26 at 0848 hours, during the initial tour of the facility, Resident 6 was observed in bed. A nasal cannula tubing dated 1/13/26 was observed on top of an oxygen concentrator beside Resident 6's bed. There was no set-up bag. Medical record review for Resident 6 was initiated on 1/20/26. Resident 6 was readmitted to the facility on [DATE]. Further review of Resident 6's medical record did not show any physician's order to administer oxygen to Resident 6. On 1/20/26 at 0949 hours, an observation for Resident 6 and concurrent interview and medical record review were conducted with RN 1. RN 1 verified a nasal cannula tubing dated 1/13/26, was observed on top of an oxygen concentrator beside Resident 6's bed. RN 1 verified there was no set-up bag provided to place the nasal cannula when not in use. RN 1 also verified there was no physician's order to administer oxygen to Resident 6. 6. On 1/20/26 at 0849 hours, during the initial tour of the facility, Resident 1 was observed in bed. An undated nebulizer mask was observed inside a set-up bag. The set-up bag was dated 12/3/25. Medical record review for Resident 1 was initiated on 1/20/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following physician's order dated 2/13/25, to administer ipratropium-albuterol solution (bronchodilator) 0.5-2.5 mg/ 3ml one dose inhale via nebulizer every six hours as needed for shortness of breath. On 1/20/26 at 0952 hours, an observation for Resident 1, interview and concurrent medical record review was conducted with RN 1. RN 1 verified an undated nebulizer mask was observed inside a set-up bag which was dated 12/3/25. RN 1 stated the nebulizer mask, and the set-up bag should be dated and changed every seven days. 7. On 1/20/26 at 0912 hours, during the initial tour of the facility, Resident 52 was observed in bed. A nebulizer mask was observed dated 1/13/26, and stored inside a set-up bag, which was undated and observed worn and brownish in color. Medical record review for Resident 52 was initiated on 1/20/26. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report showed the following physician's orders dated 12/30/25: - to administer levalbuterol solution (bronchodilator) 1.25 mg/ 3ml one dose inhale via nebulizer every six hours four times a day; and - to change the nebulizer set-up (mouthpiece, mask, tubing, chamber) every 14 days and as needed every night shift. Review of Resident 52's MAR for January 2026 showed Resident 52 was administered the levalbuterol medication via nebulizer from 1/1 to 1/20/26 at 0630, 1100, 1600 and 2000 hours, and on 1/21/26 at 0630 and 1100 hours. On 1/20/26 at 0943 hours, an observation for Resident 52 and concurrent interview and medical record review were conducted with RN 1. RN 1 verified the nebulizer mask was dated 1/13/26, and stored inside an undated set-up bag, which was word and brownish in color. RN 1 stated when the NOC shift licensed nurses changed the nebulizer mask and tubing, the set-up bag should also be changed, dated and labeled. 8. Review of the facility's P&P titled Oxygen Administration dated October 2010 showed: - Under the Preparation section: verify there is a physician's order for this procedure. - Under the Steps in the Procedure section: turn on the oxygen, unless otherwise ordered, start the flow of oxygen at the rate of two to three LPM. On 1/20/26 at 0855 hours, during the initial tour of the facility, an observation was conducted in Resident 115's room. Resident 115 was observed in bed with the oxygen being administered via nasal cannula at 3.5 LPM. Medical record review for Resident 115 was initiated on 1/20/26. Resident 115 was admitted to the facility on [DATE]. Review of Resident 115's Order Summary Report showed a physician's order dated 1/15/26, to administer oxygen at two LPM via nasal cannula, continuously. Review of Resident 115's H&P examination dated 1/16/26, showed Resident 115 had the capacity to make medical decisions. On 1/20/26 1438 hours, an observation and concurrent interview was conducted with CNA 7. CNA 7 verified Resident 115's oxygen rate was at 3.5 LPM. CNA 7 further stated the RN Supervisors were the ones who adjusted the oxygen rate. On 1/20/26 1447 hours, an observation, interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified Resident 115's oxygen rate administered was at 3.5 LPM and stated the resident's oxygen should be at two LPM. 9. On 1/20/26 at 1426 hours, during the initial tour of the facility, Resident 9 was observed lying in bed with the oxygen being administered between 1 and 1.5 LPM via nasal cannula. Medical record review for Resident 9's was initiated on 1/23/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed the resident had a BIMS score of seven, indicating severe impaired cognition. Review of Resident 9's Order Summary Report dated 1/21/26, showed a physician's order dated 8/20/25, to administer oxygen at two LPM via nasal cannula continuously. On 1/20/26 at 1439 hours, an interview was conducted with CNA 7. CNA 7 verified Resident 9's oxygen rate was at 1.5 LPM. CNA 7 stated the RN Supervisors were the ones responsible for adjusting the oxygen. On 1/20/26 at 1445 hours, an observation, interview and concurrent medical record review were conducted with LVN 4. LVN 4 verified Resident 9's oxygen rate was between 1 and 1.5 LPM. LVN 4 also verified Resident 9's physician's order showed to administer oxygen at two LPM via nasal cannula continuously. LVN 4 stated the resident's oxygen rate was being checked during the start of the shift to make sure the resident was receiving the correct oxygen rate. LVN 4 stated she did not know what happened to Resident 9's oxygen rate. 10. Review of the facility's P&P titled Suctioning the Upper Airway dated 10/2010 showed to place the catheter in a clean, dry area. On 1/20/26 at 1127 hours, during the initial tour of the facility, an observation was conducted for Resident 131. A suction machine was observed on top of Resident 131's nightstand at the bedside. Two tubing were attached to the suction machine and observed hanging on the front of the nightstand with no date and stored inside a set-up bag. Medical record review for Resident 131 was initiated on 1/20/26. Resident 131 was admitted to the facility on [DATE]. Review of Resident 131's H&P examination dated 8/10/25, showed Resident 131 had no capacity to understand and make decisions. Review of Resident 131's Order Summary Report dated 1/21/26, did not show a physician's order for the suction machine. On 1/20/26 1131 hours, an observation and concurrent interview was conducted with RN 4. RN 4 verified the two suction tubing were not stored inside a set-up bag and undated. LVN 4 stated the tubing should have been dated and placed inside a bag. On 1/20/26 at 1137 hours, an observation and concurrent interview was conducted with the IP. The IP verified the two suction tubing were not stored inside a bag and undated. The IP stated the tubing should have been stored inside a bag and dated. 11. On 1/20/26 at 0830hours, during initial tour of the facility, Resident 121 was observed with oxygen at 2.5 LPM via a nasal cannula. Medical record review for Resident 121 was initiated on 1/20/26. Resident 121 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 121's H&P examination dated 5/10/25, showed Resident 121 had no capacity to understand and make decisions. Review of Resident 121's Order Summary Report showed a physician's order dated 7/10/25, to administer oxygen at three LPM via nasal canula continuously for shortness of breath every shift. On 1/20/26 at 1228 and 1429 hours, Resident 121 was observed receiving oxygen via nasal canula at 2.5 LPM. On 1/20/26 at 1530 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 121 was receiving oxygen at 2.5 LPM. On 1/21/26 at 1430 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 121 was receiving oxygen via nasal cannula at 2.5 LPM. LVN 1 reviewed Resident 121's physician's order and verified the resident should have been receiving oxygen at three LPM. LVN 1 stated the importance of having the rate at the correct setting was to ensure sufficient oxygen flow was being administered to the residents due to their shortness of breath. On 1/26/26 at 1549 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 1. The Administrator, DSD, and Nurse Consultant 1 were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. *The facility failed to ensure a dented can was removed. *The facility failed to ensure the resident food refrigerator was clean. * The facility failed to ensure the chlorine strips for the low-temperature dishwashing machine had not expired * The facility failed to air dry the blender prior to the puree preparation. These failures had the potential for exposure to food-borne illnesses for medical vulnerable population of 134 residents who received food prepared in the kitchen. Findings: Review of the facility's Order Listing Report dated 1/20/26, showed 134 of 137 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Receiving and Storage revised 11/2022 showed all foods stored in the refrigerator or freezer are covered, labeled, and dated ( use-by date). On 1/20/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following was observed:- a bag of orange colored beverage was connected to the juice dispenser. The bag was not observed labeled with the opened date;- five juice boxes labeled cranberry, prune, orange, apple, and sugar-free strawberry kiwi juice were connected to the juice dispenser. The juice boxes were not observed labeled with the opened date. The label on the juice boxes showed to use the product 45 days after connecting;- an opened bag of frozen veggie patties was observed in the walk-in freezer. The bag was not observed labeled with the open or use-by date;- three opened bags of bread were observed on the bread rack inside the dry storage room. The bags of bread were not observed with the opened date; The DSS verified the above findings. The DSS stated the juice boxes should be labeled with the delivery date and the opened date when it was first opened and connected to the juice dispenser. The DSS stated the food items in the kitchen should be labeled with the opened date when it was opened. 2. According to FDA Food Code 2022, 4-601.11, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils (undated), showed the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to FDA Food Code 2022, 4-602.13, Non-Food Contact Surfaces (undated), showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility P&P titled Sanitation revised 11/2022 showed all utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. On 1/20/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following was observed:- the drawer containing multiple clean kitchen utensils was observed with a clear, thick residue at the bottom of the drawer.- the can opener was observed with the can opener blade containing a brown colored residue and the rotating compartment was observed with brownish-orange discoloration. The DSS verified the above findings. 3. According to FDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics (undated) showed multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated.According to FDA Food Code 2022, Section 4-501.12, Cutting Surfaces (undated), showed surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. Review of the facility P&P titled Sanitation revised 11/2022 showed plastic ware, China, and glassware that cannot be sanitized or are hazardous because of chips, cracks, or loss of glaze are discarded. Damaged or broken equipment that can't be repaired is discarded. On 1/20/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following was observed:- one brown cutting board was observed heavily marred and fuzzy, with brown colored stain,- one green cutting board was observed heavily marred and fuzzy, and- one blue-handle spatula had a melted and discolored handle. The DSS verified the above findings. 4. On 1/20/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. A can of tomato sauce was observed dented and placed in rotation for use. The DSS verified the above findings. The DSS stated the cans were checked when the shipment was received and when the cans were placed on the shelf. The DSS stated if dents were noted on the cans, then the can should be placed on the shelf labeled dented cans. 5. According to FDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch. On 1/20/26 at 0855 hours, an inspection of the resident food refrigerator and concurrent interview was conducted with the DSS. The resident food refrigerator was located in the therapy room. The resident food refrigerator was observed with multiple black colored particles on the shelf, and observed with a brownish color stain on the handle of the top and bottom left refrigerator drawers. A paper towel was used to wipe the refrigerator shelf and was observed with brownish-black residue on the paper towel. The DSS verified the above findings. The DSS stated the refrigerator storing the residents' food should be kept clean. On 1/26/26 at 1030 hours, an interview was conducted with the DSD. The DSD stated the residents' food refrigerator should be cleaned by the housekeeping weekly. When asked to see the cleaning log for the residents' refrigerator, the DSD stated a log was not kept for the cleaning of the residents' refrigerator. 6. According to FDA Food Code 2022, 4-501.18, Ware washing Equipment, Clean Solutions (undated), showed failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the ware washing operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food. Review of the facility P&P titled Sanitation revised 11/2022 showed the dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitations are: b. Low-Temperature Dishwasher (Chemical Sanitization): 1. Wash temperature (120 degrees F); 2. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and 3. The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. On 1/21/26 at 0940 hours, an interview and concurrent observation was conducted with the Dietary Aide. When asked about the process for checking the concentration of the sanitizer solution used for the low temperature dishwasher, the Dietary Aide stated during the rinse cycle she would use the chlorine dip strip and dip the strip into the rinse water for one second. The Dietary Aide performed how she would check the chlorine test strip with the key located on the chlorine test strip bottle. The Dietary Aide stated the concentration should be between 50 to 100 ppm. However, the Precision Chlorine Test Paper container was observed with the expiration date of 8/2025. On 1/21/26 at 0948 hours, an interview and concurrent observation was conducted with the DSS. The DSS verified the above findings. The DSS was asked about the purpose of checking the sanitation concentration levels for the low temperature dishwasher and the DSS stated it was to ensure the adequate sanitation of the dishes and utensils for the residents. 7. According to FDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required (undated), showed items must be allowed to drain and to air-dry before being stacked or stored.Review of the facility P&P titled Sanitation revised 11/2022, showed food preparation equipment and utensils that are manually washed ae allowed to air dry whenever practical. On 1/21/26 at 0951 hours, a pureed food preparation observation and concurrent interview was conducted with the Cook. The [NAME] was observed placing a stainless-steel blender on the blender base. The stainless-steel blender with the blade attached was observed wet. The [NAME] was observed preparing to add the chicken to the blender. The [NAME] verified the blender and blender blade was still wet. The [NAME] stated the blender should be completely air dried before use. On 1/26/26 at 1357 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD. The Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 135) reviewed for pressure injuries. * The facility failed to reposition Resident 135, who had a pressure injury, at least every two hours as addressed in Resident 135's plan of care. This failure had the potential for Resident 135 to develop pressure injuries or worsening of the existing pressure injuries.Findings: Review of the National Pressure Ulcer Advisory Panel's (NPIAP) Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline 2025 showed under the Repositioning for Pressure Injury Prevention section, extended periods of lying or sitting on a particular part of the body without redistribution of the pressure could lead to a pressure injury. Furthermore, repositioning and mobilization were essential preventative measures for reducing pressure injury occurrences. Review of the facility's P&P titled Pressure Ulcers / Skin Breakdown - Clinical Protocol revised 4/2018 showed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The physician will guide the care plan as appropriate. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. On 1/21/26 at 1036, 1230, and 1420 hours, Resident 135 was observed in her bed in a supine position and on a low air loss mattress. Medical record review for Resident 135 was initiated on 1/21/26. Resident 135 was admitted to the facility on [DATE]. Review of Resident 135's H&P examination dated 11/28/25, showed Resident 135 had the capacity to understand and make decisions. Review of Resident 135's Skin Assessment (Non-Pressure Injury) - WGC - V2 dated 11/28/25, showed Resident 135 had blanchable redness on her coccyx (tailbone) area that was present on admission to the facility. Review of Resident 135's care plan risk for skin breakdown/further skin breakdown due to decreased mobility/immobility and incontinence dated 11/29/25, showed interventions including intervention included repositioning Resident 135 at least every two hours and as needed. Review of Resident 135's Skin Assessment (Non-Pressure Injury) - WGC - V2 dated 12/7/25, showed Resident 135 had non-blanchable redness on her sacrum and Resident 135 stated there was tenderness to the site. Review of Resident 135's Skin Assessment (Non-Pressure Injury) - WGC - V2 dated 12/24/25, showed Resident 135's coccyx showed evidence of superficial skin breakdown with reddened, fragile tissue and areas of excoriation (a scrape or scratch to the skin). The skin was at high risk for further deterioration and progression to pressure injury due to moisture exposure, limited mobility, and recent unintentional weight loss. The resident was encouraged and assisted as needed to reposition and shift weight while in bed to relieve pressure to the buttocks and coccyx. Review of Resident 135's Skin Assessment (Pressure Injury) - WGC - V3 dated 12/30/25, showed Resident 135 had an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough in the wound bed) that was acquired during the resident's stay at the facility. Resident 135's unstageable pressure injury to the coccyx had 100% slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds). Review of Resident 135's Documentation Survey Report V2 for December 2025, Section - Turning and Repositioning every two hours and PRN, showed Resident 135 was not turned in bed every two hours. For example, the following dates and times showed when Resident 135 was not turned in bed prior to her unstageable pressure injury:- on 12/7/25 at 0121, 0509, 1139, 1402, 1605, and 2108 hours;- on 12/24/25 at 0425, 0643, 1050, 1149, 1454, and 2136 hours; and- on 12/29/25 at 0024, 0559, 0745, 1045, 1153, 1353, 1909, and 2254 hours. Review of Resident 135's Documentation Survey Report V2 for January 2026, Section - Turning and Repositioning every two hours and PRN, showed Resident 135 was not turned in bed every two hours. For example, the following dates and times showed when Resident 135 was not turned in bed after her unstageable pressure injury:- on 1/4/26 at 0033, 0603, 1031, 1441, and 2148 hours; and- on 1/10/26 at 0043, 0609, 1123, 1400, and 2159 hours.- on 1/21/26 at 0044, 0507, 0850, 0950, 1150, 1454, 2018, and 2112 hours. On 1/21/26 at 1230 hours, an interview was conducted with Resident 135 in her room. Resident 135 stated she developed the pressure injury on her coccyx while in the facility. Resident 135 stated the facility staff members were not turning her every two hours prior to the development of her pressure injury. Furthermore, Resident 135 stated the facility staff members were not turning her every two hours after her pressure injury was present. On 1/21/26 at 1420 hours, a follow up interview was conducted with Resident 135 and Family Member 1 in Resident 135's room. When asked if Resident 135 was able to turn on her own in bed, Resident 135 stated she was able to turn, however, it was hard for her to turn due to the low air loss mattress. In addition, Resident 135 stated she would put her hands under her coccyx to help reduce the pressure. When asked if a facility staff member would assist her to turn in bed or remind her to turn in bed every two hours, Resident 135 stated no. In addition, when asked if Resident 135 refused to turn in bed, Resident 135 stated no. On 1/22/26 at 1045 hours, an interview and medical record review for Resident 135 was conducted with LVN 1. LVN 1 stated Resident 135 had an unstageable pressure injury due to her incontinence. LVN 1 stated Resident 135 was able to turn herself in bed, however, LVN 1 also stated Resident 135 was forgetful. LVN 1 stated she expected the facility staff members to remind Resident 135 to turn every two hours and to let her know if Resident 135 was refusing to turn and reposition. LVN 1 verified the above findings. On 1/22/26 at 1112 hours, an interview and medical record review was conducted with the DON for Resident 135. The DON stated the risk factors for pressure injuries included nutrition, positioning, mobility, and the resident's co-morbidities. The DON further stated the interventions to prevent development or worsening of Resident 135's pressure injury included nutritional supplements, a low air loss mattress and turning and repositioning every two hours. The DON stated he expected the facility staff members to follow Resident 135's care plan interventions. The DON verified the above findings. On 1/26/26 at 1500 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 2. The Administrator, DSD, and Nurse Consultant 2 were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services. * The facility failed to ensure orally administered medications were stored separate from the externally used medications in Medication room [ROOM NUMBER]. *The facility failed to ensure the expired supplies were removed from the current treatment supply in Treatment Cart A. * The facility failed to ensure there were no medications left at bedside. * The facility failed to ensure RN 4 and LVN 7 did not leave medications on top of medication cart during medication pass observation. * The facility failed to ensure a medication cup with white paste was not left on Resident 1's overbed table. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness.Findings: Review of the facility's P&P titled Storage of Medications revised on 4/2007 showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed; external use drugs in liquid, tablet, capsule or powder from shall be stored separately from drugs for internal use. 1. On [DATE] at 0850 hours, a medication room inspection for Medication room [ROOM NUMBER] was conducted with RN 3. The following was observed on the second shelf of the cabinet: - one bottle of omeprazole (acid reducer) 20 mg tablet was stored with one box of bisacodyl (stool softener) suppositories and one bottle of earwax softener drops on the right side of the second shelf of the cabinet; and - one bottle of vitamin B complex (nutritional supplement) and one bottle of probiotic capsules were stored with one bottle of fluticasone propionate nasal spray (medication to relieve allergy symptoms). On [DATE] at 0900 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated the external and internal medications needed to be stored separately to prevent accidental mix up of the medications. LVN 1 verified the above findings. 2. On [DATE] at 0920 hours, an observation of Treatment Cart A and concurrent interview was conducted with LVN 1. The following was observed: - alcohol wipes with an expiration date of 7/2025; and - five packs individuals DermaCol/Ag Collagen Matrix (collagen dressing with silver) with an expiration date of [DATE]. LVN 1 stated expired biological or supplies should be removed from the treatment cart. LVN 1 further stated expired supplies such as alcohol wipes or dressing may not be potent and would not have full effectiveness. On [DATE] at 1650 hours, an interview was conducted with the DON. The DON was informed and acknowledge of the above findings. 3. Review of the facility's P&P titled Storage of Medications dated 11/2020 showed: - drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications; -any medications found at bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On [DATE] at 0935 hours, an initial tour was conducted in Resident 148's room with CNA 6 present in the room. A bottle of Colace (medication used to treat constipation) 100 mg capsules was observed on top of Resident 148's nightstand at bedside. Resident 148 stated she sometimes self-administered the medication. Resident 148 further stated she wasn't sure how long she had the medication at bedside. On [DATE] at 0942 hours, an observation and concurrent interview was conducted with CNA 6. CNA 6 verified the bottle of Colace was on top of Resident 148's nightstand. On [DATE] at 0944 hours, an observation and concurrent interview was conducted with RN 4. RN 4 verified the bottle of Colace was on top of Resident 148's nightstand and should have been stored securely. 4. On [DATE] at 0804 hours, a medication administration observation for Resident 88 was conducted with RN 4. RN 4 was observed preparing the following medications: - One tablet of Eliquis (anticoagulant medication) 2.5 mg; - One tablet of hydralazine (blood pressure medication) 50 mg; and - One tablet of rosuvastatin (statin, lipid-lowering medication) 5 mg. After preparing the medications for Resident 88, the call light above the door of Resident 88's room was on. RN 4 stated she would answer the call light and went inside the room. RN 4 left the medications on top of the medication cart. The medications were out of sight by RN 4. Staff were observed passing by, and one CNA went to the medication cart to get a straw. On [DATE] at 0809 hours, RN 4 went back to the cart. RN 4 was observed going inside Resident 88's room again. RN 4 left the medications on top of the medication cart. The medications were out of sight by RN 4. A CNA was observed going inside the room On [DATE] at 0810 hours, RN 4 went back to the cart. On [DATE] at 0813 hours, RN 4 was observed going inside Resident 88's room again and asked Resident 88 if she wanted cranberry juice. RN 4 left the medications on top of the medication cart. The medications were out of sight by RN 4. On [DATE] at 1035 hours, an interview for Resident 88 was conducted with RN 4. RN 4 verified the above findings. 5. On [DATE] at 1619 hours, one nebulizer unit dose duoneb (bronchodilator medication) was observed on top of a medication cart and was unattended. Staff were observed passing by. On [DATE] at 1620 hours, LVN 7 was observed coming out of Resident 2's room. A medication administration observation for Resident 2 was conducted with LVN 7. On [DATE] at 1626 hours, after preparing the medications for Resident 2, LVN 7 was observed going inside Resident 2's room. LVN 7 left one nebulizer unit dose on top of the medication cart. One staff was coming out of Resident 2's room, and another staff was observed passing by the medication cart. On [DATE] at 1035 hours, an interview for Resident 2 was conducted with LVN 7. LVN 7 verified the above findings. 6. [DATE] at 0849 hours, during the initial tour of the facility, a medication cup containing white paste was observed on Resident 1's overbed table. Resident 1 was observed in bed. Resident 1 stated the CNAs applied the white paste medication on her. Medical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report did not show a physician's order for any skin treatment. On [DATE] at 0952 hours, an observation for Resident 1 and concurrent interview and medical record review was conducted with RN 1. RN 1 verified a medication cup containing white paste was on Resident 1's overbed table. RN 1 also verified there was no physician's order for any skin treatment for Resident 1. On [DATE] at 1109 hours, an interview for Resident 1 was conducted with LVN 1. When asked about the skin treatment ointments, LVN 1 stated the CNAs could apply barrier creams to the residents, however, the barrier creams should be stored in the treatment cart, and not at the resident's bedside.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 27 final sampled residents (Residents 6 and 10) were free from the unnecessary medications. * The facility failed to ensure Resident 10's carvedilol (blood pressure medication) was administered as per the physician's order. * The facility failed to ensure Resident 6's pulse was monitored prior to the administration of the atenolol (blood pressure medication). These failures had the potential for Residents 6 and 10 to receive unnecessary medications and develop significant adverse effects related to the use of the medications. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: a. allergies to medications; and b. vital signs, if necessary. 1. Medical record review for Resident 10 was initiated on 1/20/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's MDS assessment dated [DATE], showed Residents 10 was cognitively intact. Review of Resident 10's Order Summary Report showed a physician's order dated 10/15/25, to administer carvedilol 3.125 mg one tablet by mouth two times a day for hypertension. To hold if the SBP (systolic blood pressure-the top number in a blood pressure reading measuring the pressure in the arteries when the hear beats and pushes blood out) was less than 110 mmHg or the heart rate was less than 60 beats per minute; and to call the physician. Review of Resident 10's MAR for January 2026 showed Resident 10 was administered the carvedilol 3.125 mg medication on the following dates and times, when the BP was outside of the ordered parameters, to hold if the SBP was less than 110 mmHg: - on 1/1 at 0900 hours, the BP was 106/68 mmHg. - on 1/7 at 1700 hours, the BP was 93/64 mmHg. - on 1/10 at 0900 hours, the BP was 107/78 mmHg. - on 1/14 at 0900 hours, the BP was 108/67 mmHg. - on 1/18 at 0900 hours, the BP was 109/68 mmHg. On 1/21/26 at 1603 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 5. LVN 5 stated for the administration of the BP medication, the residents' blood pressure and heart rate were obtained by the licensed nurses and the BP medication administered to the residents if the BP and heart rate were within the ordered parameters. LVN 5 stated after the administration of the medication, the licensed nurses signed in the MAR and the check mark in the MAR indicated the medication was administered. LVN 5 reviewed Resident 10's medical record and verified the above findings and stated the medication should have not been administered as per the physician's orders. On 1/22/26 at 1352 hours, an interview was conducted with the DON. The DON stated for the administration of the BP medications, the licensed nurses were expected to obtain the residents' vital signs and administer the BP medication if the vital signs were within the ordered parameters. On 1/26/26 at 1410 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, and the DSD. The Administrator, Nurse Consultants 1 and 2, and the DSD were informed and acknowledged the above findings. 2. Medical record review for Resident 6 was initiated on 1/20/26. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 5/11/25, to administer atenolol 50 mg one tablet by mouth in the morning. Hold if SBP is less than 110 mmHg, or pulse less than 60 beats per minute. Review of Resident 6's MAR for January 2026 showed Resident 6 was administered the atenolol medication from 1/1 to 1/22/26. Further review of the MAR showed Resident 6's blood pressure readings were monitored, but there was no monitoring of Resident 6's pulse prior to the administration of the atenolol medication. Further review of Resident 6's medical record failed to show documented evidence Resident 6's pulse was monitored prior to the administration of the atenolol medication. On 1/22/26 at 1046 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the licensed nurses should have monitored the blood pressure and the pulse before administering the atenolol medication.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents remained free from accident hazards for two of 27 final sampled residents (Residents 14 & 22). * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care for Residents 14 and 22. These failures had the potential to place Residents 14 and 22 at risk for serious injuryFindings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. On 1/22/26 at 0851, 0951 and 1021 hours, Resident 14 was observed lying in bed and had one floor pad positioned on the left side of the bed. Medical record review for Resident 14 was initiated on 1/19/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's plan of care showed a care plan problem dated 8/19/24, addressing Resident 14's risk for falls/injuries related to behavior of getting up without asking for assistance, confusion, impaired mobility, weakness. The interventions included having floor pads on both sides of the bed for safety. Review of Resident 14's H&P examination dated 3/30/25, showed Resident 14 had no capacity to understand and make decisions. On 1/22/26 at 1053 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 14 was confused and at times the resident thought they could walk and try to get up unassisted. CNA 8 stated Resident 14 only used one floor pad and the resident attempted to pull themselves up on the right side of the bed. However, there was no floor pad observed on the right side of the bed. On 1/22/26 at 1508 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 14 had care plan intervention for floor pads on both sides of the bed for safety. RN 2 stated there should always be two floor pads positioned on each side of the bed when Resident 14 was lying in bed. 2. On 1/22/26 at 0846 and 0956 hours, Resident 22 was observed lying in bed with one of the bilateral floor pads observed folded up and leaning up against the foot of the bed. Medical record review for Resident 22 was initiated on 1/22/26. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 22's H&P examination dated 11/5/25, showed Resident 22 had the capacity to understand and make decisions. Review of Resident 22's plan of care showed a care plan problem revised 11/12/25, addressing Resident 23's risk for falls/further falls due to poor/no safety awareness, impaired vision/hearing, unsteady gait/balance problem. and episodes of wandering. The interventions included having bilateral floor mats. On 1/22/26 at 1029 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified one of Resident 22's floor pads was folded up against the foot of the bed while Resident 22 was lying in bed. CNA 3 stated sometimes both floor pads were used and other times only one floor pad was used. CNA 3 verified Resident 22 had history of falls and was considered a fall risk. On 1/22/26 at 1455 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 22 was considered a fall risk and the resident's last fall episode was on 12/20/25. RN 2 verified Resident 22 had a care plan intervention for bilateral floor pads when in bed. RN 2 was informed of the above observations for Resident 22's floor pad. RN 2 stated both floor pads should be on each side of the bed. On 1/26/26 at 1549 hours, an interview was conducted with Administrator, DSD, and Nurse Consultant 1. The Administrator, DSD, and Nurse Consultant 1 were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for one of 27 final sampled resident (Resident 111). * The facility failed to ensure Resident 111 was served two milk cartons, as per the meal ticket, for his lunch meal. This failure had the potential to affect the resident's overall meal intake and nutritional status.Findings: Review of the facility's P&P titled Food and Nutrition Services revised 10/2017 showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable effort will be made to accommodate resident choices and preferences. On 1/20/26 at 1220 hours, a lunch observation and concurrent interview was conducted with Resident 111 in the dining room. Resident 111 was observed eating his lunch with one eight-ounce carton of non-fat milk. Review of Resident 111's lunch meal ticket showed under Standing Orders, to send two eight-ounce cartons of non-fat milk for the lunch meal. Resident 111 was asked about the non-fat milk and the resident stated it happened frequently when he would receive only one carton of milk, when he should have two. On 1/20/26 at 1235 hours, an observation and concurrent interview was conducted with CNA 9. CNA 9 verified the above findings and stated the resident should be served with what was on the meal ticket. CNA 9 was observed asking Resident 111 if he wanted his second carton of milk and Resident 111 stated yes. On 1/20/26 at 1245 hours, an interview and concurrent observation was conducted with the RD. The RD verified the above findings and stated the items on the meal ticket should match what the residents received for that meal, including any substitutions/preferences of the resident. The RD further stated Resident 111 should have been served two cartons of milk for his lunch meal. On 1/26/26 at 1357 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD. The Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD were informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to ensure the quality care and services were provided for one of one final sampled resident (Resident 31) reviewed for hospitalization. * The facility failed to provide necessary care when Resident 31's blood pressure was 76/51 mmHg. This failure had the potential for Resident 31 to not receive the necessary care and services to maintain their highest physical well-being. Findings: Medical record review for Resident 31 was initiated on 1/21/26. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 31's H&P examination dated 1/10/26, showed Resident 31 had no capacity to understand and make decisions. Review of Resident 31's Weights and Vitals Summary - Blood Pressure Summary showed blood pressure readings on the following dates:- dated 12/28/25 at 1800 hours, Resident 31 had a blood pressure reading of 76/51 mmHg;- dated 12/28/25 at 1818 hours, Resident 31 had a blood pressure reading of 90/51 mmHg; and- dated 12/28/25 at 1935 hours, Resident 31 had a blood pressure reading of 153/74 mmHg. Further review of Resident 31's medical record did not show an intervention was implemented for Resident 31's low blood pressure reading between 1800 and 1818 hours on 12/28/25. Review of Resident 31's progress note dated 12/29/25 at 0100 hours, showed at 0005 hours Resident 31 was lethargic, slow to respond to verbal and tactile stimuli, and had a blood pressure reading of 68/80 mmHg. At 0020 hours, RN 5 called the paramedics via 911. At 0037 hours, the paramedics transported Resident 31 to the acute care hospital. At 0500 hours, RN 5 contacted the acute care hospital and Resident 31 was admitted with a diagnosis of septic shock. On 1/26/26 at 1138 hours, an interview and concurrent medical record review for Resident 31 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated when the residents had low blood pressure readings, the expectation was to inform the clinician for further evaluation at the acute care hospital, to implement interventions such as elevating the resident's legs, and/or to start the resident on intravenous fluids. RN 2 stated she did not find further documentation to show an intervention or notification about Resident 31's low blood pressure was implemented. On 1/26/26 at 1500 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 2. The Administrator, DSD, and Nurse Consultant 2 were informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to implement their QAPI plan of action. * There was no documentation to show the facility had provided an in-service for medication storage, specifically storing internally administered medication separately from externally administered medications for one repeated deficient practice cited at F761 in accordance with their POC from the last recertification survey completed on 1/9/25. This failure had the potential for medication errors and negatively impact the residents' well-being.Finding: On 1/26/26 at 1443 hours, an interview and concurrent facility document review was conducted with the Administrator and DSD. Review of the POC submitted by the facility to the CDPH, L&C Program for F761 cited from the last recertification survey completed on 1/9/25, showed the DON in-serviced the licensed nursing staff on 1/7/25, regarding medication storage and labeling. The Administrator and DSD failed to show documented evidence the DON in-serviced the licensed nursing staff regarding medication storage and labeling, specifically storing internally administered medication separately from externally administered medications.

Based on observation, interview, and medical record review, the facility failed to ensure the medical records were accurately completed for four of 27 final residents (Residents 3, 5, 8 and 135). * The facility failed to ensure Resident 3's MAR for [DATE] was completed and signed. * The facility failed to ensure Resident 5's POLST Section D was completed. * The facility failed to ensure Resident 135's POLST Section D was completed. * The facility failed to ensure Resident 8's POLST Section D was completed. These failures posed a potential risk for residents to not be provided with the care and treatment since their medical record information was incomplete.Findings: Review of the facility's P&P titled Charting and Documentation dated 7/2017 showed the following information is to be documented in the resident medical record as follows - objective information - medication administered - treatment or services performed - changes in residents' condition - events, incidents or accidents involving the resident and - progress toward or changes in the care plan goals and objectives. 1. Review of the facility's P&P titled Administering Medications dated 4/2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of Resident 3's medical record was initiated on [DATE]. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MAR for [DATE] failed to show entries for the following: - dated [DATE] at 1400 hours, Tylenol (pain medication) oral tablet 325 mg, give two tablets by mouth in the afternoon for knee pain; - dated 11/25-[DATE] for the day shift, behavior monitoring for anxiety manifested by restlessness, to document episodes per shift, to document the number of episodes per shift of target behavior and tally by hashmarks every shift. There were missing entries for the number of episodes and the nurse signature; - dated 11/25-[DATE] for the day shift, behavior monitoring for sertraline for bipolar disorder manifested by mood swings, document number of episodes per shift of target behaviors. There were missing entries for the number of episodes and the nurse signature; - dated 11/25-[DATE] for the day shift, monitor side effects of antipsychotic Seroquel. There were missing entries for the number of episodes and the nurse signature; - dated 11/25-[DATE] for the day shift, assess pain level every shift. There were missing entries for pain level and nurse signature; - dated 11/25-[DATE] for the day shift, behavior monitoring for use of Seroquel. There were missing entries for the number of episodes of target behaviors and nurse signature; - dated [DATE] for the day shift, monitor for BBW (Black Box Warning) side effect every shift for apixaban (blood thinner); - dated [DATE] for the day shift, monitor BBW Acetaminophen/ Narcotic combination (Norco- pain reliever) for risk of liver toxicity; - dated [DATE] for the day shift, monitor for BBW of sertraline; - dated [DATE] for the day shift, monitor BBW atypical antipsychotics (medications primarily used to treat schizophrenia, bipolar disorder and severe depression) quetiapine; - dated 11/25-[DATE] for the day shift, notify MD if the patient has any of the following symptoms: temperature less than 96.8 or greater than 99F, heart rate greater than 90 beats per minute, respiratory rate greater than 20 per minute, acute change in mental status, oxygen saturation of less than 90%, systolic BP greater than 100 mmHg baseline, less than 100 mmHg, more than 5 mmHg lower than the baseline every shift for sepsis. There were missing entries for monitoring level of consciousness, BP, temperature, pulse rate, respiratory rate, oxygen saturation; - dated [DATE] at 1400 hours, water three times a day for hydration eight ounces between meals at 1000, 1400 and 2000 hours; - dated [DATE] for the day shift, monitor signs/symptoms of central nervous system depression due to combo use of methocarbamol and Norco every shift. On [DATE] at 1417 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 6. LVN 6 verified the above missing entries in Resident 3's [DATE] MAR. On [DATE] at 1441 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 2. LVN 2 verified the above findings and stated his responsibilities were to check the residents' well-being after medication pass and document right after the medications were administered. On [DATE] at 1457 hours, an interview and concurrent medical record review for Resident 3 was conducted with the MRD. The MRD verified the above findings and stated the medical records department audited the MARs daily. 2. Review of the facility's P&P titled Do Not Resuscitate Order revised 3/2021 showed the POLST may be used to specify whether to administer CPR in case of a medical emergency. The interdisciplinary care planning team will review advance directives with the resident to determine if the resident wishes to make changes in such directives. a. Medical record review for Resident 5 was initiated on [DATE]. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated [DATE], showed Resident 5 had the capacity to make his own decisions. Review of Resident 5's POLST dated [DATE], showed Section D for the advance directive was not completed. Review of Resident 5's IDT – Care Conference and Care Plan Review (WGC) – V4 dated [DATE], showed Resident 5 had issued an advance directive about his care and treatment. On [DATE] at 1059 hours, an interview and concurrent medical record review for Resident 5 was conducted with the SSD. The SSD verified the above findings. The SSD stated the Section D of Resident 5's POLST should have been completed upon admission or updated as needed. The SSD stated Resident 5 had an advanced directive but was unable to provide a copy. b. Medical record review for Resident 135 was initiated on [DATE]. Resident 135 was admitted to the facility on [DATE]. Review of Resident 135's H&P examination dated [DATE], showed Resident 135 had the capacity to understand and make decisions. Review of Resident 135's POLST dated [DATE], showed Section D for the advance directive was not completed. Review of Resident 135's IDT – Care Conference and Care Plan Review (WGC) – V4 dated [DATE], showed Resident 135 had not executed an advance directive. On [DATE] at 1058 hours, an interview and concurrent medical record review for Resident 135 was conducted with the SSD. The SSD verified the above findings. c. Medical record review for Resident 8 was initiated on [DATE]. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated [DATE], showed Resident 8 had no capacity to understand and make decisions. Review of Resident 8's POLST dated [DATE], showed Section D for the advance directive was not completed. Review of Resident 8's IDT – Care Conference and Care Plan Review (WGC) – V4 dated [DATE], showed Resident 8 had not executed an advance directive. On [DATE] at 1058 hours, an interview and concurrent medical record review for Resident 8 was conducted with the SSD. The SSD verified the above findings. On [DATE] at 1500 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 2. The Administrator, DSD, and Nurse Consultant 2 were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for three of three final sampled residents (Residents 3, 8, and 10) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's orders for Resident 8. In addition, the facility failed to ensure the nonpharmacological interventions were provided to Resident 8 prior to the administration of the pain medication. * The facility failed to ensure the hydrocodone-acetaminophen (narcotic pain medication) pain medication was administered per the physician's orders for Resident 10. In addition, the facility failed to ensure non-pharmacological interventions were provided to Resident 10 and documented prior to the administration of the PRN hydrocodone-acetaminophen and Tylenol medications. * The facility failed to implement the non-pharmacological interventions to Resident 3 prior to the administration of pain medication. These failures had the potential to put the residents at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.Findings: Review of the facility's P&P titled Administering Pain Medications revised 3/2020 showed the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain. The steps in the program included to conduct a pain assessment, to evaluate and document the effectiveness of non-pharmacologic interventions, to administer pain medications as ordered, and to re-evaluate the resident's level of pain 30-60 minutes after administration. 1. Medical record review for Resident 8 was initiated on 1/21/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/7/25, showed Resident 8 had no capacity to understand and make decisions. Review of Resident 8's Care Plan Report dated 12/7/25, showed a care plan problem addressing Resident 8's risk for pain related to their right femoral fracture status post open reduction and internal fixation (ORIF – a surgery to repair broken bones). The interventions showed to administer pain medications as ordered and assess for pain every shift using the following pain scale: 0 = no pain, 1-3 = mild pain, 4-6= moderate pain, and 7-10 = severe pain. Review of Resident 8's Order Summary Report dated 1/26/26, showed a physician's order dated 12/5/25, to indicate the non-pharmacological interventions attempted prior to PRN pain medication administration. To document 1. Reposition / limb evaluation, 2. Dim light / quiet environment / rest periods, 3. Snacks / drinks, 4. Therapeutic touch / massage, if not contraindicated, 5. Redirect / reassurance / emotional support, 6. Music, 7. Guided imagery / meditation, 8. Provide distraction / diversionary activities, 9. Exercise / ROM / ambulation / stretching, 10. Deep breathing / relaxation exercises, 11. Laughter / socialization, 12. Other (describe). Review of Resident 8's January 2026 MAR showed the following: - dated 12/29/25, and discontinued on 1/23/26, to administer acetaminophen ( over the counter pain medication) 325 mg one tablet by mouth every six hours as needed for mild to moderate pain and - dated 12/7/25, and discontinued 1/23/26, to administer hydrocodone – acetaminophen 5-325 mg one tablet by mouth every six hours as needed for severe pain. a. Review of Resident 8's December 2025 and January 2026 MAR showed Resident 8 was administered hydrocodone-acetaminophen 5-325mg for a pain level of 6 on the following dates and times: - on 12/10/25 at 0027 hours; - on 12/15/25 at 1753 hours; - on 12/19/25 at 1717 hours; - on 12/22/25 at 1359 hours; - on 12/29/25 at 0814 hours; - on 12/30/25 at 0816 hours; - on 12/31/25 at 0835 hours; and - on 1/22/26 at 2146 hours. On 1/23/26 at 1342 hours, an interview and concurrent medical record review was conducted with LVN 3 for Resident 8. LVN 3 verified the above findings. LVN 3 stated per the Resident 8's pain level, Resident 8 should have been administered acetaminophen 325 mg per physician's order. On 1/23/26 at 1535 hours, an interview and concurrent medical record review was conducted with RN 2 for Resident 8. RN 2 verified the above findings. RN 2 stated the numerical pain scale from 1 to 3 indicated mild pain, 4 to 6 indicated moderate pain, and 7 to 10 indicated severe pain. Furthermore, RN 2 stated Resident 8 should have been administered acetaminophen 325 mg for a pain level of 6. b. Further review of Resident 8's December 2025 and January 2026 MAR showed Resident 8 was administered hydrocodone-acetaminophen 5-325mg on the following dates and times: - on 12/11/25 at 0200 hours, for a pain level of 7; and at 2026 hours, for a pain level of 8; - on 12/12/25 at 0253 hours, for a pain level of 7; and at 1915 hours, for a pain level of 8; - on 12/13/25 at 0136 hours, for a pain level of 7; - on 12/14/25 at 0018 hours, for a pain level of 8; - on 12/16/25 at 0600 hours, for a pain level of 7; - on 12/17/25 at 0004, 0607, and 1544 hours, for a pain level of 7; - on 12/18/25 at 0257 hours, for a pain level of 7; - on 12/19/25 at 0319 hours, for a pain level of 7; - on 12/22/25 at 0545 hours, for a pain level of 7; - on 12/23/25 at 0613 hours, for a pain level of 7; - on 12/24/25 at 1717 hours, for a pain level of 8; and - on 1/3/26 at 0122 hours, for a pain level of 8. However, further review of Resident 8's medical record failed to show the documented evidence to show what non-pharmacological pain interventions were attempted prior to the administration of the hydrocodone-acetaminophen pain medication for the above dates and times. On 1/23/26 at 1342 hours, an interview and concurrent medical record review was conducted with LVN 3 for Resident 8. LVN 3 verified the above findings. LVN 3 stated the non-pharmacological interventions should be implemented first, as it might address the resident's pain. If the non-pharmacological interventions were ineffective, the resident's pain should be reassessed for the need of pain medication. On 1/26/26 at 1500 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 2. The Administrator, DSD, and Nurse Consultant 2 were informed and acknowledged the above findings. 2. Medical record review for Resident 10 was initiated on 1/20/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's MDS assessment dated [DATE], showed Residents 10 was cognitively intact. Review of Resident 10's plan of care showed a care plan problem dated 5/3/25, addressing Resident 10's risk for pain. The interventions included administering medications as ordered, and to assess Resident 10 for pain every shift, using the pain scale: 0- no pain, 1 to 3- mild pain, 4 to 6- moderate pain, and 7 to 10- severe pain. Review of Resident 10's Order Summary Report dated 1/21/26, showed the following physician's orders: - dated 5/2/25, to indicate the non-pharmacological interventions attempted prior to the PRN pain medication administration. To document 1. Reposition/limb elevation 2. Dim light/quiet environment/rest periods 3. Snacks/drink 4. Therapeutic touch/massage if not contraindicated 5. Redirect/reassurance/emotional support 6. Music 7. Guided imagery/meditation 8. Provide distraction/diversionary activities 9. Exercise/ROM/ambulation/stretching 10. Deep breathing/relaxation exercises 11. Laughter/socialization 12. Other (describe). - dated 5/2/25, to administer hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every six hours as needed for severe pain. - dated 5/2/25, to administer Tylenol 325 mg, two tablets by mouth every six hours as needed for mild pain. a. Review of Resident 10's MAR for January 2026, showed Resident 10 was administered the hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six hours as needed for severe pain (pain levels of 7 to 10) on the following dates and times, when the resident's pain level was not within the pain levels of 7 to 10 as ordered by the physician: - On 1/3/26 at 0900 hours, for a pain level of 3; and at 1558 hours, for a pain level of 5. - On 1/4/26 at 1600 hours, for a pain level of 5. - On 1/5/26 at 1607 hours, for a pain level of 6. - On 1/6/26 at 1800 hours, for a pain level of 5. - On 1/7/26 at 1546 hours, for a pain level of 5. - On 1/8/26 at 1531 hours, for a pain level of 6. - On 1/9/26 at 1600 hours, for a pain level of 5. - On 1/10/26 at 2028 hours, for a pain level of 6. - On 1/11/26 at 1754 hours, for a pain level of 5. - On 1/14/26 at 1048 hours, for a pain level of 5. - On 1/15/26 at 1622 hours, for a pain level of 5. - On 1/17/26 at 1545 and 2145 hours, for a pain level of 5. - On 1/18/26 at 1553 hours, for a pain level 5. b. Further review of Resident 10's MAR for January 2026, showed Resident 10 was administered the following medications for pain: * for the Tylenol 325 mg, two tablets by mouth every six hours as need for mild pain (pain levels of 1 to 3). Resident 10 was administered the Tylenol pain medication on the following dates and times: - On 1/1/26 at 0600 hours, for a pain level of 3; and at 1532 hours, for a pain level of 4. - On 1/16/26 at 0500 hours, for a pain level of 3. * for the hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every six hours as needed for severe pain(pain levels of 7 to 10). Resident 10 was administered the hydrocodone-acetaminophen pain medication on the following dates and times: - On 1/1/26 at 0904 hours, for a pain level of 7. - On 1/2/26 at 0755 and 1845 hours, for a pain level of 7. - On 1/4/26 at 0828 hours, for a pain level of 7. - On 1/5/26 at 0808 hours, for a pain level of 7. - On 1/6/26 at 0809 hours, for a pain level of 7. - On 1/7/26 at 0041 and 0800 hours, for a pain level of 7. - On 1/8/26 at 0731 hours, for a pain level of 7. - On 1/9/26 at 0132 and 0746 hours, for a pain level of 7. - On 1/10/26 at 1001 hours, for a pain level of 7. - On 1/11/26 at 0817 hours, for a pain level of 7. - On 1/12/26 at 0823 and 1754 hours, for a pain level of 7. - On 1/13/26 at 0756 and 1614 hours, for a pain level of 7. - On 1/15/26 at 0809 hours, for a pain level of 7. - On 1/17/26 at 0929 hours, for a pain level of 7. - On 1/18/26 at 0905 and 2352 hours, for a pain level of 7. - On 1/20/26 at 0747 hours, for a pain level of 7. However, further review of Resident 10's medical record failed to show the documentation of the non-pharmacological pain interventions attempted prior to the administration of the hydrocodone-acetaminophen and Tylenol pain medications for the above dates and times. On 1/21/26 at 1542 hours, an interview and concurrent medical record review was conducted with LVN 5 for Resident 10. LVN 5 stated when the residents complained of pain, the pain would be assessed and the non-pharmacological interventions would be implemented. LVN 5 stated if the non-pharmacological interventions were ineffective, then the resident would be administered the pain medication as per the physician's order. LVN 5 reviewed Resident 10's medical record and verified the above findings. On 1/22/26 at 1352 hours, an interview was conducted with the DON. The DON stated when the resident reported pain, the licensed nurses were expected to implement and document the non-pharmacological interventions. The DON stated if the non-pharmacological interventions were ineffective, the licensed nurse should administer the PRN pain medication as per the physician's orders. On 1/26/26 at 1410 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, and the DSD. The Administrator, Nurse Consultants 1 and 2, and the DSD were informed and acknowledged the above findings. 3. Medical record review for Resident 3 was initiated on 1/26/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/12/25, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's plan of care showed a care plan problem dated 3/12/25, addressing Resident 3's risk for pain. The interventions showed to assess for pain every shift using pain scale, consider non-pharmacological measures – relaxation, diversion activities, music therapy, positioning, turning, application of heat or cold, massage, back rub. Review of Resident 3's Order [NAME] Report for January 2026 showed the following physician's orders: - dated 4/30/25, to apply lidocaine patch (topical pain medication) 4% to the right knee topically one time a day for pain management. Apply at 0900 hours and remove at 2100 hours. - dated 1/24/26, to administer Norco 5-325 mg (hydrocodone-acetaminophen) one tablet by mouth every 12 hours for chronic pain. Review of Resident 3's MAR for January 2026 showed Resident 3 administered the lidocaine patch 4% medication to the right knee once a day from 1/1-1/26/26 and the Norco tablet 5-325 mg tablet was administered every 12 hours for chronic pain on the following dates: - on 1/3 through 1/26/26 at 0900 hours; and -on 1/2 through 1/25/26 at 2100 hours. However, further review of Resident 3's MAR for January 2026 showed the licensed nurses documented Resident 3's pain level as zero for the following dates and shifts: - on 1/3 through 1/8/26 and 1/11 through 1/26/26 at 0900 hours, for the Norco pain medication; and - on 1/2 through 1/6/26 and on 1/9, 1/10, 1/12, 1/13, 1/15 through 1/25/26 at 2100 hours for the Norco pain medication. In addition, further review of Resident 3's medical record failed to show the documentation of the non-pharmacological pain interventions attempted prior to the administration of the Norco and lidocaine patch medications for the above dates and times. On 1/26/26 at 1435 hours, an interview and concurrent medical record review was conducted with LVN 2 for Resident 3. LVN 2 stated for the residents who reported pain, the non-pharmacological pain interventions would be implemented and documented prior to the administration of the pain medication. LVN 2 stated if the non-pharmacological pain interventions were effective, then pain medication would not be needed. LVN 2 further stated if the pain level was zero, then the pain medication shouldn't have been given, and the physician should have been notified of the consistent pain level of zero. LVN 2 verified the non-pharmacological interventions were not being implemented or monitored for Resident 3's pain medications. On 1/26/26 at 1549 hour, an interview was conducted with the Administrator, DSD, and Nurse Consultant 1. The Administrator, DSD, and Nurse Consultant 1 acknowledged the above findings.

Based on interview, and medical record review, the facility failed to accurately monitor the fluid intake and output for one of two final sampled residents (Resident 145) reviewed for hemodialysis care. * The facility failed to ensure Resident 145's fluid intake and output was accurately monitored. This failure had the potential for Resident 145 to not be provided with the appropriate care and treatment, and to experience life threatening conditions associated with fluid deficit/overload.Findings: Medical record review for Resident 145 was initiated on 1/20/26. Resident 145 was readmitted to the facility on [DATE], with a diagnosis of ESRD requiring hemodialysis treatment. Review of Resident 145's Order Summary Report showed the following physician's orders dated 10/31/25:- for hemodialysis treatment on Tuesdays, Thursdays, and Saturdays;- to record intake and output every shift; and- for fluid restriction of 1200 ml day. The kitchen will provide 840 ml total (360 ml for breakfast, 240 ml for lunch, and 240 ml for dinner), and the nursing will provide 360 ml total (180 ml in the AM shift, 120 ml in the PM shift, and 60 ml in the NOC shift). Review of Resident 145's Documentation Survey Report v2 for December 2025 and January 2026 showed Resident 145 exceeded the prescribed dietary fluid intake of 840 ml. For example:- On 12/2/25, Resident 145 had a total of 860 ml fluid intake;- On 12/4/25, Resident 145 had a total of 1340 ml fluid intake;- On 12/9/25, Resident 145 had a total of 920 ml fluid intake;- On 12/10/25, Resident 145 had a total of 960 ml fluid intake;- On 12/11/25, Resident 145 had a total of 1160 ml fluid intake;- On 12/12/25, Resident 145 had a total of 940 ml fluid intake;- On 12/13/25, Resident 145 had a total of 1140 ml fluid intake;- On 12/16/25, Resident 145 had a total of 1280 ml fluid intake;- On 12/16/25, Resident 145 had a total of 900 ml fluid intake;- On 12/19/25, Resident 145 had a total of 960 ml fluid intake;- On 12/25/25, Resident 145 had a total of 1000 ml fluid intake;- On 12/30/25, Resident 145 had a total of 880 ml fluid intake;- On 1/2/26, Resident 145 had a total of 960 ml fluid intake;- On 1/11/26, Resident 145 had a total of 940 ml fluid intake;- On 1/16/26, Resident 145 had a total of 1160 ml fluid intake;- On 1/18/26, Resident 145 had a total of 960 ml fluid intake; and- On 1/21/26, Resident 145 had a total of 860 ml fluid intake; Review of Resident 145's MAR for December 2025 and January 2026 showed Resident 145 exceeded the prescribed nursing fluid intake of 360 ml, and the total 1200 ml daily, including the amount of fluid intake documented under TI (total intake). For example:- On 12/1, 12/5 and 12/24/25, Resident 145 had a total of 1660 ml fluid intake;- On 12/3/25, Resident 145 had a total of 1800 ml fluid intake;- On 12/4/25, Resident 145 had a total of 1860 ml fluid intake;- On 12/6, 12/16 and 12/23/25, and 1/1/26, Resident 145 had a total of 1460 ml fluid intake;- On 12/7/25, Resident 145 had a total of 1380 ml fluid intake;- On 12/8/25, Resident 145 had a total of 2280 ml fluid intake;- On 12/9/25, Resident 145 had a total of 1280 ml fluid intake;- On 12/14/25, Resident 145 had a total of 1260 ml fluid intake;- On 12/20 and 12/21/25, Resident 145 had a total of 2000 ml fluid intake;- On 12/22/25, Resident 145 had a total of 2620 ml fluid intake;- On 12/25/25, Resident 145 had a total of 2240 ml fluid intake;- On 12/29/25 and 1/10 and 1/15/26, Resident 145 had a total of 1440 ml fluid intake;- On 1/2/26, Resident 145 had a total of 1740 ml fluid intake;- On 1/3/26, Resident 145 had a total of 1600 ml fluid intake;- On 1/4 and 1/5/26, Resident 145 had a total of 1620 ml fluid intake;- On 1/7/26, Resident 145 had a total of 1780 ml fluid intake;- On 1/8/26, Resident 145 had a total of 1420 ml fluid intake;- On 1/9/26, Resident 145 had a total of 1270 ml fluid intake;- On 1/16 and 1/22/26, Resident 145 had a total of 1540 ml fluid intake;- On 1/19/26, Resident 145 had a total of 1940 ml fluid intake; and- On 1/21/26, Resident 145 had a total of 1530 ml fluid intake. Further review of Resident 145's MAR for January 2026 showed Resident 145 had a total fluid intake of 400 ml during the day shift. On 1/23/26 at 1339 hours, an interview was conducted with CNA 2 for Resident 145. CNA 2 stated Resident 145 was on fluid restriction for a total of 360 ml for breakfast, and 120 ml for lunch. CNA 2 stated Resident 145 had a total of 240 ml fluid intake for breakfast, and 120 ml fluid intake for lunch. CNA 2 stated she reported Resident 145's fluid intake today to the licensed nurse. On 1/23/26 at 1355 hours, an interview and concurrent medical record review for Resident 145 was conducted with LVN 2. When asked about Resident 145's fluid intake, LVN 2 stated Resident 145 was on fluid restriction, and the charge nurses documented the daily total of Resident 145's fluid intake from the nursing and dietary in the resident's MAR. When asked to explain where the licensed nursed got the fluid intake amount documented under TI, LVN 2 stated TI meant the total intake and this was the total of Resident 145's breakfast and lunch intake from the dietary services. LVN 2 stated Resident 145's fluid intake on his shift was 180 ml, and he reported this to RN 3. On 1/23/26 at 1355 hours, an interview and concurrent medical record review was conducted with RN 3 for Resident 145. When asked about Resident 145's fluid intake, RN 3 stated she documented Resident 145's fluid intake today. RN 3 verified CNA 2 reported Resident 145 had 240 ml fluid intake from breakfast, and LVN 2 reported Resident 145 had a 180 ml fluid intake from the morning medication pass. RN 3 verified Resident 145 had a total of 420 ml fluid intake in the AM shift. RN 3 verified she documented 400 ml total fluid intake for Resident 145. When asked why she documented 400 ml instead of 420 ml, RN 3 stated she was in a rush. On 1/23/26 at 1425 hours, an interview and concurrent medical record review was conducted with RN 1 for Resident 145. RN 1 verified Resident 145's MAR showed TI, which meant the total intake of Resident 145's fluid intake from the nursing and dietary department from all shifts. RN 1 verified the amount of Resident 145's fluid intake documented under TI was inaccurate, as it did not match the total of Resident 145's fluid intake from the nursing and dietary department from all shifts. RN 1 also verified Resident 145 exceeded the prescribed dietary fluid intake as documented by the CNAs in the Documentation Survey Report. RN 1 also verified Resident 145 exceeded the prescribed total fluid intake of 1200 ml daily as documented in the resident's MAR.

Based on observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 85 residents (Resident 82) who received food from the kitchen. * The facility failed to ensure Resident 82 was served the corn on the cob or street corn, as per the menu. Resident 82 was served green beans. This failure posed the risk for negatively impacting the residents' satisfaction and dietary compliance. Findings: Review of the facility document titled Order Listing Report dated 1/20/26, showed 85 residents had regular diets and received food from the kitchen. Review of the facility's document titled Week at a Glance- Menu showed the menu for 1/20/26, for the lunch meal was BBQ pork loin, Spanish rice, corn on the cob, bread or roll with margarine, apple pie, street corn, and choice of beverage. Further review of the menu showed the menu items were for the regular diet. Medical record review for Resident 82 was initiated on 1/20/26. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's H&P examination dated 9/18/25, showed Resident 82 had the capacity to understand and make decisions. Review of Resident 82's Order Summary Report dated 1/20/26, showed a physician's order dated 12/26/25, for Resident 82 to have a fortified IDDSI- regular level 7 texture diet with thin liquids. On 1/20/26 at 1240 hours, during the dining observation in the dining room, Resident 82 was observed eating his lunch independently. On Resident 82's plate, the following were observed: the Spanish rice, BBQ pork loin, and steamed green beans. Resident 82 was asked about the green beans on his plate, and Resident 82 stated he did not ask for the green beans instead of the corn that was on the menu. On 1/20/26 at 1245 hours, an interview and concurrent observation was conducted with the RD. The RD stated the residents should be served what was listed on the menu, unless requested by the residents. The RD stated the items on the meal ticket, should match what the resident would be receiving for that meal, including any substitutions/preferences of the residents. The RD reviewed Resident 82's meal ticket and stated there was no documentation Resident 82 wanted green beans instead of the corn on the cob. On 1/26/26 at 1357 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD. The Administrator, Nurse Consultants 1 and 2, DSD, DSS, and RD were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the food preference was honored for one of 27 final sampled residents (Resident 3). * The facility failed to ensure Resident 3 was served white bread per the resident's meal ticket. This failure had the potential for the resident to not receive a meal to meet the resident's needs and preferences.Findings: Review of the facility's P&P titled Therapeutic Diets dated 10/2017 showed therapeutic diets are prescribed by the physician to support the residents' treatment and plan of care and in accordance with the residents' goals and preferences. On 01/20/26 at 1212 hours, a dining observation was conducted in the dining room. The meal cart arrived and LVN 1 was observed checking the meal trays against the residents' diet list. The meal trays were then distributed to the residents by the facility staff in the dining room. On 1/20/26 at 1225 hours, an observation and concurrent interview was conducted with CNA 10 for Resident 3. Resident 3's meal tray had a small plate of mashed potatoes and a plate with a wheat sandwich cut into 12 pieces. Resident 3's meal ticket showed turkey sandwich finely chopped on white bread. CNA 10 was then attempted to feed Resident 3 but was asked about Resident 3's wheat sandwich. CNA 10 reviewed Resident 3's meal ticket which showed to serve with white bread. CNA 10 stated it should be white bread, let me call the kitchen. On 1/20/26 at 1228 hours, an interview was conducted with LVN 1. LVN 1 stated aside from the diet order, she also checked the residents' preferences. When LVN 1 was shown Resident 3's meal tray with the wheat sandwich, LVN 1 stated Oh I did not see that. Medical record review for Resident was initiated on 1/23/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/5/25, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report dated 1/23/26, showed a physician's order dated 11/10/25, for a regular diet - minced and moist texture. On 1/23/26 at 0959 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated Resident 3 was cleared by the ST to have a sandwich as outlined on Resident 3's meal ticket. The RD further stated the white bread was Resident 3's preference as expressed by Resident 3's son. The RD also stated each meal tray was checked three times in the kitchen, in addition to the licensed nurses checking in the dining room, however, the kitchen staff had a miscommunication and missed the wheat bread served on Resident 3's tray. On 1/23/26 at 1043 hours, an interview and concurrent medical record review was initiated with the ST. The ST stated Resident 3 preferred white bread for a while now.

Based on observation, interview and facility P&P review, the facility failed to ensure the garbage and refuse were properly stored for one of three dumpsters. * The facility failed to ensure one of three dumpster's lid was fully closed. This failure had the potential to attract pests and rodents that carried diseases.Findings: According to the USDA Food Code 2022, Chapter 5 Water, Plumbing, and Waste, Section 5-501.113 Covering Receptacles showed outside garbage receptacles shall be kept covered with tight-fitting lids or covers. Review of the facility's P&P titled Food related Garbage and Refuse Disposal dated 10/2017 showed all garbage and refuse containers are provided with tight- fitting lids or covers and must be kept covered when stored or not in continuous use, and outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. On 1/22/25 at 0917 hours, an observation of the facility's outside dumpsters was conducted with the Maintenance Supervisor. One dumpster lid was not fully closed with visible bags of trash on the left side of the dumpster. The Maintenance Supervisor verified the findings and stated the housekeeping, dietary and maintenance staff were educated to keep the dumpster lids closed. On 1/26/26 at 1204 hours, an interview was conducted with the IP. The IP stated he was informed by the Maintenance Supervisor about the observation of the open dumpster lid. The IP stated the garbage was not picked up on Monday (1/21/26) because it was a holiday. The IP was informed the dumpster was not filled up on the right side, and the garbage was not overflowing, however, the trash bags were not evenly placed on the dumpster, causing the lid not fully closed. The IP was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure seven of seven final sampled residents (Residents 1, 3, 6, 8, 10, 68, and 121) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 10's orthostatic BP was monitored for the use of the olanzapine (antipsychotic medication); and failed to ensure the nonpharmacological interventions and its effectiveness were documented for the documented observed behaviors related to the use of the olanzapine, hydroxyzine (antihistamine) and Ativan (antianxiety) medications. * The facility failed to ensure Resident 68's orthostatic BP was monitored for the use of the aripiprazole (antipsychotic medication); failed to ensure the diagnoses for Resident 68's use of the aripiprazole (schizophrenia) and Cymbalta (schizoaffective depressive disorder) were appropriate when Resident 68 did not have those diagnoses; and failed to ensure the appropriate monitoring of Resident 68's behavior related to the use of the temazepam (hypnotic) medication. * The facility failed to ensure an appropriate behavior manifestation was identified for Resident 6 related to the use of Cymbalta. In addition, the facility failed to ensure the monitoring for pain, used as the behavior manifestation related to the use of Cymbalta medication, was accurate. * The facility failed to ensure the monitoring of Resident 1's meal intake was accurate to identify when the resident had a meal intake of less than 50% and failed to complete the monthly behavior summary related to the use of Remeron (antidepressant medication). *The facility failed to ensure the non-pharmacological interventions were implemented prior to the use of lorazepam (antianxiety medication) and Remeron medications for Resident 8. * The facility failed to ensure Resident 3's orthostatic blood pressure, side-effects, and non-pharmacological interventions were monitored and accurately documented for the use of quetiapine fumarate (antipsychotic) and sertraline (antidepressant) medications. * The facility failed to ensure Resident 121's non-pharmacological interventions were monitored and accurately documented for the use of lorazepam medication. These failures had the potential for the residents to experience potential harm from the adverse consequences from the use of the psychotropic medications and prevented the facility from accurately monitoring the behaviors and the effectiveness of the behavioral interventions in an effort to discontinue the use of the psychotropic medications. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying, and responding to adverse consequences. Nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of the medication when possible. The residents receiving the psychotropic medications are monitored for adverse consequences, including: b. cardiovascular effects – irregular heart rate or pulse, palpitation, lightheadedness, shortness of breath. orthostatic hypotension. If the psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued and document the rationale for the decision. Further review of the P&P showed the categories of medications which affect brain activity such as antihistamines, anticholinergic medications, and central nervous system medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications. 1. Medical record review for Resident 10 was initiated on 1/20/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's MDS assessment dated [DATE], showed Resident 10 was cognitively intact and had diagnoses including anxiety disorder and bipolar disorder. a. Review of Resident 10's Order Summary Report dated 1/21/26, showed the following physician's orders: - dated 5/13/25, to administer olanzapine 15 mg one tablet by mouth at bedtime for bipolar disorder manifested by mood swings high to low; - dated 8/18/25, to administer olanzapine 5 mg one tablet by mouth in the morning for bipolar disorder manifested by mood swings from high to low; and - dated 8/18/25, related to the use of olanzapine, to monitor Resident 10 for the behavior of mood swings from high to low, every shift. Further review of Resident 10's Order Summary Report failed to show a physician's order to monitor Resident 10 for orthostatic hypotension related to the use of the olanzapine medication. Review of Resident 10's care plan for the use of the psychotropic medications for bipolar disorder, psychosis, and anxiety dated 5/3/25, showed the interventions included observing the resident closely for significant side effects of the olanzapine antipsychotic medications. Postural hypotension was listed under the common side effects. Review of Resident 10's MAR for January 2026 showed Resident 10 was administered the olanzapine medication 5 mg one tablet by mouth every morning from 1/1 to 1/21/26 at 0900 hours, and olanzapine 15 mg one tablet by mouth at bedtime from 1/1 to 1/22/26 at 2100 hours. Further review of Resident 10's MAR showed from 1/1 to 1/20/26, the licensed nurses' documented Resident 10 had a total of 122 episodes of mood swings from high to low. Further review of Resident 10's medical record failed to show the documentation of the monitoring for the orthostatic hypotension and failed to show the documentation of the non-pharmacological interventions implemented for the documented observed behaviors of mood swings from high to low, for Resident 10's use of the olanzapine medication. b. Review of Resident 10's Order Summary Report dated 1/21/26, showed the following physician's orders: - dated 10/20/25, to initiate the non-pharmacological interventions first before offering as needed psychotropics for the behaviors. To document 1- Redirect, 2- 1:1 intervention, 3- Speak in calm manner, 4- Reposition, 5- Kept clean/comfortable, 6- Offer snacks/fluids, 7- Provide quiet environment, dim light, 8- adjust temperature, 9- Encourage to express feelings/concerns, 10- Backrub/massage, 11- Meaningful activities, 12- Encourage slow, deep breaths, 13- Offer toileting assist, 14- Essential oils, 15- Reminiscing, 16- Diversional activities, 17- Assign consistent caregiver, 18- Other, describe; - dated 10/22/25, for the use of the antianxiety medication, to monitor for the behavior of uncontrolled crying causing physical exhaustion. To document the number of episodes per shift of target behavior and tall by hashmarks; - dated 1/17/26, to administer hydroxyzine 25 mg by mouth every 12 hours as needed for anxiety manifested by uncontrolled crying causing physical exhaustion for 14 days. To be used as first line treatment prior to any Ativan use; and - dated 1/17/26, to administer Ativan 1 mg tablet by mouth every 12 hours as needed for anxiety manifested by uncontrolled crying causing physical exhaustion for 14 days, this medication is to be used as second line treatment if hydroxyzine is not effective. Review of Resident 10's MAR for January 2026 showed the following licensed nurses' documentation: * for the hydroxyzine 25 mg by mouth every 12 hours as needed for anxiety, Resident 10 was administered the medication from 1/3 to 1/6, from 1/8 to 1/15, and on 1/17/26; * for the Ativan 1 mg by mouth every 12 hours as needed for anxiety, Resident 10 was administered the medication from 1/3 to 1/8 and from 1/10 to 1/15/26; and * for the monitoring of the behavior of uncontrolled crying causing physical exhaustion, the MAR showed from 1/1 to 1/20/26, the licensed nurses' documented Resident 10 had a total of 112 episodes. Further review of Resident 10's MAR, for the documentation of the nonpharmacological interventions initiated prior to offering the PRN medication for the behavior, failed to showed the licensed nurses' documentation of the non-pharmacological interventions implemented for the above dates. On 1/21/26 at 1603 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 5. LVN 5 stated Resident 10 had behaviors of crying for no apparent reason and mood changes from happy to sad. LVN 5 stated Resident 10 was administered the Zyprexa (brand name for olanzapine) medication for her mood swings and the hydroxyzine and Ativan medication for her anxiety related to her uncontrolled crying. LVN 5 stated for the residents administered psychotropic medications, the residents were monitored for the specific behavior manifestations related to the use of each psychotropic medication. LVN 5 further stated, if the specific behaviors were observed, the nonpharmacological interventions would be implemented and its effectiveness documented in the MAR. LVN 5 reviewed Resident 10's medical records and verified there were no documentation of the non-pharmacological interventions implemented for the documented observed behaviors for the olanzapine, hydroxyzine, and Ativan medications. On 1/22/26 at 1352 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON stated the residents prescribed with the antipsychotic medications should be monitored for orthostatic hypotension. Additionally, the DON stated the residents administered with the psychotropic medications would be monitored by the licensed nurses for the specific behaviors related to the use of the psychotropic medication. The DON stated if the behaviors were observed, the non-pharmacological interventions should be implemented and documented. The DON reviewed Resident 10's medical record and verified Resident 10 was not being monitored for orthostatic hypotension related to the use of the olanzapine medication and verified there were no documentation in Resident 10's medical record of the non-pharmacological interventions implemented for the observed behaviors for the routine olanzapine and PRN hydroxyzine and Ativan medications. 2. Medical record review for Resident 68 was initiated on 1/20/26. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's MDS assessment dated [DATE], showed Residents 68 had moderately impaired cognition and had diagnoses including non-Alzheimer's dementia and major depressive disorder. a. Review of Resident 68's Order Summary Report dated 1/22/26, showed the following physician's orders: -dated 1/7/26, to administer aripiprazole (antipsychotic) 15 mg one tablet by mouth at bedtime for schizophrenia manifested by resistive to care; and - dated 1/14/26, to administer Cymbalta (medication to treat several mental heal health and chronic pain condition) 60 mg delayed-release by mouth in the evening for schizoaffective depressive type manifested by verbally feeling depressed. Review of Resident 68's care plan for the use of psychotropic medications dated 12/30/25, showed interventions including to observe the resident closely for significant side effects related to the use of the antipsychotic medications. Postural hypotension was listed under common side effects. Review of Resident 68's MAR for January 2026 showed Resident 68 was administered the following: - aripiprazole 15 mg at bedtime, from 1/1 to 1/7, and from 1/9 to 1/21/26 at 2100 hours; and - Cymbalta 60 mg DR (delayed release) in the evening, from 1/14 to 1/21/26 at 1800 hours. Further review of Resident 68's medical record failed to show the documentation Resident 68 was monitored for orthostatic hypotension for the use of the aripiprazole antipsychotic medication. On 1/22/26 at 1026 hours, an interview and concurrent medical record review for Resident 68 was conducted with LVN 6. LVN 6 stated Resident 68 had diagnoses including dementia and major depressive disorder and was taking the aripiprazole and Cymbalta medications. LVN 6 reviewed Resident 68's medical record and verified Resident 68 did not have the diagnoses for the use of the aripiprazole and Cymbalta medications. LVN 6 further stated the indication for the use of the medication should match the resident's diagnoses. LVN 6 was asked about the monitoring of the side effects related to the use of the aripiprazole antipsychotic medication. LVN 6 stated the orthostatic hypotension was a side effect related to the use of the antipsychotic medication and the residents should be monitored. LVN 6 was asked how Resident 68 was monitored for orthostatic hypotension. LVN 6 reviewed Resident 68's medical record and verified there were no documentation Resident 68 was monitored for orthostatic hypotension related to the use of the aripiprazole medication. b. Review of Resident 68's Order Summary Report dated 1/22/26, showed the following physician's orders: - dated 12/30/25, for the use of the temazepam (medication to treat insomnia), monitor Resident 68 for the number of hours of sleep every evening and night shift for insomnia, - dated 1/18/26, to administer temazepam 15 mg one capsule by mouth every 24 hours as needed for insomnia for 14 days manifested by the inability to sleep. Review of Resident 86's MAR for January 2026 showed Resident 86 was administered the temazepam 15 mg delayed release capsule on the following dates and times: - on 1/2/26 at 2205 hours; - on 1/3/26 at 2000 hours; - on 1/4/26 at 2216 hours; - on 1/5/26 at 2000 hours; - on 1/7/26 at 0230 hours; - on 1/10/26 at 2000 hours; - on 1/11/26 at 2000 hours; - on 1/12/26 at 2100 hour; - on 1/18/26 at 2000 hours, and - on 1/21/26 at 2100 hours. Further review of Resident 68's MAR for January 2026 showed Resident 86 was only monitored for the hours of sleep every shift from 1/1 to 1/6/26. On 1/22/26 at 1026 hours, an interview and concurrent medical record review for Resident 68 was conducted with LVN 6. LVN 6 reviewed Resident 68's medical record and verified the above findings. LVN 6 verified there was no documentation Resident 68 was monitored for the hours of sleep related to the use of the temazepam medication after 1/6/26. On 1/22/26 at 1429 hours, an interview and concurrent medical record review for Resident 68 was conducted with the DON. The DON reviewed Resident 68's medical record and verified the above findings. The DON stated major depressive disorder and schizoaffective depressive type were not the same diagnosis. The DON further stated Resident 68 should be monitored for orthostatic hypotension related to the use of the aripiprazole medication. The DON stated for the use of psychotropic medications, routine and/or PRN medications, the residents should be monitored for the behaviors related to the use of the medication. The DON verified there was no monitoring of Resident 68's hours of sleep for the use of the temazepam medication from 1/7 to 1/21/26. On 1/26/26 at 1410 hours, an interview was conducted with the Administrator, Nurse Consultants 1 and 2, and the DSD. The Administrator, Nurse Consultants 1 and 2, and the DSD were informed and acknowledged the above findings. 3. Medical record review for Resident 6 was initiated on 1/20/26. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed the following physician's orders: - dated 5/11/25, to assess pain level every shift; - dated 11/20/25, to administer Cymbalta 60 mg one capsule by mouth for depression manifested by pain; - dated 11/20/25, to monitor behavior for Cymbalta manifested by pain. Document number of episodes per shift of target behaviors; and - dated 11/21/25, to add up all behaviors of pain exhibited from previous month for antidepressant medication (Cymbalta) use every night shift starting on the 5th and ending on the 5th every month. Review of Resident 6's neuro-psychiatric note dated 12/16/25, did not show a justification from the prescribing physician for using pain as the behavior manifestation related to the use of Cymbalta. Review of Resident 6's MAR for December 2025 and January 2026 showed the following: -Resident 6 was administered the Cymbalta medication from 12/1 to 12/31/25 at 0900 hours, and 1/1 to 1/20/26 at 0900 hours; and -Resident 6 was assessed with nine episodes of pain in December 2025, and zero episodes of pain in January 2026. Review of Resident 6's IV record for January 2026 showed the monthly behavior monitoring for December 2025 related to antidepressant medication was documented as zero episodes. On 1/22/26 at 1046 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified there was no documentation from the prescribing physician to justify pain as the behavior manifestation related to the use of Cymbalta. RN 1 also verified there was no documentation the nurses clarified from the prescribing physician why pain was the behavior manifestation related to the use of Cymbalta. When asked about the monthly behavior summary, RN 1 stated the RN from the noc shift completed the monthly behavior summary by tallying the number of episodes documented from the previous month every 5th day of the current month. RN 1 verified there were nine episodes when Resident 6 was assessed with pain as documented in the MAR, however, the monthly behavior summary related to the use of Cymbalta showed Resident 6 had zero episodes. 4. Medical record review for Resident 1 was initiated on 1/20/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following physician's orders: - dated 11/12/24, behavior monitoring for depression manifested by poor oral intake; - dated 11/29/24, to add up all behaviors exhibited from previous month for antidepressant medication manifested by poor oral intake, every night shift starting on the 5th and ending on the 5th every month; and - dated 12/16/25, to administer Remeron (antidepressant) 30 mg by mouth at bedtime for depression manifested by poor oral intake, eating less than 50% every meal. Review of Resident 1's MAR for December 2025 and January 2026 showed the following: - Resident 1 was administered the Remeron medication from 12/16 to 12/31/25 at 2100 hours, and from 1/1 to 1/8/26, and from 1/10 to 1/21/26 at 2100 hours; and - There were zero episodes of poor oral intake every shift for Remeron use. Review of Resident 1's Documentation Survey Report v2 for December 2025 and January 2026, under Amount Meal Eaten section, showed Resident 1's meal intake as follows: - no documented meal intake on 12/4, 12/5, 12/10, and 12/12/25 for dinner, and 12/12 and 12/16/25 for breakfast and lunch; - 0 to 25% meal intake on 12/4/25 for breakfast and lunch, on 12/7/25 for dinner, on 12/4/25 for breakfast and lunch, and on 12/25/25 for breakfast; and - 26 to 50% meal intake on 12/1/25 for breakfast and lunch, 12/2 and 12/9/25, and 1/15/26 for breakfast and dinner, 12/5/25 and 1/1/26 for breakfast, 12/10 and 12/25/25 for lunch, 12/14 and 12/15, 12/23 and 12/25/25, and 1/6, 1/9, 1/10, 1/12, 1/16, and 1/20/26 for dinner. Review of Resident 1's IV record for January 2026, showed the monthly behavior monitoring for December 2025 related to antidepressant medication was documented as zero episode. On 1/22/26 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. When asked what the licensed nurses considered as poor intake, RN 1 stated the poor intake was when a resident consumed less than 50% of the meal tray. RN 1 stated Resident 1's meal intake was documented by the CNAs in the Task Documentation Survey Report, and by the charge nurses in the MAR. RN 1 verified the documentation of Resident 1's meal intake as documented by the CNAs and charge nurses did not match. When asked how the facility monitored Resident 1's poor oral intake when the CNAs were documenting 26 to 50%, RN 1 stated they could not identify when it would be less than 50% because the range was documented as 26 to 50%. RN 1 verified there were eight episodes when there were no documented meal intake and six episodes when Resident 1 was documented to have eaten 0 to 25% in December 2025, however, the monthly behavior summary related to the use of Remeron showed Resident 1 had zero episodes of poor oral intake 5. Medical record review for Resident 8 was initiated on 1/21/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/7/25, showed Resident 8 had no capacity to understand and make decisions. Review of Resident 8's Order Summary Report showed the following physician's orders: - dated 12/18/25, to administer lorazepam 1 mg one tablet by mouth in the evening for anxiety manifested by inability to relax due to health issues. In addition, to document the following non-pharmacological interventions used: 1– music / radio / TV, 2– 1:1 conversation, 3- food / drink, 4- act. / exercise, 5- verbal cues / prompting; - dated 12/6/25, for the use of antianxiety medication, to monitor for the behavior of the inability to relax. To document the number of episodes per shift of target behaviors and tally by hashmarks; and - dated 1/16/26, to administer Remeron 15 mg half a tablet by mouth at bedtime for depression manifested by poor oral intake eating less than 50%. Further review of Resident 8's Order Summary Report failed to show a physician's order to implement non-pharmacological interventions attempted prior to the administration of Resident 8's Remeron medication. Review of Resident 8's MAR for January 2026 showed for the monitoring of the behavior of the inability to relax, the licensed nurses documented Resident 8 had a total of 20 episodes from 1/1 to 1/22/26 during the day shift. Further review of Resident 8's MAR failed to show the licensed nurses' documentation of the non-pharmacological interventions implemented prior to offering lorazepam medication. On 1/23/26 at 1342 hours, an interview and concurrent medical record review for Resident 8 was conducted with LVN 3. LVN 3 stated Resident 8 had an order for lorazepam for their inability to relax and had an order for Remeron due to her poor oral intake. When asked if Resident 8's Remeron and lorazepam medications had documented evidence of implemented non-pharmacological interventions, LVN 3 stated no and verified the above findings. On 1/26/26 at 1500 hours, an interview was conducted with the Administrator, DSD, and Nurse Consultant 2. The Administrator, DSD, and Nurse Consultant 2 were informed and acknowledged the above findings. 6. Review of the facility's P&P titled Antipsychotic Medication Use revised 12/2016 showed the nursing staff shall monitor for and report any of the following side effects and adverse consequences of the antipsychotic medications to the Attending Physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension (a condition where blood pressure drops suddenly when a person stands up from sitting or lying down), arrhythmia (an irregular heartbeat, where the heart beats too fast, too slow, or in an erratic rhythm); c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia (feeling of inner restlessness and an urge to move, often making it difficult to stay still), dystonia (involuntary muscle contractions), extrapyramidal effects (involuntary movements, muscle stiffness, and tremor ), akinesia ( loss or impairment of voluntary movement); or tardive dyskinesia (involuntary, repetitive, and rhythmic movements, often of the face and limbs), stroke or TIA (transient ischemic attack, a short period of symptoms similar to those of a stroke); And for enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: Not due to a medical condition or problem (e.g., headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia, unrecognized hearing or visual impairment, medication side effects, or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued; and Persistent or likely to reoccur without continued treatment; and Not sufficiently relieved by non-pharmacological interventions; and Not due to environmental stressors (e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and Not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed. Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents receiving psychotropic medications are monitored for adverse consequences, including: anticholinergics effects – flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation; cardiovascular effects – irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension; metabolic effects – increased cholesterol and triglycerides, poorly controlled or unstable blood sugar, weight gain; neurologic effects – agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia, cerebrovascular events; and psychosocial effects – inability to perform ADLs or interact with others, withdrawal or decline from usual social patterns, decreased engagement in activities, diminished ability to think or concentrate. Medical record review for Resident 3 was initiated on 1/26/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/12/25, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 3/13/25, monitor black box warning atypical antipsychotics QS – quetiapine (Seorquel). Increases risk for mortality in the elderly with dementia-related psychosis. Monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. Every shift notify MD if any symptoms are identified; - dated 12/19/25, quetiapine fumarate oral tablet, give 12.5 mg by mouth in the morning for bipolar disorder m/b mood swings; - dated 12/19/25, quetiapine fumarate oral tablet, give 25 mg by mouth at bedtime for bipolar disorder m/b mood swings; - dated 10/20/25, sertraline HCL (hydrochloride) oral tablet, give 25 mg by mouth one time a day for bipolar disorder m/b mood swings; - dated 12/17/25, antidepressant: add up all behaviors exhibited from previous month for antidepressant medication use. Every night shift starting on the 5th and ending on the 5th of every month for antidepressant use. Specify number of behaviors being monitored in the supplementary documentation below; and - dated 10/20/35, antidepressant: behavior monitoring for sertraline for bipolar disorder m/b mood swings. Document number of episodes per shift of target behaviors every shift. Review of Resident 3's care plan for sertraline and quetiapine fumarate dated 3/13/25, showed the goal would be for Resident 3 to be free from adverse effects of these medications through next review of medications. Interventions to be implemented were to monitor signs and symptoms, side effects, black box warning, behavior monitoring every shift, follow-up by social services as needed and mental health consultation as needed. Review of Resident 3's medical record failed to show the resident was monitored for the side effects, orthostatic hypotension, or non-pharmacological interventions for quetiapine fumarate, and for monitoring for orthostatic hypotension or non-pharmacological interventions for Sertraline. On 1/26/26 at 1208 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 2. RN 2 verified there was no order for the monitoring of the side effects, orthostatic hypotension, or non-pharmacological interventions for quetiapine fumarate. RN 2 also verified there was no order for monitoring for orthostatic hypotension or non-pharmacological interventions for sertraline. On 1/26/26 at 1435 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 2. LVN 2 stated when monitoring for antipsychotic use, the facility monitored for mood changes, abnormal activities or behaviors, side effects, non-pharmacological interventions, and orthostatic hypotension. LVN 2 verified Resident 3 was not monitored for side effects, orthostatic hypotension, or implementing non-pharmacological interventions. LVN 2 verified Resident 3 was not monitored for orthostatic hypotension or implementation of non-pharmacological interventions. On 1/26/26 at 1549 hours, the Administrator, DSD, and Nurse Consultant 1 acknowledged the above findings. 7. Medical record review for Resident 121 was initiated on 1/26/26. Resident 121 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 121's H&P examination dated 5/10/25, showed Resident 121 had no capacity to understand and make decisions. Review of Resident 121's Order Summary Report dated 1/26/26, showed the following physician's orders: - dated 3/15/23, monitor black box warming side effects of lorazepam – risk from concomitant use with opioids: concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs fo

Based on interview, and medical record review, the facility failed to provide the NOMNC and the SNF ABN Form CMS-10055 to one of three final sampled residents (Resident 100) reviewed for beneficiary notification. * The facility failed to ensure Resident 100 was provided with the NOMNC and SNF ABN forms before Resident 100's last covered date of 10/8/25. The NOMNC and SNF ABN forms were signed by Resident 100's representative on 1/26/26. This failure had the potential of not allowing Resident 100 and his representative to make an informed decision regarding their Medicare services and to understand their financial responsibilities and options concerning their medical care.Findings: Medical record review for Resident 100 was initiated on 1/20/26. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's NOMNC form showed the resident's Medicare coverage of current skilled Part A services would end on 10/8/25. The form also showed the Resident 100's representative signed the form on 1/26/26. Review of Resident 100's SNF ABN showed beginning on 10/8/25, the resident may have to pay out of pocket for the care if no other insurance covers the cost. The form also showed Resident 100's representative signed the form on 1/26/26. Further medical record review for Resident 100 did not show Resident 100 and/or Resident 100's representative were provided the NOMNC or SNF ABN Form before Resident 100's last covered day. On 1/26/26 at 1358 hours, an interview and concurrent medical record review for Resident 100 was conducted with the SSD. When asked to explain the purpose of the NOMNC and SNF ABN forms, the SSD stated the NOMNC was to notify the residents of their last covered day of Medicare Part A, their right to appeal, and how to appeal. The SSD stated the SNF ABN notified the residents of what care may not be covered, the reason Medicare may not pay, and the estimated cost of the care, and would allow the residents to decide of whether to receive the care and bill Medicare, receive the care and not bill Medicare, or decline the care. On 1/26/26 at 1413 hours, an interview and concurrent medical record review for Resident 100 was conducted with the TRC Program Director. The TRC Program Director stated Resident 100's Medicare Part A skilled services episode start date was 9/23/25, and the last covered day of Part A service was 10/8/25. The TRC Program Director stated the NOMNC and SNF ABN forms should be given at least two days before the last cover date. The TRC Program Director stated the original notice for Resident 100's NOMNC and SNF ABN were misplaced and was not followed up by the TRC social services department.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's advanced directive was obtained and maintained in the medical record for one of 27 final sampled residents (Resident 3). * The facility failed to ensure the advanced directive copy for Resident 3 was available in the resident's medical record. This failure had the potential for the resident's decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 9/2022 showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. If the resident or the resident's representative has executed one or more advance directive(s), or executed one upon admission, copies of these documents are obtained and maintained in the same section of the residents' medical record and are readily retrievable by any facility staff. Medical record review for Resident 3 was initiated on 1/20/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/12/25, showed the resident had no capacity to understand and make decisions. Review of Resident 3's POLST dated 3/12/25, showed Resident 3 had an advance directive. Review of Resident 3's IDT Care Conference and Care Plan Review dated 12/18/25, showed Resident 3 had an advance directive. Further review of Resident 3's medical record failed to show a copy of Resident 3's advance directive was obtained and maintained in the medical record. On 1/21/26 at 0805 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 3's medical record did not contain the copy of Resident 3's advance directive. The SSD stated she would speak to Resident 3's representative to obtain the copy of the resident's advance directive.

Based on interview, medical record review, facility P&P review, and coroner's autopsy report review, the facility failed to provide the necessary interventions to assist one of two sampled residents (Resident 1) during a life-threatening emergency. * Resident 1 was in her room while eating breakfast when she began choking on her meal. LVN 4 was in the room assisting Resident 1's roommate and observed the resident choking. The facility failed to attempt to notify the emergency medical services (911) when their efforts to clear the food bolus blocking Resident 1's airway was unsuccessful. This failure contributed to Resident 1's untimely death. Findings: Review of the facility's P&P titled Emergency Procedure-Choking dated [DATE] showed the trained staff will assist the resident who is choking by attempting to expel the foreign body from the airway. If unable to clear the foreign body from obstructing the resident's airway, arrange the emergency transport of the resident to the nearest acute care hospital emergency department. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE], with diagnoses, including unspecified dementia with behavioral disturbance and dysphagia (difficulty swallowing). Review of Resident 1's history and physical examination [REDACTED]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment. Review of Resident 1's plan of care showed a care plan problem initiated on [DATE], addressing the resident's risk of aspiration/choking distress related to [DIAGNOSES REDACTED]. On [DATE], the facility initiated an SBAR for Resident 1 for coughing/choking while eating lunch. The SBAR documentation showed Resident 1 was observed at 1230 hours coughing out liquidly fluid, mainly water, and carrots that were chopped. Resident 1's physician was notified and an order was received for ST evaluation. Resident 1's family member, who was identified as the resident's responsible party, was informed about the coughing and choking. The SBAR showed Resident 1's responsible party had forgotten to inform the facility Resident 1 was allergic to carrots. On [DATE], the ST evaluation was conducted for Resident 1. The ST documentation showed Resident 1 was on regular diet. Resident 1 was assessed by the ST with eating a regular diet and thin liquid trial. The ST documented Resident 1 demonstrated slight slow mastication (chewing) but was able to clear. On [DATE], the facility initiated an SBAR for Resident 1 having difficulty swallowing. Documentation on [DATE] at 1800 hours, showed Resident 1 was noted coughing during dinner and had gurgling sound after drinking the liquids. Resident 1's physician was notified, and a physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the Swallow Evaluation dated [DATE], showed the evaluation was completed by the ST. The ST notes showed Resident 1 was on mechanical soft diet, with her own teeth, and the nursing staff noted increased coughing difficulty, which tended to be in the evening. The ST documented during the evaluation, Resident 1 kept talking about coughing or choking while eating and not wanting to eat. The ST documented Resident 1 kept trying to extend her head back while drinking, and the ST had to physically hold the resident's head in neutral position. In addition, Resident 1 had slow mastication (chewing) and was talking with food in her mouth. Resident 1 demonstrated moderate oral phase deficits and poor safety swallow strategies, which increased the risk for aspiration while eating. Additional review of the Swallow Evaluation dated [DATE], showed documentation from the ST the nursing staff had charted over the past two nights that Resident 1 had difficulty swallowing and was coughing throughout the evening meal last evening. The evaluation also showed Resident 1 demonstrated slow mastication and poor bolus management with unsafe swallowing practices such as extension of head back to help with swallowing. The evaluation notes showed the nursing staff downgraded the resident's diet to mechanical soft, but Resident 1 was still coughing. The ST recommended to continue working with the resident to determine the safest diet for Resident 1, along with providing education to the resident, staff, and the resident's family for safe swallow strategies. Review of the form titled Part B Therapy Request Form showed a request was made on [DATE], for Resident 1 to have the ST due to a change in condition related to difficulty swallowing. The form showed Resident 1 was evaluated two weeks earlier. The documentation showed Resident 1's current function was noted by the nursing staff as having difficulty eating her meals as evidenced by increased coughing. On [DATE], the facility initiated a new SBAR for Resident 1 due to episode of choking while eating breakfast. The staff documented on [DATE] at 0750 hours, Resident 1 was eating breakfast in bed while sitting upright. Resident 1 was witnessed to choke by LVN 4 who was feeding Resident 1's roommate and providing supervision to Resident 1. LVN 4 reported she noticed Resident 1 coughing and then started choking. LVN 4 called for help, removed some food from Resident 1's mouth, and tapped Resident 1's back multiple times. The documentation showed more staff came into Resident 1's room to assist and attempted the [MEDICATION NAME] maneuver, abdominal thrusts, and called a Code Blue. Documentation showed RN 1 went inside Resident 1's room, and Resident 1 was unresponsive and face was turning blue. RN 1 removed more food. Resident 1 clenched her teeth. RN 1 suctioned Resident 1's mouth and obtained yellow particles. RN 1 suctioned Resident 1's nose and obtained white thick mucus. Resident 1's facial color returned to normal, and she moved her head but remained unresponsive. There was no blood pressure, respiratory rate, heart rate. The staff had continued oral and nasal suctioning until nothing was obtained. At 0812 hours, the resident's pupils were dilated and the vital signs were not present. On [DATE] at 1314 hours, a list of the food items served to Resident on her breakfast tray on [DATE] was received from the Administrator. Resident 1 was served with coffee, nonfat milk, oatmeal, scrambled eggs, corn tortilla with margarine, salsa, and sugar substitute. On [DATE] at 1335 hours, an interview was conducted with the facility's RD. The RD was asked if Resident 1 had swallowing difficulties, was pocketing of food, or exhibited choking episodes in the past. The RD stated there was an episode of prolonged mastication. The RD stated on [DATE], a CNA reported Resident 1 was having more chewing difficulty and more throat clearing and had episodes of confusion, but Resident 1 denied having any problems. The RD stated she was still in the facility at the time and intervened by downgrading Resident 1's diet to mechanical soft and recommending ST evaluation. The RD was asked if she knew what Resident 1 may have choked on, she stated she did not know. The RD stated she saw what was left on Resident 1's breakfast tray because she had to get it for the coroner. The RD stated Resident 1's breakfast tray had no more tortilla, some of the eggs were gone, the oatmeal looked like it was not touched, the milk was gone, and the coffee was full. On [DATE] at 1405 hours, an interview was conducted with CNA 4. CNA 4 stated she was assigned to Resident 1 on [DATE]. CNA 4 stated the breakfast trays were already out when she arrived at the facility. CNA 4 stated she made sure Resident 1 was pulled up in bed, head of bed was high, as high as it could go, and a pillow was behind Resident 1. CNA 4 stated she served Resident 1's breakfast tray. CNA 4 was asked if Resident 1 needed assistance with feeding. CNA 4 stated no, and Resident 1 was a setup only. CNA 4 stated Resident 1's meal tray contained scrambled eggs, corn tortilla, hot salsa, coffee, and milk. CNA 4 stated she did not remember the exact time she served the breakfast tray to Resident 1 but recalled LVN 4 was in the room assisting Resident 1's roommate with feeding. CNA 4 stated she checked on Resident 1 after she passed the breakfast trays to the other residents and observed Resident 1 making a little breakfast taco. CNA 4 stated she asked Resident 1 if she wanted coffee and gave the resident coffee and sugar. CNA 4 stated when she left the room, Resident 1 was fine, and LVN 4 was still in the room. CNA 4 stated she was feeding another resident when CNA 5 came to get her. CNA 4 stated she ran right away to Resident 1's room and found Resident 1 sitting up in bed and her face was turning purple. CNA 4 stated she started performing the [MEDICATION NAME] maneuver (a technique used to expel a trapped object from a person's airway). CNA 4 stated it was very difficult to do the [MEDICATION NAME] maneuver with the resident in bed. CNA 4 stated RN 1 came into Resident 1's room and started suctioning the resident. CNA 4 was asked if 911 was called, CNA 4 stated there were no paramedics, but the staff did not stop the [MEDICATION NAME] maneuver until Resident 1 took her last breath. On [DATE] at 1427 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 1 was a little confused, but was able to follow simple directions. CNA 5 stated Resident 1 did not need assistance with feeding, but needed setup with the meal tray and adding sugar to her coffee. CNA 5 stated Resident 1 did not need her food to be cut up or chopped since Resident 1 liked it whole. CNA 5 stated they were not in Resident 1's when the resident was choking. CNA 5 was assigned to care for Resident 1's roommate, and when she went into the room on [DATE], she observed LVN 4 at Resident 1's bedside, and LVN 4 was calling Resident 1's name. The resident's face was bluish/purple. CNA 5 stated LVN 4 was trying to push Resident 1's stomach and straightening Resident 1's back. CNA 5 stated before entering the room, she heard Resident 1 coughing and sounded like she was trying to clear her throat. CNA 5 stated she yelled for CNA 4 who was in a room across the hallway. LVN 4 paged Code Blue, and everybody came to Resident 1's room. CNA 5 stated LVN 4 and CNA 4 performed the [MEDICATION NAME] maneuver. On [DATE] at 1145 hours, an interview was conducted with RN 1. RN 1 stated she was the supervisor on duty when Resident 1's choking incident occurred. RN 1 stated she heard Code Blue being paged at around 0800 hours. RN 1 stated Resident 1 was lying flat in bed and observed CNA 6 performing chest compressions and abdominal thrusts. RN 1 stated the staff performed the [MEDICATION NAME] maneuver for approximately 10 minutes and RN 1 observed Resident 1's face turned blue, but no food was not coming out. CNA 4 and LVN 4 helped RN 1 to open Resident 1's mouth and suctioned Resident 1. RN 1 stated she retrieved yellow food particles like eggs and corn tortilla. RN 1 stated Resident 1 was still unresponsive, and she suctioned Resident 1's nose. RN 1 stated she suctioned white thick mucus. RN 1 stated Resident 1's face returned to a normal color, but the staff were not able to obtain any vital signs. RN 1 stated she continued to suction Resident 1 until she could not get anything. Resident 1's pupils were dilated and was pronounced dead at 0812 hours. RN 1 was asked if anyone called 911. RN 1 stated she did not attempt to call the paramedics because Resident 1 was a DNR. On [DATE] at 1630 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the ST. The ST was asked about Resident 1 and the ST evaluation conducted on [DATE], which identified Resident 1 was coughing while eating, and the ST was to request authorization for further ST treatment. According to the ST, Resident 1's insurance required prior authorization before therapy could be done. The ST stated Resident 1 had two choking episodes on two different occasions, and the ST wanted to assess the resident further to make a determination on the Resident 1's diet. The ST stated there was a concern identified on [DATE], and a request for further treatment authorization was faxed to the resident's insurance. The ST stated Resident 1 as unsafe with swallowing and she needed to be supervised with eating meals. On [DATE] at 1725 hours, review of the facility's P&P on Choking and concurrent interview was conducted with the DON. The DON stated Code Blue was paged because of Resident 1's choking incident. The DON stated the staff were performing the [MEDICATION NAME] maneuver and suctioning the resident, but Resident 1 passed away. The DON was asked why the 911 was not called. The DON stated the staff were suctioning the Resident 1 and she was getting her oxygen. The DON stated Resident 1 was a DNR, which was why the paramedics (911) were not notified. The DON then stated Resident 1 had no vital signs, which was also why the paramedics were not notified. The DON stated the staff was able to remove the foreign body since they could not get anything else from Resident 1's mouth. However, Resident 1 no longer had vital signs, she was a DNR status, and therefore, the paramedics were not called. On [DATE] at 1417 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 1 was able to feed herself but needed supervision because she had difficulty swallowing, and therefore, somebody needed to be with Resident 1. LVN 4 stated on [DATE] at around 0750 hours, while she was assisting Resident 1's roommate with breakfast, LVN 4 noticed Resident 1 was having a hard time swallowing her food. Resident 1 was observed closing her mouth and was trying to grab something. LVN 4 said she was not sure what Resident 1 was trying to reach out for but Resident 1 was trying to cough out something. LVN 4 stated she responded immediately by calling out Resident 1's name. Resident 1 was not talking. Resident 1 continued to extend her hand trying to grab something. LVN 4 stated she kept asking Resident 1 if she was okay, but Resident 1 did not respond verbally. LVN 4 stated all of a sudden, she saw food coming out of Resident 1's nose and mouth. LVN 4 stated she was trying to tap Resident 1's back multiple times, but Resident 1 could not talk and her face turned blue. LVN 4 stated she tried to open Resident 1's mouth, but she could not do it because Resident 1 was clenching her teeth. LVN 4 was asked if she initiated the [MEDICATION NAME] maneuver. LVN 4 stated she was supposed to, but Resident 1 was a big lady and she was a small person and could not initiate the [MEDICATION NAME] maneuver. LVN 4 stated it was hard for her to move Resident 1 forward, but she tried her best to put her hand in between Resident 1's back and the mattress. LVN 1 stated CNA 5 tried to tap on Resident 1's back as well. LVN 4 was asked if there was anything else that could have been done when a resident was choking. LVN 4 stated the [MEDICATION NAME] maneuver was initiated, but she was more focused on grabbing a suction machine so she left Resident 1 and paged Code Blue from the nurse's station and grabbed a suction machine. LVN 4 stated when she came back to Resident 1's room, CNA 4, CNA 6, RN 1, and the DON were in the room. LVN 4 was asked if she called the paramedics. LVN 4 stated no. LVN 4 was asked why the paramedics were not notified. LVN 4 stated she was already assisting back and forth and did not really get a chance to call the paramedics. LVN 4 was asked if she should have called the paramedics. LVN 4 stated she should have but missed to do that because everything happened so fast. Review of Resident 1's POLST showed Do Not Attempt Resuscitation/DNR (Allow Natural Death), Selective Treatment-goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubated. May use non-invasive positive airway pressure. Generally avoid intensive care. On [DATE] at 1240 hours, a telephone interview was conducted with Resident 1's physician. The physician was asked if he had been notified regarding Resident 1's swallowing difficulty and choking episodes. The physician stated he was notified and ordered ST evaluation. The physician was asked about Resident 1's unsafe swallowing identified by the ST during their evaluation conducted on [DATE]. The physician stated the resident's swallowing difficulty was not so much about foods but rather liquids. The physician was asked if he considered choking as a medical emergency. The physician stated yes. The physician was asked if the nurses should have called the paramedics to intervene regardless of Resident 1's DNR status. The Resident 1's POLST was read to the physician. The physician responded, Choking by itself is not enough reason to call 911 immediately because nurses have a chance to intervene. However, when the resident becomes pulseless, they need to call 911. Giving someone a [MEDICATION NAME] does not necessarily mean resuscitating the person, but more of clearing what is obstructing the resident's airway. DNR does not mean do not call 911. In this case, the staff needed to have called the paramedics, regardless of the DNR status, because the POLST was not comfort care. On [DATE] at 1439 hours, a telephone interview was conducted with Family Member 1, Resident 1's Responsible Party. Family Member 1 was asked regarding her understanding of Resident 1's POLST. Family Member 1 stated she remembered she signed the POLST document in the event that the resident stopped breathing, Resident 1 would not be revived, placed on a ventilator, and in the event that she stopped eating there would be no feeding tubes used to feed her. Family Member 1 was asked if she remembered what happed to Resident 1 on [DATE]. Family Member 1 stated she received a telephone call at 0830 hours, informing her Resident 1 had choked on food at around 0800 hours and passed away. Family Member 1 was asked if she would have wanted the facility to have called her while Resident 1 was choking, she stated yes. Family Member 1 was asked if she would have wanted the facility to have called the paramedics when Resident 1 was choking, she stated yes because she wanted the paramedics to help Resident 1. Review of the facility's follow-up letter to the Department dated [DATE], showed Resident 1's choking incident took place on [DATE] at around 0750 hours. A licensed nurse was assisting Resident 1's roommate and observed Resident 1 having difficulty swallowing her food and coughing. The licensed nurse immediately assisted Resident 1 by trying to swipe some of her food out of her mouth, but Resident 1 was clenching her teeth, making it impossible for the licensed nurse to do so. The licensed nurse tapped Resident 1's back and called for assistance which came in right away. The nurses started to suction her and performing the [MEDICATION NAME] maneuver, but Resident 1 became unresponsive and the vital signs were no longer detected. The resident had a DNR order. Review of the coroner's autopsy report dated [DATE], showed Resident 1 had expired on [DATE] at 0812 hours, and the cause of death was choking.