Every finding on record at Berkley Post-Acute

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and adequate supervision to prevent accidents for three of four sampled residents (Resident 2, Resident 125, and Resident 92) by failing to: 1. Ensure medications were not left at bedside readily available for resident self- administration for Resident 2 and Resident 125. These failures had the potential to result in resident harm from omission of medications, overdose of medications, and residents ingesting medications not intended for their use. (Cross Reference F554). 2. Ensure there was no puddles of liquid on Resident 92's the bedside floor mat (a cushioned floor pad designed to help prevent injury should a person fall) and that the resident's bed was not left in a high elevated position while the resident was left unattended. These failures had the potential to result in injury to Resident 92 in the event of a fall. Findings: a. During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 7/21/2026 with diagnoses that included wedge compression fracture (the broken bone collapses, creating a wedge shape) of second lumbar vertebra (second bone from the top in the lower back), history of falls, and hypertension (high blood pressure). During a review of Resident 125's History and Physical (H&P) dated 7/22/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 7/27/2026 at 9:17 a.m. with Resident 125, in the resident's room, observed a tube of diclofenac sodium topical gel and a tube of hydrocortisone anti-itch lotion sitting on the resident's bedside rolling table while the resident was unattended by staff. Resident 125 stated he used the hydrocortisone for a rash from the brace that he wore and the diclofenac helped with the pain of his bruises on the legs. During an observation on 7/27/2026 at 9:30 a.m., observed the Certified Nursing Assistant (CNA) 3 entered Resident 125's room and stood at bedside with the hydrocortisone and diclofenac topical medication in view on the bedside rolling table. CNA 3 stated he was not assigned to care for Resident 125 but would find the resident's assigned CNA. Observed CNA 3 exited the resident's room and the medications remained on Resident 125's bedside rolling table. During an observation on 7/27/2026 at 9:37 a.m., observed CNA 4 entered Resident 125's room and stood at bedside with the hydrocortisone and diclofenac topical medication in view on the bedside rolling table. CNA 4 stated he was assigned to care for Resident 125. Observed CNA 4 spoke with Resident 125 and then exited the resident's room and the medications remained on Resident 125's bedside rolling table. During an observation on 7/27/2026 at 1:20 p.m., observed Resident 125 in the room unattended by staff with the hydrocortisone and diclofenac topical medication remained on the bedside rolling. During an observation on 7/27/2026 at 4:04 p.m., observed Resident 125's door was open and the hydrocortisone and diclofenac topical medication remained on the bedside rolling table while the resident was in the facility front lobby. During a concurrent observation and interview on 7/27/2026 at 4:06 p.m., with CNA 5, CNA 5 entered Resident 125's room and confirmed the diclofenac topical medication remained on the bedside rolling table. CNA 5 stated she did not know if Resident 125 self-applied the medication because she had not previously cared for the resident. Observed CNA 5 then exited the resident's room and the and the hydrocortisone and diclofenac topical medication remained. During a concurrent interview and record review on 7/27/2026 at 4:13 p.m., with Licensed Vocational Nurse (LVN) 4, reviewed Resident 125's physician orders. LVN 4 stated she was assigned to care for Resident 125. LVN 4 stated the facility process for residents that want to keep topical medication at bedside to self-administer is the resident needs a physician's order for the medication and needs to be assessed for the ability to safely administer and store the medication. LVN 4 stated it was important to have a physician's order and to document resident applications to ensure the resident did not overuse the medication. LVN 4 stated medications should not be left at bedside on the table because there was also risk that other confused residents may get the medication. LVN 4 then confirmed Resident 125 had diclofenac and hydrocortisone topical medications at bedside without a physician's order. LVN 4 stated she was not aware that Resident 125 was storing diclofenac and hydrocortisone topical medications at bedside, but she should have been. During a concurrent interview and record review on 7/27/2026 at 4:24 p.m., with Registered Nurse (RN) 1, reviewed Resident 125's admission Assessment, CPs, and physician orders. RN 1 stated residents have the right to request to self-administer medications but there is a process to follow. RN 1 stated there was no documented evidence that Resident 125 was assessed for medication self-administration. RN 1 stated when Resident 125 stored diclofenac and hydrocortisone at bedside, the CNA or LN should have identified that the resident wanted to self-administer and ensure there was an assessment and physician order, but they did not. During a concurrent observation and interview on 7/27/2026 at 4:35 p.m. with RN 1 and Resident 125, in the hallway in the presence of the Administrator (ADM), Resident 125 stated nobody explained to him that he could not keep medications at bedside for self-administration. RN 1 stated to Resident 125 that the resident had the right to request to self-administer medications, but they required a physician's order and safe storage. Observed Resident 125 then requested physician's orders for diclofenac, hydrocortisone, and lidocaine patches (adhesive medication used for topical pain relief). During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedures (P&P) regarding self-administration of medications. The DON stated she was made aware that Resident 125 stored diclofenac and hydrocortisone at bedside for self-administration. The DON stated residents have the right to self-administer medication with a self-administration of medication assessment and physician's order. The DON stated it was important to obtain a physician's order for all medications to ensure there are no interactions with other prescribed medications, that the administration is documented in the medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and the medication use is monitored for effectiveness and side effects. The DON stated it was the responsibility of all the staff to make sure medications are not stored at bedside for self-administration and the medication should have been identified and was not. The DON stated the P&P was not followed potentially resulting in Resident 125 not knowing or being able to exercise his right to self-administer, the resident may overuse the medication, or other residents may use medication not intended for them resulting in allergic reactions or other adverse effects. During a review of the facility P&P titled, Accident, Incidents, and Safety - Investigating and Reporting last reviewed 5/20/2026, the P&P indicated, . 7. The facility oriented and resident oriented approaches to safety are used to implement a system approach to safety and adjust interventions accordingly. 8. Resident supervision the type and frequency vary among resident. The type and frequency of resident supervision is determined on individual resident assessed needs and identified hazards in the environment. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 5/20/2026, the P&P indicated, Policy Statement.Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation. 1.Resident who expresses a desire to self-administer medications, as part of the evaluation, the staff and practitioners will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the residents. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the residents: a. Comprehension of the purpose and proper dosage and administration time for his or her medications; b. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication or licensed nurse to prepare meds and resident to self-administer medications. c. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. 4.The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. 5. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 6. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. All medications and treatments shall be administered only by licensed medical or licensed nursing personnel. Medications shall be administered in accordance with the orders, including any required time frame. The licensed nursing/ medical personnel administering the medication shall document his/ her initials on the resident's eMAR after giving medication. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 6/5/2026 with diagnoses that included cirrhosis of liver (permanent scarring that damages the liver [organ that removes toxins from the body's blood supply), hepatic encephalopathy (brain dysfunction caused by liver insufficiency), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/11/2026, the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident required partial/moderate (helper does less than half the effort) staff assistance dressing and personal hygiene and required substantial /maximal (helper does more than half the effort) assistance for toileting. During a review of Resident 2's H&P dated 6/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following orders: -Apixaban (medication that thins the blood) oral tablet 2.5 milligrams (mg, a unit of measurement), give one (1) tablet by mouth one time a day for portal vein thrombosis (formation of a blood clot in the veins of the liver) prophylaxis (PPX), dated 6/9/2026. -Ascorbic acid (a dietary supplement) tablet, 500 mg, give 1 tablet by mouth one time a day for supplement, dated 6/6/2026. -Furosemide (medication to treat high blood pressure and fluid retention) oral tablet 40 mg, give 1 tablet by mouth one time a day for hepatic cirrhosis, dated 6/5/2026. -Lactulose (laxative medication) oral solution 10 gm/15 milliliters (ml, a unit of measurement) give 30 ml by mouth three times a day for hepatic cirrhosis, dated 6/5/2026. -Multivitamin with minerals (a dietary supplement) tablet, give 1 tablet by mouth one time a day for supplement, dated 6/6/2026. -Ammino acids - protein hydrolysate (a dietary supplement), give 30 mL by mouth one time a day for supplement, dated 6/11/2026. -Xifaxan (a medication that treats bacterial infection in the intestines) oral tablet, 550 mg, give 1 tablet by mouth every morning and at bedtime for Hepatic Cirrhosis, dated 6/5/2026. -Vitamin D3 (a dietary supplement) oral capsule, 125 micrograms (MCG, a unit of measurement), Give 1 capsule by mouth in the morning for supplement, dated 6/5/2026. -Spironolactone (medication that eliminate excess fluid and salt from the body) oral tablet 100 mg, give 1 tablet by mouth one time a day for hepatic cirrhosis, dated 6/6/2026. During a concurrent observation and interview on 7/29/2026 at 8:05 a.m., with LVN 2 and Resident 2, at Resident 2's shared room, observed Resident 2's curtains were drawn and the resident was not visible from the hallway. Observed LVN 2 walk down the hallway from Station 2 towards Resident 2's room. Observed LVN 2's hands were empty when LVN 2 entered Resident 2's room directly ahead of the surveyor. Observed LVN 2 walked past the curtains to Resident 2's bedside where the resident was eating breakfast. Observed a clear medication cup containing tablets and capsules and two clear medication cups containing clear liquid medications. Observed LVN 2 reminded Resident 2 to take the medication and Resident 2 responded that she wanted to eat first, and she promised she would take them like she always does. Observed LVN 2 remained at bedside until Resident 2 agreed to take the medication. During a follow-up interview on 7/29/2026 at 8:12 a.m., with LVN 2, in the hallway outside Resident 2's room, LVN 2 stated the facility process for medication self-administration is to prepare all the medication, observe the resident take the medication, then document the administration in the MAR. LVN 2 stated he prepared and gave Resident 2 all her morning medications and left them at bedside for the resident to take. LVN 2 stated he left the medication for the resident to self-administer because he needed to get something for Resident 2's roommate. LVN 2 stated he should not have left medications in the room with Resident 2 because it was a safety issue because the resident may not take all the medications or another resident may accidentally ingest the medication. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the DON, reviewed the facility P&P regarding self-administration of medications. The DON stated she was made aware that Resident 2 wanted to self-administer her medication. The DON stated residents have the right to self-administer medication with a self-administration of medication assessment and physician's order. The DON stated Resident 2 expressed to LVN 2 that she wanted to self-administer medications so LVN 2 should have had a medication self-administration assessment completed and notified the physician prior to leaving medications at bedside, but he did not. The DON stated the P&P was not followed potentially resulting in Resident 2 not taking all her medications resulting in worsening liver issues or other residents may use medication not intended for them resulting in adverse effects. During a review of the facility P&P titled, Accident, Incidents, and Safety - Investigating and Reporting last reviewed 5/20/2026, the P&P indicated, . 7. The facility oriented and resident oriented approaches to safety are used to implement a system approach to safety and adjust interventions accordingly. 8. Resident supervision the type and frequency vary among residents. The type and frequency of resident supervision is determined on individual resident assessed needs and identified hazards in the environment. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 5/20/2026, the P&P indicated, Policy Statement.Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation. 1.Resident who expresses a desire to self-administer medications, as part of the evaluation, the staff and practitioners will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the residents. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the residents: Comprehension of the purpose and proper dosage and administration time for his or her medications; Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication or licensed nurse to prepare meds and resident to self-administer medications. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. 4.The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. 5. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 6. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. All medications and treatments shall be administered only by licensed medical or licensed nursing personnel. Medications shall be administered in accordance with the orders, including any required time frame. The licensed nursing/ medical personnel administering the medication shall document his/ her initials on the resident's eMAR after giving medication. c. i. During a review of Resident 92's admission Record, the admission Record indicated the facility originally admitted the resident on 6/26/2025 and most recently admitted the resident on 3/21/2026 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), lack of coordination, and muscle weakness. During a review of Resident 92's H&P dated 6/30/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 92's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident was dependent on staff assistance for dressing, personal and oral hygiene, toileting, and mobility. The MDS indicated the resident had fallen in the facility. During a review of Resident 92's CP titled At risk for falls related to unsteady gait, weakness., dated 3/21/2026, the CP indicated a goal that the resident would have no incident of falls or injury with interventions that included to maintain a safe and hazard free environment including no wet floors. During an observation on 7/27/2026 at 10:05 a.m. observed Resident 92 being rolled down the hallway by staff in a shower chair. Observed the resident dripped water onto the floor in the hallway and a staff member followed with a mop. After the staff assisted the resident back into the bed and exited the room, observed puddles of clear liquid on the bedside floor mat while no staff were in attendance. During an observation on 7/27/2026 at 10:28 a.m. observed Resident 92 lying in bed while not attended by staff. Observed the clear liquid puddles remained on the bedside floor mat. During a concurrent observation and interview on 7/27/2026 at 11:45 a.m. observed Resident 92 lying in bed while RN 10 assisted Resident 92's roommate. Observed the clear liquid puddle remained on the bedside floor mat and RN 10 exited the room. Surveyor requested that RN 10 observe Resident 92's fall mat. RN 10 stated there was water on Resident 92's fall mat and there should not be because it is a safety risk and Resident 92 was at risk for falls. RN 10 stated she was assisting Resident 92's roommate and did not see the water, but she should have. RN 10 stated when the staff return the resident to bed after a shower, they should have ensured there was no water left on the floor, but they did not. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the DON, reviewed the facility P&P regarding fall prevention and accidents, the DON stated the facility process when a resident returns from the shower room is the housekeeping staff is called to clean the water and place a wet floor sign to prevent any staff, visitors, or residents from slipping. The DON stated all staff are responsible for observing the resident's environment when they enter the room and should have identified the puddles on Resident 92's floor and cleaned them, but they did not. The DON stated the facility P&P was not followed when there were puddles on Resident 92's floor mats potentially resulting in injuries from falls. During a review of the facility P&P titled, Accident, Incidents, and Safety - Investigating and Reporting last reviewed 5/20/2026, the P&P indicated, . The facility oriented and resident oriented approaches to safety are used to implement a system approach to safety and adjust interventions accordingly. Resident supervision the type and frequency vary among residents. The type and frequency of resident supervision is determined on individual resident assessed needs and identified hazards in the environment. During a review of the facility P&P titled, Falls Management Program last reviewed 5/20/2026, the P&P indicated, Purpose: To provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. Policy:. -It is the policy of this facility to provide residents with a safe environment which is free from accident hazards as is possible. -The facility will provide residents with adequate supervision and assistive device to prevent accidents. c.ii. During a review of Resident 92's CP titled At risk for falls ., initiated 7/8/2025 and last revised 6/9/2026, the CP indicated a goal that the resident would have no documented falls or fall related injuries with interventions that included to keep the bed in the low position. During an observation on 7/30/2026 at 9:42 a.m., observed Resident 92 in bed with the bed in the high elevated position. Observed Restorative Nurse Assistant (RNA) 1 and RNA 2 enter Resident 92's shared room, assisted Resident 92's roommate, then walked past Resident 92 and exited the room. Observed Resident 92's bed remained in the high elevated position while unattended by staff. During a concurrent observation and interview on 7/30/2026 at 9:55 a.m., with CNA 6, CNA 6 stood at Resident 92's room entrance and stated she left the resident's bed in the high position because she did not want the indwelling catheter (a flexible tube placed in the bladder to drain urine) drainage bag to touch the basin on the floor. Observed a basin placed on the floor directly below the indwelling catheter. Observed CNA 6 then entered Resident 92's room and slightly lowered the bed and then exited. During a concurrent observation and interview on 7/30/2026 at 10:03 a.m., with CNA 7, CNA7 stood at Resident 92's room entrance, CNA 7 stated she has cared for Resident 92 but was not assigned to him today. CNA 7 stated the basin on the floor was used to keep the indwelling catheter drainage bag from making direct contact with the floor and the bed should be lowered so the bag rests in the basin. CNA 7 stated Resident 92 is at risk for falls and the bed should be kept in the low position at all times when not attended by staff. CNA 7 stated Resident 92's bed was elevated to the high position and should not be. CNA 7 stated they are always told by the Director of Staff Development (DSD) to keep the beds in the lowest position for residents that can move, like Resident 92. CNA 7 stated CNA 6 did not lower Resident 92's bed to the low position. During a concurrent observation and interview on 7/30/2026 at 10:10 a.m., with the DSD, the DSD entered Resident 92's room and stated the bed was in the elevated position. The DSD stated all staff are responsible for ensuring Resident 92's bed remained in the low position while unattended by staff. Observed Resident 92 moved his leg out of the bed. The DSD stated Resident 92 was able to move and the bed should have been in the low position for safety and was not. Observed the DSD lowered Resident 92's bed. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the DON, reviewed the facility P&P regarding fall prevention and accidents, the DON stated the facility process is to place a basin below the indwelling catheter bag so the residents' beds can be lowered. The DON stated Resident 92 has had a fall in the past few months and was at risk for injuries from falls and the bed should be maintained in the lowest position to minimize injuries from falls. The DON stated when Resident 92's bed was left in the elevated position the facility P&P was not followed potentially resulting in injuries to the resident. During a review of the facility P&P titled, Accident, Incidents, and Safety - Investigating and Reporting last reviewed 5/20/2026, the P&P indicated, . 7. The facility oriented and resident oriented approaches to safety are used to implement a system approach to safety and adjust interventions accordingly. 8. Resident supervision the type and frequency vary among residents. The type and frequency of resident supervision is determined on individual resident assessed needs and identified hazards in the environment. During a review of the facility P&P titled, Falls Management Program last reviewed 5/20/2026, the P&P indicated, Purpose: To provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. Policy:. -It is the policy of this facility to provide residents with a safe environment which is free from accident hazard as is possible. -The facility will provide residents with adequate supervision and assistive device to prevent accidents.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, and administering of all drugs and biologicals to meet the needs of each resident for five of 25 sampled residents (Resident 21, 23, 132, 51, and 3) by failing to: 1.Ensure the Controlled Drug Record (CDR, accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for: 1a. Resident 21 who was prescribed tramadol (an opioid pain medicine used to treat moderate to severe pain). 1b. Resident 23 who was prescribed hydrocodone (an opioid pain medicine used to treat moderate to severe pain). 1c. Resident 132 who was prescribed hydrocodone. This failure had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).Cross reference F697. 2.Ensure Licensed Vocational Nurse (LVN) 2 checked the resident's heart rate (HR, the number of times the heart beats per minute [bpm]) prior to administering chlorthalidone (a medication to treat fluid retention and hypertension [HTN - high blood pressure]) with a physician's ordered parameter (a set of defined limits) to hold (do not give) if the HR was less than (<) 60 bpm. This failure had the potential to cause complications such as irregular or low heart rate or injury to the heart resulting in hospitalization. 3. Ensure a breathing treatment medication was not used past the expiration date for one (Station One Medication Cart Two) of two medication carts that were inspected during the survey affecting Resident 51 and Resident 3). This failure had the potential for residents to receive medication that had become ineffective due to using the medication after the expiration date. Findings: 1a. During a review of Resident 21's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 1/27/2026 with diagnoses that included presence of right artificial hip (hip replacement). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 21 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 21 was required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. During a review of Resident 21's Physician's Orders, the orders indicated Resident 21 is to receive tramadol 50 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every four hours as needed for severe pain (7-10/10 on numeric pain scale with zero being no pain and ten being the most excruciating pain), dated 1/29/2026. During a review of Resident 21's CDR, the document indicated the medication Tramadol was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic bubbles [or blisters] that is punched out to administer to a resident) on the following dates, which had no corresponding documented entries in the MAR: 7/27/2026 at 12 p.m. 7/26/2026 at 8 p.m. 7/26/2026 at 3 p.m. 7/26/2026 at 11 a.m. 7/26/2026 at 5:20 a.m. 7/25/2026 at 6 p.m. 7/25/2026 at 12:45 p.m. 7/25/2026 at 8:45 a.m. 1b. During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 6/26/2026 with diagnoses that included aftercare following joint replacement surgery. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 23 required setup or clean-up assistance with eating and oral hygiene. During a review of Resident 23's Physician's Orders, the orders indicated Resident 23 is to receive hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for moderate to severe pain 4-10/10 pain scale, dated 6/26/2026. During a review of Resident 23's CDR, the document indicated the medication Tramadol was removed from the blister pack on the following dates, which had no corresponding documented entries in the MAR: 7/27/2026 at 2:35 a.m. 7/20/2026 at 12 p.m. 7/19/2026 at 12:10 a.m. 7/18/2026 at 9 a.m. 7/17/2026 at 11:45 a.m. 7/10/2026 at 12:38 p.m. 1c. During a review of Resident 132's admission Record, the admission Record indicated the facility admitted the resident on 7/22/2026 with diagnoses that included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 132's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 7/23/2026, the BIMS indicated the resident was severely impaired in cognitive skills required for daily decision making. During a review of Resident 132's Physical Therapy Evaluation, dated 7/23/2026, indicated that Resident 132 was dependent on staff for bed mobility and transfers from bed to wheelchair. During a review of Resident 132's Physician's Orders, the orders indicated Resident 132 is to receive hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain 4-10/10 pain scale, dated 7/22/2026. During a review of Resident 132's CDR, the document indicated the medication Tramadol was removed from the blister pack on the following dates, which had no corresponding documented entries in the MAR: 7/25/2026 at 11:30 a.m. 7/25/2026 at 7:30 a.m. 7/24/2026 at 12:15 p.m. 7/24/2026 at 8 a.m. During a concurrent interview and record review with the Director of Nursing (DON) on 7/28/2026 at 4:45 p.m., the DON reviewed Resident 21, 23, and 132's CDRs and 7/2026 MARS. The DON confirmed there were entries in the CDR for the above dates for the hydrocodone and tramadol but were no corresponding entries in their 7/2026 MARs. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated this is important to ensure there is accountability of controlled medications. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those dates and times. The DON stated it is important to sign the MAR for pain medication to ensure an assessment and reassessment of the effectiveness of the pain medication is completed. The DON stated that without the assessment and re-assessment for pain a resident's pain, the licensed nurses will not know if a resident has pain relief During a second interview with the DON on 7/29/2026 at 8:03 a.m., the DON reviewed the facility's policy and procedure titled, Controlled Medications, last reviewed 5/20/2026. The DON stated according to the facility's policy the process when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. During a concurrent interview and record review with LVN 1 on 7/29/2026 at 10:20 a.m., LVN 1 reviewed Resident 132's hydrocodone CDR and 7/2026 MAR. LVN 1 confirmed that she signed Resident 132's CDR on 7/24/2026 at 8 a.m. and 12:15 p.m. but did not sign Resident 132's MAR. LVN 1 stated she should have signed both the CDR and MAR. LVN 1 stated this is important so that the next nurse will know when the last medication was given so the resident will not receive too soon or have to needlessly wait for pain relief. LVN 1 stated it is important to sign the MAR because that is where pain is accessed and re-assessed and is important to ensure the resident's pain is relieved. During a concurrent interview and record review on 7/29/2026 at 11:15 a.m., with Registered Nurse (RN) 6, RN 6 reviewed Resident 21's physician orders, MAR for 7/2026, CDR Record for 7/2026, and Progress Notes for 7/2026. RN 6 stated controlled medications are medications that are high risk for loss and diversion because they are habit-forming. RN 6 stated the facility process for PRN narcotic pain medication administration is to assess the resident's pain level, provide nonpharmacologic interventions, remove the narcotic from the locked drawer, document the removal on the Controlled Drug Record, administer the medication and document in the MAR before moving on to another resident. RN 6 stated the MAR is a communication tool used to document the medications a resident has been administered. RN 6 stated it was important to immediately document in the MAR to ensure the accurate documentation of the time and medication the resident receives to be able to assess the resident for the effectiveness of the PRN medication and to know when the next dose may be administered if the medication was not effective. RN 6 stated when narcotic pain medication is administered too close together there is the potential to result in adverse effects like sedation and respiratory depression. RN 6 stated Resident 21 is prescribed and administered tramadol, a controlled narcotic medication. RN 6 reviewed Resident 21's CDR and MAR and noted that tramadol was documented as removed from the bubble pack on the CDR but there was no documented evidence that Resident 21 had pain, was administered PRN tramadol for pain, or that the resident was assessed for the effectiveness of the medication on the following dates and times: -On 7/25/2026 at 8:45 a.m. -On 7/25/2026 at 12:45 p.m. -On 7/25/2026 at 6 p.m. -On 7/26/2026 at 5:20 a.m. -On 7/26/2026 at 8:45 a.m. -On 7/26/2026 at 11 a.m. -On 7/26/2026 at 3 p.m. - On 7/26/2026 at 8 p.m. -On 7/27/2026 at 12 p.m. RN6 stated when tramadol was removed from the bubble pack and not documented as administered in the MAR, there was the potential that the medication was not administered per physician's orders, that Resident 21's pain was not properly managed, and there was also a potential for possible loss or diversion of the controlled medications. During a concurrent interview and record review with RN 9 on 7/29/2026 at 1:11 p.m., RN 9 reviewed Resident 23's CDR for hydrocodone 5-325 mg tablet and the 7/2026 MAR. RN 9 confirmed for the dates 7/10/2026 at 12:38 p.m. and for 7/17/2026 at 11:45 a.m., she signed Resident 23's CDR but not the MAR. RN 9 stated she should have documented in both the CDR and MAR but did not. RN 9 stated this was important for accuracy of records and for pain assessment and re-assessment. During a review of the facility's policy and procedure titled, Controlled Medications, last reviewed 5/202/2026, the policy indicated the following: When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): -Date and time of administration. -Amount administered. -Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. -Initials of the nurse administering the dose on the MAR after the medication is administered. 3. During a review of Resident 3's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 7/28/2022 and re-admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/08/2026, the MDS indicated Resident 3 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. During a review of Resident 3's Physician's Orders, the orders indicated the following: -Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated (a medication that relieves inflammation by stopping certain cells in your body from releasing the chemical signals that cause swelling, itching, and mucus production) 100-50 micrograms per actuation (mcg/act, a unit of measure for breathing treatments), one puff inhale orally two times a day for COPD, dated 5/22/2026 and clarified 6/30/2026. -Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 micrograms per actuation one puff inhale orally two times a day for COPD, rinse mouth with water after use, dated 6/30/2026. During a review of Resident 3's 7/2026 Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated Resident 3 received Fluticasone – Salmeterol from 7/01/2026 until 7/28/2026, stopping after the received 9 a.m. dose. During a review of Resident 3's Care Plan for Potential for Airway Obstruction, initiated 5/22/2026, the care plan indicated a goal that Resident 3 will be free from signs/symptoms of respiratory distress. The care plan indicated an intervention to administer medication, breathing treatment and oxygen as ordered. During a medication cart observation and record review with Registered Nurse 8 (RN 8) on 7/28/2026 at 3:33 p.m., reviewed Medication Cart Station One, Cart Two with RN 8. Observed Resident 3's Fluticasone with an open date of 6/23/2026. The Fluticasone box indicated the medication expires in 30 days or when blisters are zero whichever comes first. RN 8 stated the medication should have been discarded after 7/23/2026. RN 8 looked in the medication cart and saw no other Fluticasone medication that was opened on 7/24/2026 or after. RN 8 reviewed Resident 3's 7/2026 MAR and confirmed that Resident 3 received medication from 7/24/2026 until 7/28/2026 for a total of nine doses. During a concurrent interview and record review with the Director of Nursing (DON) on 7/29/2026 at 8:16 a.m., the DON reviewed Resident 3's 7/2026 MAR. The DON stated the licensed nurses should have ordered a new Fluticasone medication so that Resident 3 would not receive after 7/23/2026. The DON stated this is important to follow the manufacturer's instructions to discard after the expiration date to ensure the efficacy of the medication. During a review of the Fluticasone Manufacturer's Recommendations, last revised 12/2024, indicated the following: Safely through away Fluticasone Propionate and Salmeterol inhalation powder in the trash one month after you open the foil pouch or when the counter reads zero, whichever comes first. 3. During a review of Resident 51's admission Record, the admission Record indicated the facility admitted the resident on 7/3/2013 with diagnoses that included essential (primary) hypertension, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral vascular accident (stroke, loss of blood flow to a part of the brain) affecting the right non dominant side, and history of falling. During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate (helper does less than half of the effort) assistance from staff for personal hygiene, substantial/ maximal helper does more than half the effort) assistance with toileting and upper body dressing and was dependent on staff for lower body dressing. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated an order for chlorthalidone tablet 25 mg, give one tablet by mouth one time a day for HTN, hold for systolic blood pressure (SBP - the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) less than 120 millimeters of mercury (mmHg-a unit of measure) or HR less than 60 beats per minute (bpm), dated 4/19/2024. During a review of Resident 51's Care Plan (CP) titled, At risk for cardiac distress. Irregular pulse., initiated 2/20/2021, the CP indicated a goal that the resident would be free from signs and symptoms of cardiac distress with interventions that included to administer prescribed medication chlorthalidone and monitor the pulse as indicated in the medication parameter. During a medication administration observation on 07/29/2026 at 8:22 a.m., with LVN 2 at Station 2 Medication Cart 2, LVN 2 prepared Resident 51's medications. Observed LVN 2 manually checked Resident 51's BP and stated the resident's SBP was 124 mmHg, and he would administer the medication. Observed LVN 2 administered Resident 51's chlorthalidone. Observed LVN 2 exited Resident 51's room and documented the administration of the medications in the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) with the exception of the chlorthalidone. LVN 2 then stated he did not check the resident's HR prior to administering the chlorthalidone, but he should have. LVN 2 stated he did not check Resident 51's HR because he was nervous. LVN 2 stated he would now check Resident 51's HR. Observed LVN 2 entered the room, checked the residents HR, and stated the HR was 82 bpm. LVN 2 stated it was important to check the resident's HR prior to administering chlorthalidone because if the HR was below 60 bpm, he should not give the medication per the physician's order. LVN 2 stated if chlorthalidone is given with HR below 60 bpm it may cause bradycardia (abnormally slow HR). During a concurrent interview and record review on 07/30/2026 10:32 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding medication administration. The DON stated chlorthalidone is a medication that has a hold parameter for the HR. The DON stated the HR must be checked prior to administering the medication to know if the medication should not be administered. The DON stated it was important to not administer chlorthalidone if the HR was too low because it may further drop the resident's HR potentially leading to complications from bradycardia. The DON stated when LVN 2 gave Resident 51 the chlorthalidone without first checking his HR, it was a medication error, and the facility policy was not followed. During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . 4. Medications shall be administered in accordance with the orders . 9. The following information must be checked/verified for each resident prior to administering medications:.b. Vital signs (measurements of the body's most basic and essential physiological functions), if necessary. During a review of the facility P&P titled, Procedures for All Medications, last reviewed 5/20/2026, the P&P indicated, Policy. To administer medications in a safe and effective manner. Procedures. I. Obtain and record any vital signs as necessary prior to medication administration.

Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for three of 25 sampled residents (Resident 21, 23, 132, and 124) reviewed for pain by failing to: 1. Ensure the licensed nurse (LN) administered as needed (PRN) tramadol (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 21. 2. Ensure the LN administered PRN tramadol and PRN hydrocodone (an opioid to relieve pain) per the physician's order and based on the assessed numeric pain rating scale for Residents 23 and Resident 132. 3. Ensure Resident 124 had pain assessments and pain medication administration documentation in the resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). These failures had the potential to result in adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the unnecessary administration of narcotics and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings: a. During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2026, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), acute kidney failure (a sudden loss of kidney function), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and history of falling. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2026, the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident required partial/moderate (helper does less than half the effort) staff assistance for bathing, dressing, and personal hygiene; and was dependent (helper completes all of the effort for the activity or the assistance of two or more helpers is required to complete the activity) on staff for toileting. The MDS indicated the resident frequently had pain and was prescribed opioids. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated orders for the following: -Monitor for signs and symptoms of pain every shift, zero (0) equals (=) no pain, one (1) to (-) three (3) = mild pain, four (4) - six (6) = moderate pain, and seven (7) - 10 = severe pain. -Tramadol HCL oral tablet 50 milligrams (mg, a unit of measurement) every 4 hours (hrs.) as needed (PRN) for severe pain 7-10, dated 1/29/2026. During a review of Resident 21's Care Plan (CP) regarding pain, initiated 1/27/2026, the CP indicated a goal that the resident's episodes of pain would be resolved within one hour of interventions that included assessing for pain and medicate per standing order and to monitor for side effects of narcotic medications. During a concurrent observation and interview on 7/27/2026 at 9:44 a.m., with Resident 21, in Resident 21's room, observed Resident 21 lying in bed. Resident 21 stated she was not doing well and had pelvic and back pain. Resident 21 stated the nurses gave her pain medication, but it did not really work. During a follow up interview on 7/29/2026 at 10:50 a.m., with Resident 21, Resident 21 stated the nurses ask her pain level and she tells them a number. Resident 21 stated she sometimes had a lower pain level and receives acetaminophen (a mild pain-relieving medication). During a concurrent interview and record review on 7/29/2026 at 11 a.m., with Licensed Vocational Nurse (LVN) 1, reviewed Resident 21's physician orders and MAR for 7/2026. LVN 1 stated the facility process for pain management is the resident is assessed, non-pharmacologic treatments are provided, and PRN medication is administered if the nonpharmacologic treatments are not affective. LVN 1 stated the MAR is used to document the residents' pain level, the non-pharmacologic treatments provided, the administration of PRN pain medication, and the effectiveness of the PRN pain medication. LVN 1 stated Resident 21 received tramadol PRN for severe pain 7 to 10. LVN 1 reviewed Resident 21's MAR and stated there were days when tramadol was administered for a pain level of zero and she (LVN 1) could not really say what happened, but it appeared the medication was not administered per the physician's orders. LVN 1 stated maybe there was a progress note indicating why Resident 21 received PRN tramadol for a pain level of zero. During a concurrent interview and record review on 5/20/2026 at 8:04 a.m., with Registered Nurse (RN) 6, RN 6 reviewed Resident 21's physician orders, and MAR for 7/2026, and Progress Notes for 7/2026. RN 6 stated the MAR is a communication tool used to document the medications a resident has received. RN 6 stated documentation in the MAR is considered accurate and reflects what actually happened to a resident. RN 6 stated the pain level documented in the MAR is the amount of pain the resident reported prior to the administration of PRN pain medication. RN 6 reviewed Resident 21's MAR and Progress notes and noted PRN tramadol for pain level 7 to 10 was not administered per physician's orders on the following dates and times: On 7/4/2026 at 2 a.m. for a pain level of 0. On 7/7/2026 at 2:30 a.m. for a pain level of 0. On 7/11/2026 at 12 a.m. for a pain level of 0. On 7/14/2026 at 12 a.m. for a pain level of 0. On 7/14/2026 at 5:06 a.m. for a pain level of 0. On 7/17/2026 at 11:30 p.m. for a pain level of 0. On 7/18/2026 at 3:30 a.m. for a pain level of 0. On 7/19/2026 at 9:59 a.m. for a pain level of 0. On 7/20/2026 at 12 a.m. for a pain level of 0. On 7/20/2026 at 11:28 p.m. for a pain level of 0. On 7/26/2026 at 1:25 a.m. for a pain level of 4. On 7/29/2026 at 2:06 p.m. for a pain level of 0. RN 6 stated Resident 21 was able to ask for pain medication by name, but the licensed nurse (LN) should identify the appropriate PRN medication to administer based on the pain scale. RN 6 stated if the resident refuses to give a number, then the LN should notify the physician instead of administering tramadol without the report of the pain scale. RN 6 stated when a resident is administered narcotic pain medication when they are not in pain or for a pain level of zero, there is the potential that the resident would get used to the narcotic and it would be less effective over time when the resident actually needs the medication. During an interview on 7/30/2026 at 8:58 a.m. with LVN 3, reviewed Resident 21's MAR for 7/2026 and stated she (LVN 3) administered PRN tramadol to resident 21 on 7/19/2026 with a documented pain level of zero. LVN 3 stated she did not remember what happened on 7/19/2026. LVN 3 stated Resident 21 usually verbalized the pain score. LVN 3 stated documentation in the MAR is considered accurate, and the resident's pain level was documented as zero. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m. with the Director of Nursing (DON), reviewed the facility policy and procedures (P&P) regarding pain and medication administration. The DON stated the MAR is a tool used by staff and physicians that communicates the resident treatments based on their pain management needs. The DON stated the documentation in the MAR can affect the residents' future treatments and is considered an accurate account of what really happened to a resident. The DON stated when the LN administers PRN tramadol to Resident 21, the LN should follow the physician's orders and administer the medication per the PRN parameters based on the pain scale. The DON stated when Resident 21 reported a pain level of zero, as the MAR indicated, and tramadol was administered for a pain level of 7-10, the tramadol was not administered per the physician's orders. The DON Stated the facility P&P was not followed for Resident 21 potentially resulting in the overuse of narcotics leading to adverse effects or poor pain management over time leading to a decline in the resident. During a review of the facility P&P titled, Pain Assessment and Management, last reviewed 5/20/2026, the P&P indicated, Policy. It is the facility policy to provide pain management to those who require such services, consistent with professional standards of practice, comprehensive care plan , and residents' goals and preferences.This policy applies to those able to self-report pain. Pain Assessment. pain will be assessed. as clinically indicated. Residents capable of self-reporting pain will be encouraged to use a 0-10 severity rating scale. Residents unable to self-report pain will be assessed for non-verbal indicators of pain. Pain Management Interventions. pain management will be individualized and implemented in accordance with practitioner orders, accepted standards of practice. opioids will be prescribed / dosed in accordance with current professional standards of practice . to optimize their effectiveness and minimize adverse consequences. Documentation. Pain assessments. will be documented in medical record. During a review of the facility P&P titled, Procedures for All Medications, last reviewed 5/20/2026, the P&P indicated, Policy. To administer medications in a safe and effective manner. Procedures . L. When administering an as needed (PRN) medication, observe for medication actions/reactions and record on the PRN documentation record. During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . 8. The licensed nursing or medical personnel administering the medication shall check the label at least TWO (2) to THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: . e. Any complaints or symptoms for which the drug was administered. b. During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 6/26/2026 with diagnoses that included aftercare following joint replacement surgery. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 23 required setup or clean-up assistance with eating and oral hygiene. During a review of Resident 23's Physician's Orders, the orders indicated Resident 23 is to receive hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for moderate to severe pain 4-10/10 pain scale, dated 6/26/2026. During a review of Resident 23's CDR, the document indicated the medication Tramadol was removed from the blister pack on the following dates, which had no corresponding documented entries in the MAR: 7/27/2026 at 2:35 a.m. 7/20/2026 at 12 p.m. 7/19/2026 at 12:10 a.m. 7/18/2026 at 9 a.m. 7/17/2026 at 11:45 a.m. 7/10/2026 at 12:38 p.m. During a concurrent interview and record review with the DON on 7/28/2026 at 4:45 p.m., the DON reviewed Resident 23's CDRs and 7/2026 MARS. The DON confirmed there were entries in the CDR for the above dates for the hydrocodone and tramadol but were no corresponding entries in their 7/2026 MARs. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated this is important to ensure there is accountability of controlled medications. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those dates and times. The DON stated it is important to sign the MAR for pain medication to ensure an assessment and reassessment of the effectiveness of the pain medication is completed. The DON stated that without the assessment and re-assessment of resident's pain, the licensed nurses will not know if a resident has pain relief. During a second interview with the DON on 7/29/2026 at 8:03 a.m., the DON reviewed the facility's P&P titled, Controlled Medications, last reviewed 5/20/2026. The DON stated according to the facility's policy the process when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. During a concurrent interview and record review with RN 9 on 7/29/2026 at 1:11 p.m., RN 9 reviewed Resident 23's CDR for hydrocodone 5-325 mg tablet and the 7/2026 MAR. RN 9 confirmed for the dates 7/10/2026 at 12:38 p.m. and for 7/17/2026 at 11:45 a.m., she signed Resident 23's CDR but not the MAR. RN 9 stated she should have documented in both the CDR and MAR but did not. RN 9 stated this was important for accuracy of records and for pain assessment and re-assessment. c. During a review of Resident 132's admission Record, the admission Record indicated the facility admitted the resident on 7/22/2026 with diagnoses that included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 132's Brief Interview for Mental Status (BIMS, an assessment tool to screen and identify memory, orientation, and judgment status of the resident) dated 7/23/2026, the BIMS indicated the resident was severely impaired in cognitive skills required for daily decision making. During a review of Resident 132's Physical Therapy Evaluation, dated 7/23/2026, the evaluation indicated that Resident 132 was dependent on staff for bed mobility and transfers from bed to wheelchair. During a review of Resident 132's Physician's Orders, the orders indicated Resident 132 is to receive hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain 4-10/10 pain scale, dated 7/22/2026. During a review of Resident 132's CDR, the document indicated the medication Tramadol was removed from the blister pack on the following dates, which had no corresponding documented entries in the MAR: 7/25/2026 at 11:30 a.m. 7/25/2026 at 7:30 a.m. 7/24/2026 at 12:15 p.m. 7/24/2026 at 8 a.m. During a concurrent interview and record review with the DON on 7/28/2026 at 4:45 p.m., the DON reviewed Resident 132's CDRs and 7/2026 MARS. The DON confirmed there were entries in the CDR for the above dates for the hydrocodone and tramadol but were no corresponding entries in their 7/2026 MARs. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated this is important to ensure there is accountability of controlled medications. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those dates and times. The DON stated it is important to sign the MAR for pain medication to ensure an assessment and reassessment of the effectiveness of the pain medication is completed. The DON stated that without the assessment and re-assessment of resident's pain, the licensed nurses will not know if a resident has pain relief During a second interview with the DON on 7/29/2026 at 8:03 a.m., the DON reviewed the facility's P&P titled, Controlled Medications, last reviewed 5/20/2026. The DON stated according to the facility's policy the process when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. During a concurrent interview and record review with LVN 1 on 7/29/2026 at 10:20 a.m., LVN 1 reviewed Resident 132's hydrocodone CDR and 7/2026 MAR. LVN 1 confirmed that she signed Resident 132's CDR on 7/24/2026 at 8 a.m. and 12:15 p.m. but did not sign Resident 132's MAR. LVN 1 stated she should have signed both the CDR and MAR. LVN 1 stated this is important so that the next nurse will know when the last medication was given so the resident will not receive too soon or have to needlessly wait for pain relief. LVN 1 stated it is important to sign the MAR because that is where pain is accessed and re-assessed and is important to ensure the resident's pain is relieved. During a review of the facility's P&P titled, Controlled Medications, last reviewed 5/202/2026, the policy indicated the following: When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration. Amount administered. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. Initials of the nurse administering the dose on the MAR after the medication is administered. d. During a review of Resident 124's admission Record, the admission Record indicated the facility admitted Resident 124 on 7/25/2026. During a review of Resident 124's H&P, dated 7/27/2026, the H&P indicated Resident 124 had diagnoses including but not limited to hypertension (HTN-high blood pressure), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and chronic back pain with degenerative disc disease (a condition where the soft cushions (discs) between the spine bones wear out). The H&P indicated Resident 124 had the capacity to understand and make decisions. During a review of Resident 124's Order Summary Report, dated 7/25/2026, the Order Summary Report indicated an order for hydrocodone-acetaminophen (Norco) oral tablet 5-325 mg, give one tablet by mouth every 6 hours as needed for moderate to severe pain (4 - 10 out of 10 pain scale. During a review of Resident 124's Progress Notes (PN), dated 7/26/2026 to 7/27/2026, the PN did not indicate Resident 124 had pain assessments done and documented. During a review of Resident 124's MAR, dated 7/26/2026 and 7/27/2026, the MAR did not indicate Resident 124 was given Norco 5 mg for pain as indicated in the physician orders. During a concurrent interview and record review on 7/27/2026 at 2:57 p.m. with RN 3, the Emergency Kit Pharmacy Log (E-Kit Log), was reviewed. The E-Kit Log indicated two tablets of Norco 5 mg were removed for Resident 124's pain on: During a concurrent interview and record review on 7/27/2026 at 2:57 p.m. with RN 3, the Emergency Kit Pharmacy Log (E-Kit Log), was reviewed. The E-Kit Log indicated two tablets of Norco 5 mg were removed for Resident 124's pain on: 7/26 at 7:50 (did not indicate whether the time was AM or PM) 7/27 at 1:33 (did not indicate whether the time was AM or PM) RN 3 counted the Norco 5 mg tablets and stated the E-Kit had four tablets of Norco 5 mg, originally there were six tablets of Norco 5 mg. During a concurrent interview and record review on 7/27/2026 at 3:07 p.m. with Infection Preventionist Nurse (IPN), Resident 124's MAR, dated 7/25/2026 to 7/27/2026 was reviewed. The MAR did not indicate documentation for pain assessments and administration of Norco 5 mg for Resident 124 on 7/26/2026 and 7/27/2026. During a concurrent interview and record review on 7/27/2026 at 3:10 p.m. with the Director of Staff Development (DSD), Resident 124's MAR, dated 7/26/2026 to 7/27/2026, was reviewed. The DSD stated the MAR did not indicate documentation for pain assessments and administration of Norco 5 mg for Resident 124 on 7/26/2026 and 7/27/2026. During an interview and record review on 7/27/2027 at 3:22 p.m. with RN 3, Resident 124's MAR, dated 7/27/2026, was reviewed. RN 3 stated the administration of Norco 5 mg for Resident 124, the pain assessment prior to pain medication administration and pain reassessment after medication administration for Resident 124 were not documented in the MAR when the interventions were carried out. RN 3 stated the MAR did not indicate documentation of pain assessment and administration of Norco 5 mg on 7/26/2026. During a review of the facility's P&P titled, Pain Assessment and Management, revised 5/20/2026, the P&P indicated, Pain assessments, interventions, monitoring, and responses will be documented in the medical record. During a review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines IIA5: Controlled Medications, revised 5/20/2026, the P&P indicated, the licensed nurse administering a medication immediately documents the accountability record and the MAR, including: Date and time of the administration. Amount administered. Initials of the nurse administering the dose on the MAR after the medication is administered.

Based on interview and record review, the facility failed to follow physician's orders for taking orthostatic blood pressure (blood pressure taken when one is laying in the bed and in a sitting position to see if there is a large discrepancy between blood pressures) when Licensed Vocational Nurse 1 (LVN 1) took orthostatic blood pressure incorrectly for seven times in the months of 6/2026 and 7/2026 for one (Resident 6) of five residents reviewed for unnecessary medication. This deficient practice had the potential for Resident 6 to experience dizziness, lightheadedness, or even fainting when standing up, which can lead to falls and injury.Findings: During a review of Resident 6's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 5/10/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities caused by conditions that reduce or block blood flow to the brain) and vertigo (a type of dizziness defined by a false sensation of motion, spinning, or whirling where the person or their surroundings feel like they are moving when they are not). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 7/14/2026, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff (helper does all of the effort) with eating and personal hygiene. During a review of Resident 6's Physician's Orders, the orders indicated the following: orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from a sitting or lying position, leading to dizziness, blurry vision, or fainting) every week lying and sitting every day shift every Tuesday, dated 5/30/2026. During a review of Resident 6's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the months of 6/2026 and 7/2026, the MARs indicated the following dates in which the lying and sitting blood pressures were exactly the same values: 6/02/2026 6/09/2026 6/23/2026 6/30/2026 7/07/2026 7/14/2026 7/21/2026 7/28/2026 During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 7/29/2026 at 8:15 a.m., LVN 1 reviewed Resident 6's 6/2026 and 7/2026 MARS. LVN 1 confirmed that the above dates were the dates she took Resident 6's blood pressure. LVN 1 stated that the blood pressure values are the same for both lying and sitting positions. LVN 1 stated those days Resident 6 was already in her wheelchair, and she did not ask the resident to lie down in the bed to take a blood pressure. LVN 1 stated she uses the sitting blood pressure value for the lying blood pressure value. When LVN 1 was asked why she does not return later to take the blood pressure, she stated some residents are out of their beds for the entire day, and some residents do not want their orthostatic blood pressure taken. During an interview with Registered Nurse 1 (RN 1) on 7/30/2026 at 8:30 a.m., RN 1 stated the procedure is to take a resident's blood pressure in a lying position, assist them to a seated position, wait one to three minutes and take the blood pressure in the seated position. RN 1 stated if there is a large discrepancy in the blood pressures, then the licensed nurses would notify the resident's physician. RN 1 stated this is procedure is important to ensure a resident does not have orthostatic hypotension and ensure they are not at risk for fall. During an interview with the Director of Nursing (DON) on 7/29/2026 at 12:28 p.m., the DON stated the procedure is to take a resident's blood pressure in a lying position, assist them to a seated position, wait one to three minutes and take the blood pressure in the seated position. The DON stated if there was a difference of 20 millimeters of mercury (mm/Hg, a unit of measure for blood pressure) or greater in the systolic blood pressure (SBP, the top number in a blood pressure reading that measures the force of blood against the artery walls when the heart beats) or ten mm/Hg or greater for the diastolic blood pressure (DBP, the bottom number in a reading, measuring the pressure in the arteries when the heart rests between beats and fills with blood). The DON stated LVN 1 should have taken Resident 6's blood pressure in both lying and sitting positions. The DON stated this is important because this is part of the assessment to see if a resident has orthostatic blood pressure. The DON stated this was important to ensure a resident does not have signs or symptoms of orthostatic hypotension such as dizziness, fainting, and ensure they are not at risk for fall. During a review of the facility's policy and procedure titled, Blood Pressure, Measuring), last reviewed 5/20/2026, the policy indicated the following: -Orthostatic (postural) hypotension is defined as a 20 mm/Hg (or greater) decline in SBP or a 10 mm/Hg (or greater) decline in DBP upon sitting. -To measure orthostatic blood pressure, repeat steps eight (8) through fourteen (14) [steps in taking a blood pressure] immediately after helping the resident to a sitting position. Note the changes in both the systolic and diastolic measurements compared to the reading taken while the resident was in a lying position.

Based on observation, interview, and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (ASP- a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of five sampled residents (Resident 21) reviewed during the Infection Control task when the Infection Preventionist (IP) failed to monitor and include Resident 21's use of methenamine hippurate (a type of antibiotic) in the ASP infection surveillance data. This failure had the potential to place the resident at risk for microbial resistance and reduced resident outcomes.Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2026, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), acute kidney failure (a sudden loss of kidney function), and history of falling. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2026, the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident required partial/moderate (helper does less than half the effort) staff assistance for bathing, dressing, and personal hygiene; and was dependent (helper completes all of the effort for the activity or the assistance of two or more helpers is required to complete the activity) on staff for toileting. During a review of Resident 21's History and Physical (H&P) dated 5/3/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated an order for the following: - Methenamine hippurate oral tablet one gram (gm - a unit of measurement), give one tablet by mouth two times a day for UTI prophylaxis, dated 7/17/2026 with no end date indicated. During a review of Resident 21's Care Plan (CP) regarding methenamine hippurate, initiated 7/17/2026, the CP indicated the resident was on antibiotic therapy as prophylaxis for chronic UTI with interventions that included to administer the medication as ordered and monitor for side effects. During a review of the facility provided Infection Prevention and Control Surveillance Log, dated 7/2026, the report indicated Resident 21 was not included in the ASP surveillance. During a concurrent observation and interview on 7/27/2026 at 9:44 a.m., with Resident 21, in Resident 21's room, observed Resident 21 lying in bed. Resident 21 stated she was not doing well and had a UTI with pelvic and back pain. Resident 21 stated she was taking an antibiotic and it was not working. Resident 21 stated the facility staff stated they were going to start her (Resident 21) on a new antibiotic soon. During a concurrent interview and record review on 7/28/2025 at 2:43 p.m., with the IP, the IP reviewed Resident 21's physician orders, medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2026, and Infection Prevention and Control Surveillance Log dated 7/2026. The IP stated the facility has an ASP to make sure antibiotics are administered appropriately to prevent the misuse of antibiotics that may result in antibiotic resistance. The IP stated she (the IP) keeps track of every antibiotic administered in the facility to track the clinical appropriateness of the medication, ensure the medication is monitored, and ensure they are prescribed with a stop date. The IP stated for every antibiotic administered in the facility; the IP tracks the signs and symptoms of infection, the date of onset, the type of infection, the etiology of the infection, any lab results, and the if the antibiotic meets the criteria for administration. The IP stated if the antibiotic does not meet the criteria, the physician is notified to discontinue the medication. The IP stated Resident 21 was administered methenamine hippurate, an antibiotic, in 7/2026. The IP reviewed the Infection Prevention and Control Surveillance Log and stated the IP overlooked Resident 21's methenamine Hippurate and the resident was not included in the ASP data surveillance, but should have been. The IP stated it was important to include Resident 21's methenamine hippurate in the ASP because all antibiotics, even antibiotics ordered for prophylaxis, should be monitored to ensure the medication was effectively working, there were no side effects, and that it was clinically appropriate. During an interview and record review on 7/30/2026 at 10:32 a.m., with the Director of Nursing (DON), the DON reviewed Resident 21's physician orders, MAR, and the facility policy and procedures (P&P) regarding ASP. The DON stated the ASP is to prevent the unnecessary use of antibiotics that can lead to antibiotic resistance and re-infection in residents. The DON stated it is important to include all antibiotics in the ASP to properly evaluate the continued need for the medication and to ensure that antibiotics are prescribed with an end date to prevent prolonged administration. The DON stated Resident 21's methenamine hippurate is an antibiotic and should have been prescribed with an end date and been included in the IP's infection surveillance but was not. The DON stated the facility P&P was not followed when Resident 21's prescribed methenamine hippurate was not ordered with a stop date or included in the ASP potentially resulting in unmonitored antibiotic usage resulting in resident adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have), that the medication would become less effective, or that the resident would develop resistance to the treatment. During a review of the facility P&P titled, Antibiotic Stewardship Program, last reviewed 5/20/2026, the P&P indicated, POLICY: Establish and implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics while optimizing the treatment of infections. and simultaneously reducing the possible adverse events associated with antibiotic use. This policy is aimed at limiting antibiotic resistance in the post-acute care setting. improving treatment efficacy and resident safety, and reducing treatment-related costs. PROCEDURE: . 2. Accountability: . B. Infection Preventionist (IP) will set standards for the use of antibiotics after reviewing antibiotic trends from the previous quarter and outcome reports. C. ASP team will educate nursing staff to obtain and communicate all pertinent clinical information to the physician to promote appropriate diagnosis and prescribing of antibiotics. D. ASP team will review infections and monitor antibiotic usage patterns on a regular basis. In addition, ASP team will obtain and review results from microbial cultures resistant organisms, alerts and antibiograms from the lab, if provided by the lab. For institutional trends of resistance . F. ASP team will report on number of antibiotics prescribed (e.g., days of therapy) and the number of residents treated each month G. The IP will collect and analyze infection surveillance data and monitor the adherence to the program as well as a separate report for the number of residents on antibiotics that did not meet criteria for active infection and suggest appropriate overall changes to make it a successful well-rounded program . 5. Tracking IP will be responsible for infection surveillance and Multi Drug Resistant Organisms (MDRO) tracking IP will track, collect and review data such as: Type of antibiotic ordered, dose, route of administration, antibiotic costs and prescribing physician. Whether McGeer criteria was met to consider prescribing antibiotics Whether appropriate cultures were obtained before ordering antibiotic Whether appropriate empiric antibiotic was prescribed Whether the antibiotic was changed during the course of treatment Outcome of therapy. During a review of the facility P&P titled, Infection Prevention and Control Program, last reviewed 5/20/2026, the P&P indicated, POLICY STATEMENT: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. POLICY INTERPRETATION AND IMPLEMENTATION: . 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of . surveillance, data analysis, antibiotic stewardship, . 5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: . (3) whether antibiotic usage patterns need to be changed because of the development of resistant strains; (4) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and (5) whether there is appropriate follow-up-of acute infections.

Based on observation, interview, and record review the facility failed to implement and maintain an infection control program by failing to ensure Registered Nurse (RN) 5 performed hand hygiene between providing feeding assistance to two of five sampled residents (Resident 79 and 97) observed during the Dining Observation task. This failure had the potential to spread infectious microorganisms among residents, staff, and visitors from cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one person or object to another with harmful effect). Findings: a.During a review of Resident 79's admission Record, dated 7/30/2026, the admission Record indicated the facility admitted the resident on 11/15/2024 and most recently admitted the resident on 5/22/2026 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the left non-dominant side, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 79's History and Physical (H&P) dated 5/3/2026, the H&P indicated the resident had the capacity to make needs known but not make medical decisions. During a review of Resident 79's Minimum Data Set (MDS - resident assessment tool) dated 5/14/2026, the MDS indicated the resident usually was able to understand others and usually was able to make herself understood. During a review of Resident 79's Care Plan (CP) titled, Impaired nutritional and hydration status. initiated 12/22/2025, the CP indicated a goal that the resident would be able to eat more or equal to 75 percent at mealtime with interventions that included for staff to assist resident during mealtime. b.During a review of Resident 97's admission Record, dated 7/30/2026, the admission Record indicated the facility admitted the resident on 1/27/2020 with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone leading to a slower body metabolism), dysphagia (difficulty swallowing), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 97's H&P dated 3/16/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 97's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. During a review of Resident 97's physician orders, the physician orders indicated a diet order for regular texture, thin liquids consistency. Certified nursing assistants (CNA) must assist resident with cutting up food at meals, dated 9/18/2025. During a Dining observation on 7/27/2026 at 12:40 p.m., observed Resident 79 and Resident 97 sitting at separate tables in Dining room [ROOM NUMBER]. Observed RN 5 pull up a chair and sat next to Resident 97, picked up the resident's previously used utensils and cut the residents remaining chicken into bite sized pieces. Observed RN 5 then put down Resident 97's utensils, stood up, and walked to Resident 79. RN 5 then assisted Resident 79 by opening a sugar packet, removing plastic wrap from the brim of the almond milk, and moving the resident's packet of bread to the right side of the plate. Observed RN 5 did not perform hand hygiene (HH - act of cleaning hands with soap and water or antibacterial hand rub) between providing feeding assistance to the two residents. During a follow up interview on 7/27/2026 at 12:47 p.m., RN 5 stated she provided feeding assistance to Resident 79 and 97 and did not perform HH between the two residents because she forgot to perform HH. RN 5 stated it was important to perform HH between providing feeding assistants to residents to prevent the transfer of bacteria from one resident, their utensils or food, to another residents. RN 5 stated she should have performed HH between providing assistance to Resident 79 and 97 and did not. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding infection prevention and hand washing. The DON stated staff members should provide feeding assistance to one resident at a time and perform HH between residents. The DON stated RN 5 did not follow the facility P&Ps when she provided feeding assistance to Resident 79 and 97 and did not perform hand hygiene between resident assistance potentially resulting in cross contamination between the utensils, food, and residents resulting in illness. During a review of the facility P&P titled, Infection Prevention and Control Program, last reviewed 5/20/2026, the P&P indicated, POLICY STATEMENT: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. POLICY INTERPRETATION AND IMPLEMENTATION: . 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. During a review of the facility P&P titled, Hand Hygiene, last reviewed 5/20/2026, the P&P indicated, Policy:. To maintain the highest standards of infection prevention and control through hand hygiene adherence. Definitions:. 'Hand hygiene' is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: . 1. Staff shall perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene shall be performed under the conditions listed in, but not limited to, the attached hand hygiene reference table. Hand Hygiene Reference Table. Condition. After contact with surfaces or objects in immediate vicinity of patient. Either Soap and Water or Alcohol Based Hand Rub.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors when a breathing treatment medication that was past the expiration date was administered to one of 25 sampled residents (Resident 3). This failure had the potential to receive medication that had become ineffective and may result in Resident 3 experiencing serious complications such as shortness of breath, difficulty breathing, and exacerbation (worsening) of COPD, resulting in potential hospitalization. Findings: During a review of Resident 3's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 7/28/2022 and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/08/2026, the MDS indicated Resident 3 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. During a review of Resident 3's Physician's Orders, the orders indicated the following: -Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated (a medication that relieves inflammation by stopping certain cells in your body from releasing the chemical signals that cause swelling, itching, and mucus production) 100-50 micrograms per actuation (mcg/act, a unit of measure for breathing treatments), one puff inhale orally two times a day for COPD, dated 5/22/2026 and clarified 6/30/2026. -Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 micrograms per actuation one puff inhale orally two times a day for COPD, rinse mouth with water after use, dated 6/30/2026. During a review of Resident 3's 7/2026 Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated Resident 3 received Fluticasone - Salmeterol from 7/01/2026 until 7/28/2026, stopping after the received 9 a.m. dose. During a review of Resident 3's Care Plan for Potential for Airway Obstruction, initiated 5/22/2026, the care plan indicated a goal that Resident 3 will be free from signs/symptoms of respiratory distress. The care plan indicated an intervention to administer medication, breathing treatment and oxygen as ordered. During a medication cart observation and record review with Registered Nurse 8 (RN 8) on 7/28/2026 at 3:33 p.m., reviewed Medication Cart Station One, Cart Two with RN 8. Observed Resident 3's Fluticasone with an open date of 6/23/2026. The Fluticasone box indicated the medication expires in 30 days or when blisters are zero whichever comes first. RN 8 stated the medication should have been discarded after 7/23/2026. RN 8 looked in the medication cart and saw no other Fluticasone medication that was opened on 7/24/2026 or after. RN 8 reviewed Resident 3's 7/2026 MAR and confirmed that Resident 3 received medication from 7/24/2026 until 7/28/2026 for a total of nine doses. During a concurrent interview and record review with the Director of Nursing (DON) on 7/29/2026 at 8:16 a.m., the DON reviewed Resident 3's 7/2026 MAR. The DON stated the licensed nurses should have ordered a new Fluticasone medication so that Resident 3 would not receive after 7/23/2026. The DON stated this is important to follow the manufacturer's instructions to discard after the expiration date to ensure the efficacy of the medication. During a review of the Fluticasone Manufacturer's Recommendations, last revised 12/2024, indicated the following: Safely through away Fluticasone Propionate and Salmeterol inhalation powder in the trash one month after you open the foil pouch or when the counter reads zero, whichever comes first.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses label the intravenous (IV, plastic inserted into the skin so that fluids can be given directly into the blood stream) peripheral (on the arm) insertion dressing per facility protocol for one sampled resident who had a peripheral IV catheter. This failure had the potential for licensed nurses to fail to identify the signs and symptoms of intravenous site insertion complications such as extravasation (the unintentional leakage of fluids or medications from the vein into the surrounding tissue), swelling, and infection in the insertion site.Findings: During a review of Resident 6's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 5/10/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities caused by conditions that reduce or block blood flow to the brain) and hyponatremia (a condition when there is too little sodium in the blood). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment a tool), dated 7/14/2026, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff (helper does all of the effort) with eating and personal hygiene. During a review of Resident 6's Physician's Orders, the Physician's Orders indicated an order for IV fluids: Dextrose 5% in normal saline (D5NS, an intravenous fluid used to supply water, salt, and sugar to the body) 50 cubic centimeters per hour (cc/hr., a metric unit of volume for IV fluids) for two liters (a metric unit of measurement for IV fluids) one time only for increased weakness and variable meal intake for three days, dated 7/26/2026. During a review of Resident 6's Care Plan for Fluid Volume Deficit, initiated 7/26/2026, indicated Resident 6 has increased weakness and variable meal intake. The care plan indicated a goal that Resident 6 will be hydrated. The care plan indicated an intervention to administer fluids as ordered. During an observation on 7/27/2026 at 9:23 a.m., observed Resident 6 in her bed receiving D5NS at 50 cc/hr. as indicated on the Dial-A-Flow (a manual IV flow regulator device built into intravenous tubing to control fluid delivery rates accurately without an electronic pump). Resident 6 had gauze wrapping and elastic net mesh (a type of dressing with the mesh to protect from dirt and accidental removal of the IV) to the right hand. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 7/27/2026 at 9:29 a.m., she removed the gauze wrapping and mesh covering the right hand to expose the IV-insertion site with Tegaderm (transparent, clear covering) covering over the IV canula. RN 1 confirmed that there was no date indicated on the Tegaderm or the gauze wrapping. During a concurrent interview and record review with the Director of Nursing (DON) on 7/29/2026 at 8:28 a.m., the DON reviewed the facility's policy titled, General Policies for IV Therapy, last reviewed 1/15/2026. The DON stated that the facility's policy indicates that the IV peripheral sites will be rotated when clinically indicated (e.g. unresolved complication, discontinuation of IV therapy, or when no longer necessary for the plan of care). The DON stated, although the policy does not explicitly state labeling IV insertion sites in the policy, there should be a date and initials of the registered nurse on the insertion site to ensure that the registered nurses will know when to remove the IV. The DON stated this is important for infection prevention for residents. During a review of the facility's policy and procedure titled, General Policies for IV Therapy, last reviewed 1/15/2/2026, indicated IV peripheral sites will be rotated when clinically indicated (e.g. unresolved complication, discontinuation of IV therapy, or when no longer necessary for the plan of care).

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 4) did not have a loop (unwanted bend) in the urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine). This failure had the potential for Resident 4 to develop catheter associated urinary tract infection ([CAUTI] - an infection of the urinary tract caused by urinary catheter). Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted the resident on 1/8/2026 and readmitted on [DATE] with diagnoses including but not limited to end stage renal disease (ESRD - irreversible kidney failure), chronic pulmonary edema (a long-term condition in which air sacs in the lungs slowly build up with fluid, making it hard to breathe), and diabetes mellitus type two (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool) dated 7/3/2026, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills were intact. The MDS further indicated Resident 4 had a urinary catheter. During a review of Resident 4's Orders report, dated 6/8/2026, the Orders indicated an order for Foley (a type of urinary catheter) Catheter 20 French/10 milliliters (a medium - large sized flexible tube primarily used in adults for both short- and long-term urinary drainage) connected to drainage bag with an indication of use for neurogenic bladder (a lack of urinary bladder control caused by brain, spinal cord, or nerve problems that lead to urine storage and emptying issues). During a review of Resident 4's Care Plan (CP), revised 4/27/2026, the CP indicated the resident was at high risk of developing complications including UTI due to urinary catheter, urinary retention, and neurogenic bladder. The CP indicated interventions to keep tubing free of kinks, and maintain drainage bag below level of the bladder, During a concurrent observation and interview on 7/27/2026 at 11:40 a.m. with Registered Nurse (RN) 5 in Resident 4's room, Resident 4's urinary catheter tubing had a loop filled with stagnant (not flowing to the drainage bag) urine and white sediment. RN 5 stated staff should ensure the tubing has no loops or kinks because urine can backflow and cause UTI. RN 5 stated Resident 4 has multiple health conditions and is at high risk for UTI. During a concurrent observation and interview on 7/30/2026 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 4's room, Resident 4's urinary catheter tubing had a loop filled with stagnant urine and white sediment. LVN 2 stated the urine could be backing up and cause bladder distention (a swollen and stretched bladder because it cannot empty urine properly) and/or infection to Resident 4. During a concurrent observation and interview on 7/30/2026 at 10:15 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 4's room, Resident 4's urinary catheter tubing had a loop filled with stagnant urine and white sediment. CNA 2 stated the urinary catheter tubing was not draining into the catheter drainage bag and could cause UTI to Resident 4. During an interview on 7/30/2026 at 11:26 a.m. with RN 5, RN 5 stated all staff members providing care to Resident 4 should monitor the position of the urinary catheter tubing every time Resident 4 is turned/repositioned and/or incontinence care is provided to ensure the urine is free flowing into the urinary catheter bag. RN 5 further stated staff should review the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) to follow the urinary catheter care intervention orders. During a review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised 5/20/2026, the P&P indicated unobstructed urine flow should be maintained by frequently checking the resident is not lying on the catheter and that the tubing is kept free of kinks.

Based on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT-a group of health care professionals from different specialties who work together to plan, deliver, and review a resident's care in a coordinated way) conducted an assessment and participated in determining whether the self-administration of medications was clinically appropriate for two of four (Resident 125 and Resident 2) sampled residents. This failure had the potential to result in violating the residents' right to self-administer medications and had the potential for the residents to experience adverse effects (an undesired effect of a drug or other type of treatment) from over usage, allergic reactions, ingestion of medications not intended for resident use, or unidentified omission of necessary medications. Cross reference F689.Findings: a.During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 7/21/2026 with diagnoses that included wedge compression fracture (the broken bone collapses, creating a wedge shape) of second lumbar vertebra (second bone from the top in the lower back), history of falls, and hypertension (high blood pressure). During a review of Resident 125's History and Physical (H&P) dated 7/22/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 125's Care Plan (CP) titled, Impaired skin integrity as manifested by: redness., dated 7/21/2026, the CP indicated a goal that the resident's skin would heal with interventions that included to notify the physician for any changes and to do treatment per physician orders. During a review of Resident 125's CP titled, Risk for pain., dated 7/21/2026, the CP indicated a goal that resident would be free from pain with interventions that included to assess for pain and medicate as ordered. During a concurrent observation and interview on 7/27/2026 at 9:17 a.m. with Resident 125, in the resident's room, observed a tube of diclofenac sodium topical gel and a tube of hydrocortisone anti-itch lotion sitting on the resident's bedside rolling table while the resident was unattended by staff. Resident 125 stated he used the hydrocortisone for a rash from the brace that he wore and the diclofenac helped with the pain of his bruises on the legs. During an observation on 7/27/2026 at 9:30 a.m., observed the Certified Nursing Assistant (CNA) 3 entered Resident 125's room and stood at bedside with the hydrocortisone and diclofenac topical medication in view on the bedside rolling table. CNA 3 stated he was not assigned to care for Resident 125 but would find the resident's assigned CNA. Observed CNA 3 exited the resident's room and the medications remained on Resident 125's bedside rolling table. During an observation on 7/27/2026 at 9:37 a.m., observed CNA 4 entered Resident 125's room and stood at bedside with the hydrocortisone and diclofenac topical medication in view on the bedside rolling table. CNA 4 stated he was assigned to care for Resident 125. Observed CNA 4 spoke with Resident 125 and then exited the resident's room and the medications remained on Resident 125's bedside rolling table. During an observation on 7/27/2026 at 1:20 p.m., observed Resident 125 in the room unattended by staff with the hydrocortisone and diclofenac topical medication remained on the bedside rolling. During an observation on 7/27/2026 at 4:04 p.m., observed Resident 125's door was open and the hydrocortisone and diclofenac topical medication remained on the bedside rolling table while the resident was in the facility front lobby. During a concurrent interview and record review on 7/27/2026 at 4:13 p.m., with Licensed Vocational Nurse (LVN) 4, reviewed Resident 125's physician orders. LVN 4 stated she was assigned to care for Resident 125. LVN 4 stated the facility process for residents that want to keep topical medication at bedside to self-administer is the resident needs a physician's order for the medication and needs to be assessed for the ability to safely administer and store the medication. LVN 4 stated it was important to have a physician's order and to document resident applications to ensure the resident did not overuse the medication. LVN 4 stated medications should not be left at bedside on the table because there was also risk that other confused residents may get the medication. LVN 4 then confirmed Resident 125 had diclofenac and hydrocortisone topical medications at bedside without a physician's order. LVN 4 stated she was not aware that Resident 125 was storing diclofenac and hydrocortisone topical medications at bedside, but she should have been. During a concurrent interview and record review on 7/27/2026 at 4:24 p.m., with Registered Nurse (RN) 1, reviewed Resident 125's admission Assessment, CPs, and physician orders. RN 1 stated residents have the right to request to self-administer medications but there is a process to follow. RN 1 stated there was no documented evidence that Resident 125 was assessed for medication self-administration. RN 1 stated when Resident 125 stored diclofenac and hydrocortisone at bedside, the CNA or LN should have identified that the resident wanted to self-administer and ensure there was an assessment and physician order, but they did not. During a concurrent observation and interview on 7/27/2026 at 4:35 p.m. with RN 1 and Resident 125, in the hallway in the presence of the Administrator (ADM), Resident 125 stated nobody explained to him that he could not keep medications at bedside for self-administration. RN 1 stated to Resident 125 that the resident had the right to request to self-administer medications, but they required a physician's order and safe storage. Observed Resident 125 then requested physician's orders for diclofenac, hydrocortisone, and lidocaine patches (adhesive medication used for topical pain relief). During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedures (P&P) regarding self-administration of medications. The DON stated she was made aware that Resident 125 stored diclofenac and hydrocortisone at bedside for self-administration. The DON stated residents have the right to self-administer medication with a self-administration of medication assessment and physician's order. The DON stated it was important to obtain a physician's order for all medications to ensure there are no interactions with other prescribed medications, that the administration is documented in the medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and the medication use is monitored for effectiveness and side effects. The DON stated it was the responsibility of all the staff to make sure medications are not stored at bedside for self-administration and the medication should have been identified and was not. The DON stated the P&P was not followed potentially resulting in Resident 125 not knowing or being able to exercise his right to self-administer, the resident may overuse the medication, or other residents may use medication not intended for them resulting in allergic reactions or other adverse effects. During a review of the facility P&P titled, Resident Rights, last reviewed 5/20/2026, the P&P indicated, Policy Statement: The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 5/20/2026, the P&P indicated, Policy Statement.Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation. 1. Resident who expresses a desire to self-administer medications, as part of the evaluation, the staff and practitioners will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the residents. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the residents: a. Comprehension of the purpose and proper dosage and administration time for his or her medications; b. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication or licensed nurse to prepare meds and resident to self-administer medications. c. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. 4.The staff and practitioner will document their findings and the choices of residents who are able to self administer medications. 5. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 6. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. All medications and treatments shall be administered only by licensed medical or licensed nursing personnel. Medications shall be administered in accordance with the orders, including any required time frame. The licensed nursing/ medical personnel administering the medication shall document his/ her initials on the resident's eMAR after giving medication. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 6/5/2026 with diagnoses that included cirrhosis of liver (permanent scarring that damages the liver [organ that removes toxins from the body's blood supply), hepatic encephalopathy (brain dysfunction caused by liver insufficiency), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastro esophageal reflux disease (GERD- when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of Resident 2's H&P dated 6/6/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/11/2026, the MDS indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated the resident required partial/moderate (helper does less than half the effort) staff assistance dressing and personal hygiene and required substantial /maximal (helper does more than half the effort) assistance for toileting. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following orders: -Apixaban (medication that thins the blood) oral tablet 2.5 milligrams (mg, a unit of measurement) Give one (1) tablet by mouth one time a day for portal vein thrombosis (formation of a blood clot in the veins of the liver) prophylaxis (PPX), dated 6/9/2026. -Ascorbic acid (a dietary supplement) tablet, 500 mg, give 1 tablet by mouth one time a day for supplement, dated 6/6/2026. -Furosemide (medication to treat high blood pressure and fluid retention) oral tablet 40 mg, give 1 tablet by mouth one time a day for hepatic cirrhosis, dated 6/5/2026.gm -Lactulose (laxative medication) oral solution 10 gm/15 milliliters (ml, a unit of measurement) give 30 ml by mouth three times a day for hepatic cirrhosis, dated 6/5/2026. -Multivitamin with minerals (a dietary supplement) tablet, give 1 tablet by mouth one time a day for supplement, dated 6/6/2026. -Ammino acids - protein hydrolysate (a dietary supplement), give 30 mL by mouth one time a day for supplement, dated 6/11/2026. -Xifaxan (a medication that treats bacterial infection in the intestines) oral tablet, 550 mg, give 1 tablet by mouth every morning and at bedtime for Hepatic Cirrhosis, dated 6/5/2026. -Vitamin D3 (a dietary supplement) oral capsule, 125 micrograms (MCG, a unit of measurement), Give 1 capsule by mouth in the morning for supplement, dated 6/5/2026. -Spironolactone (medication that eliminate excess fluid and salt from the body) oral tablet 100 mg, give 1 tablet by mouth one time a day for hepatic cirrhosis, dated 6/6/2026. During a concurrent observation and interview on 7/29/2026 at 8:05 a.m., with LVN 2 and Resident 2, at Resident 2's shared room, observed Resident 2's curtains were drawn and the resident was not visible from the hallway. Observed LVN 2 walk down the hallway from Station 2 towards Resident 2's room. Observed LVN 2's hands were empty when LVN 2 entered Resident 2's room directly ahead of the surveyor. Observed LVN 2 walked past the curtains to Resident 2's bedside where the resident was eating breakfast. Observed a clear medication cup containing tablets and capsules and two clear medication cups containing clear liquid medications. Observed LVN 2 reminded Resident 2 to take the medication and Resident 2 responded that she wanted to eat first, and she promised she would take them like she always does. Observed LVN 2 remained at bedside until Resident 2 agreed to take the medication. During a follow-up interview on 7/29/2026 at 8:12 a.m., with LVN 2, in the hallway outside Resident 2's room, LVN 2 stated the facility process for medication self-administration is to prepare all the medication, observe the resident take the medication, then document the administration in the MAR. LVN 2 stated he prepared and gave Resident 2 all her morning medications and left them at bedside for the resident to take. LVN 2 stated he left the medications for the resident to self-administer because he needed to get something for Resident 2's roommate. LVN 2 stated he should not have left medications in the room with Resident 2 because it was a safety issue because the resident may not take all the medications or another resident may accidentally ingest the medication. During a concurrent interview and record review on 7/30/2026 at 10:32 a.m., with the DON, reviewed the facility P&P regarding self-administration of medications. The DON stated she was made aware that Resident 2 wanted to self-administer her medication. The DON stated residents have the right to self-administer medication with a self-administration of medication assessment and physician's order. The DON stated Resident 2 expressed to LVN 2 that she wanted to self-administer medications so LVN 2 should have had a medication self-administration assessment completed and notified the physician prior to leaving medications at bedside, but he did not. The DON stated the P&P was not followed potentially resulting in Resident 2 not taking all her medications resulting in worsening liver issues or other residents may use medication not intended for them resulting in adverse effects. During a review of the facility P&P titled, Resident Rights, last reviewed 5/20/2026, the P&P indicated, Policy Statement: The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 5/20/2026, the P&P indicated, Policy Statement.Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation. 1. Resident who expresses a desire to self-administer medications, as part of the evaluation, the staff and practitioners will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the residents. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the residents: a. Comprehension of the purpose and proper dosage and administration time for his or her medications; b. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication or licensed nurse to prepare meds and resident to self-administer medications. c. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. 4.The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. 5. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 6. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . During a review of the facility P&P titled, Medication Administration (General), last reviewed 5/20/2026, the P&P indicated, Procedure. To be able to safely administer in a timely manner, and as prescribed; in accordance to nursing scope and practices. Procedure: . Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. All medications and treatments shall be administered only by licensed medical or licensed nursing personnel. Medications shall be administered in accordance with the orders, including any required time frame. The licensed nursing/ medical personnel administering the medication shall document his/ her initials on the resident's eMAR after giving medication.

Based on observation, interview, and record review the facility failed to store medications in accordance with the facility policy and procedure in one of two medications carts (Nursing Station 2, Medication Cart 1 [NS 2 Cart 1) reviewed when: 1. One expired supplement was not discarded. 2. Medications were not stored separately according to administration route. These failures had the potential to increase the risk of residents receiving a supplement that had become ineffective; and cross-contaminated medications due to improper storage, and/or administration route mix-ups.Findings: During an observation on [DATE] at 3:38 p.m. with Registered Nurse (RN) 4 in Nursing Station 2, Medication Cart 1 (NS 2 Cart 1), NS 2 Cart 1 contained: 1. A bottle of Acerola Vitamin C (a tropical fruit vitamin supplement) 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), with expiration date 02/2026. 2. Cyclosporine Ophthalmic Emulsion 0.05% (a prescription eye drop medication) and rewetting eye drops (over-the-counter eye drops), stored in the same compartment with Vitamin B1 tablets for oral administration. 3. Cyclosporine ophthalmic emulsion, fluticasone intranasal spray (a nasal medication used to treat itching, sneezing, running nose, and congestion caused by allergies), and Nervive-Nerve Relief (a dietary supplement used to relief nerve discomfort such as burning, stabbing, or pins and needles in the hands and feet) oral tablets, stored in the same storage compartment. 4. Injectable heparin (a blood thinner medication used to prevent blood clots) stored in the same compartment with albuterol and ipratropium bromide (medications used to open the lung air passages to make breathing easier) solution for nebulizer (a machine that turns liquid medicine into a fine mist that is breathed directly into the lungs). During an interview on [DATE] at 4:00 p.m. with RN 4, RN 4 stated the Vitamin C supplement should have been discarded when it expired because expired supplements may be less effective. RN 4 stated medications for oral administration should have been stored separately from the eye drops and intranasal spray. RN 4 stated injectable heparin should have been stored separately from the nebulizer solutions. RN 4 stated medications should be stored in separate compartments based on the medication administration route, to avoid getting the administration route confused. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, revised [DATE], the P&P indicated: 1. Medications are stored in a safe, secure, and proper manner, following manufacturer's recommendations or those of the supplier. 2. Oral medications are stored separate from external use medications. 3. Intravenous medications are kept separate from oral administered medications.

Based on observation, interview, and record review, the facility failed to: 1. Ensure unopened insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) pens (a pre-filled device used to inject insulin) were stored in the refrigerator and not in the medication cart per manufacture's guidelines for one of one sampled medication cart (Medication Cart 1). 2. Discard one expired insulin injection pen after opening on 2/27/2026 according to the manufacturer's guidelines. These deficient practices had the potential to place residents at risk for ineffective medication.Findings: a. During a concurrent observation and interview on 5/7/2026 at 12:38 p.m., of Medication Cart #1 in Nursing Station 2 with Licensed Vocational Nurse 1 (LVN 1), observed three Humalog insulin (fast-acting insulin) pens in clear zipped bags stored in the top left drawer of Medication Cart #1. LVN 1 stated that the three insulin pens in the clear zipped bags were all new and unopened because there were no documented open dates on them. LVN 1 stated that all unopened insulin pens should be stored in the refrigerator because there is a sticker on the clear zipped bag indicating, Refrigerate until used. During an interview on 5/7/2026 at 4:27 p.m., with the Director of Nursing (DON), the DON stated that unopened insulin pens should not be taken out of the refrigerator until use. The DON stated insulin pens, once opened, should have an open date and are good for 28 days. The DON stated that removing insulin pens too early can reduce insulin efficacy. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, review date 5/27/2025, the P&P indicated that except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated areas. b. During a concurrent observation and interview on 5/7/2026 at 12:30 p.m., of Medication Cart #1 in Nursing Station 2 with LVN 1, observed one Humalog insulin pen in a clear zipped bag with a documented open date of 2/27/2026. LVN 1 stated that the insulin pen should have been discarded. LVN 1 stated that opened insulin pens are good for 28 days and after 28 days, the insulin pen should be thrown out for resident's safety. During an interview on 5/7/2026 at 4:29 p.m., with the DON, the DON stated the insulin pen with a documented open date of 2/27/2026 should have been discarded after 28 days and should not have been given. The DON stated that staff must check the medication carts at the beginning and end of each shift and discard any expired medications. The DON continued to state that she does not know what happened because the pharmacist checks the medication carts every month. During a review of the Humalog insulin pen manufacturer guidelines, the guidelines indicated direct users to throw out the pen 28 days after opening. Manufacturer guidelines direct not to use after expiration date and storage can be in refrigerator before opening.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1.Failing to ensure the kitchen's red sanitation buckets were at the proper concentration for three of three sampled red sanitation buckets. 2. Failing to implement the facility's quaternary ammonium (a class of positively charged chemical compounds used extensively as disinfectants or sanitizers) log policy as evidenced by failing to provide documented evidence of a quaternary ammonium log. These deficient practices had the potential to place 117 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).Findings: a. During a concurrent observation and interview on 5/7/2026 at 8:29 a.m., in the facility's kitchen with the Dietary Supervisor (DS), observed a red sanitation bucket at the food preparation area. Observed the DS testing the red sanitation bucket with a test strip. Observed the test strip not change color. The DS stated that the red sanitation bucket test strip did not change color and resulted in 0 parts per million (ppm - a unit of measurement that describes the concentration of a very dilute substance within a mixture). During a concurrent observation and interview on 5/7/2026 at 8:30 a.m., in the facility's kitchen with the DS, observed a red sanitation bucket at the dish washer area. Observed the DS testing the red sanitation bucket with a test strip. Observed the test strip not change color. The DS stated that the red sanitation bucket test strip did not change color and resulted in 0 ppm. During a concurrent observation and interview on 5/7/2026 at 8:31 a.m., in the facility's kitchen with the DS, observed a red sanitation bucket at the three compartment dishwashing area. Observed the DS testing the red sanitation bucket with a test strip. Observed the test strip not change color. The DS stated that the red sanitation bucket test strip did not change color and resulted in 0 ppm. The DS stated that the test strip should change color and the minimum ppm should be 200 ppm. The DS stated that the sanitation solution should be changed every two (2) hours and as needed if the water is cloudy. The DS stated that it is important to check the ppm of sanitation solutions to make sure that the sanitation solution is effective. b. During an interview on 5/7/2026 at 8:35 a.m., with the DS, the DS stated that the facility does not keep a log of when the sanitation solution is tested for ppm. When asked why, the DS did not answer. The DS stated that a log is important to provide proof that checking the sanitation solution was done. During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, review dated 5/27/2025, the P&P indicated the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. The quaternary solution, used for sanitizing clean work surfaces in the kitchen, will be made according to instructions on the product container or dispensing device set up for the specific quat product. The Food & Nutrition Services worker will place the solution in the appropriate bucket labeled for its contents and will test the concentration of the sanitation solution. The concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 ppm. The replacement solution will be tested prior to usage. Food and Nutrition Services staff will record the readings three times a day, Breakfast, Lunch, and dinner, to document the process was completed. The Quaternary Ammonium Log, or Quat Sanitizer Bucket will be used to record the concentration only.

Based on observation, interview, and record review, the facility failed to follow the facility diet spreadsheet by failing to serve the residents' chef's vegetable of choice as indicated on the facility spreadsheet to be served for lunch on 5/7/2026 for two of three sampled residents (Resident 2 and Resident 3). This deficiency had the potential for Resident 2 and Resident 3 to not receive the nutrition needed and the potential for unintended wight loss. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 5/2/2026 with diagnoses of unspecified sequelae of cerebral infarction (stroke, loss of blood flow to a part of the brain), cardiomyopathy (an enlarged heart), morbid (severe) obesity due to excess calories type two (2) diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's History & Physical (H&P) dated 5/4/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated an order for Consistent Carbohydrate Diet (CCHO - diet for people with diabetes or prediabetes to keep blood sugar levels stable throughout the day)/No Added Salt (NAS). During a review of the facility Diet Spreadsheet for Week 4, Day 26-Thursday, the spread sheet indicated: Lunch- CCHO: Savory Roasted Chicken, Confetti Rice, Chefs Vegetable of Choice, Bread or Roll with Margarine, Lemon Pudding, Choice of Beverage (no sugar added/no juice). During an observation on 5/7/2026 at 12:15 p.m., in Resident 2's room, observed Resident 2's lunch tray. Observed chicken, rice, beets, bread, pudding, and a beverage. During a concurrent observation, interview, and record review on 5/7/2026 at 1:09 p.m., with the Dietary Supervisor (DS), observed Resident 2's lunch tray. The DS stated that Resident 2 was served beets. The DS reviewed the facility's Diet Spreadsheet for Week 4, Day 26-Thursday. The DS stated that Resident 2 is on a CCHO diet and should have been served chef's vegetable of choice, carrots and zucchini. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 1/8/2026 with diagnoses of chronic kidney disease (kidneys are damaged and cannot filter blood properly, allowing waste and fluid to build up in the body), dependence on renal dialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed), morbid obesity due to excess calories type 2 diabetes . During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 4/16/2026, the MDS indicated Resident 3's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was intact. The MDS indicated Resident 3 required supervision or touching assistance from staff with eating and oral hygiene and was dependent on staff with toileting hygiene and personal hygiene. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated an order for renal (diet to manage kidney disease by reducing the workload on the kidneys and minimizing waste buildup in the blood) CCHO. During an observation on 5/7/2026 at 1:01 p.m., in Resident 3's room, observed Resident 3's lunch tray. Observed chicken, rice, beets, bread, peaches, soup, and beverage. During an interview on 5/7/2026 at 1:41 p.m., with the DS, the DS stated that beets should not have been served for CCHO diet and serving beets was a mistake made by the Cook. During an interview on 5/7/2026 at 1:57 p.m., with the Cook, the [NAME] stated that residents on a CCHO diet should have been served carrots and zucchini. The [NAME] stated it was a mistake that Resident 2 and 3 were served beets. The [NAME] stated that she does not know what happened. During an interview on 5/7/2026 at 2:10 p.m., with the Registered Dietician (RD), the RD stated that the [NAME] should have followed the spread sheet for residents on a CCHO diet. The RD stated that it is important to follow the facility spread sheet to make sure residents are provided with the appropriate nutrients and calories. The RD stated that by not following the facility's spreadsheet for residents on a CCHO diet, the residents have the possibility of not receiving the needed nutrition and possibly have elevated glucose levels. During a review of the facility's policy and procedure (P&P) titled, Menu Compliance and Meal Service Accuracy, reviewed date 5/27/2025, the P&P indicated the facility will ensure that all meals prepared and served follow the approved menu cycle, including all substitutions, therapeutic modifications, and portion standards, unless otherwise authorized by the Registered Dietician or Dietary Manager. Dietary staff must prepare and serve meals according to the approved menu cycle. Staff must ensure each tray reflects both the approved menu and the resident's prescribed diet.

Based on interview and record review, the facility failed to ensure that nursing staff have the specific competency and skills set necessary to care for residents' needs, as identified through residents' assessments and plan of care for three of three sampled staff (Certified Nursing Assistant 1 [CNA 1], CNA 2, and CNA 3) reviewed for competency skills check or performance evaluations for colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care. This deficient practice had the potential to place residents with a colostomy at risk of not receiving necessary care and services.Findings: During a concurrent interview and record review on 4/23/2026 at 3:37 p.m., with the Director of Staff Development (DSD), reviewed the facility document titled, Class Attendance Roster, dated 5/22/2025. The DSD stated the facility provides care to residents with a colostomy. The DSD stated that all nursing staff are provided with annual competencies specific to colostomy care to ensure that facility staff are providing quality care for residents who have a colostomy. The DSD stated that an annual skills competency day was conducted in the facility by the facility's cooperate nursing consultant on 5/22/2025. The DSD reviewed the facility document titled Class Attendance Roster, dated 5/22/2025. The Class Attendance Roster indicated course topic: Pressure Injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)/prevention/causes; incontinent care (the involuntary or accidental loss of bladder or bowel control); colostomy/indwelling catheter (a thin, flexible, sterile tube inserted into the bladder to drain urine into a collection bag) care. The DSD stated that all nursing staff (Registered Nurses [RNs], Licensed Vocational Nurses [LVNs], CNAs) attended the annual skills competency on 5/22/2025. During a concurrent interview and record review on 4/23/2026 at 4:44 p.m., with CNA 1, reviewed the facility document titled, Class Attendance Roster, dated 5/22/2025. CNA 1 stated that her signature is not on the roster. CNA 1 continued to state that CNA 1 did not attend the skills competency for colostomy care conducted on 5/22/2025 because she only works part time at the facility. During a concurrent interview and record review on 4/23/2026 at 4:51 p.m., with CNA 2, reviewed the facility document titled, Class Attendance Roster, dated 5/22/2025. CNA 2 stated that her signature is not on the roster. CNA 2 continued to state that CNA 2 did not attend the skills competency for colostomy care conducted on 5/22/2025. CNA 2 further stated that she did not attend the skills competency on 5/22/2025 because she works in the facility part time. During a concurrent interview and record review on 4/23/2026 at 4:55 p.m., with CNA 3, reviewed the facility document titled, Class Attendance Roster, dated 5/22/2025. CNA 3 stated that her signature is not on the roster. CNA 3 continued to state that CNA 3 did not attend the skills competency for colostomy care conducted on 5/22/2025. CNA 3 stated she is not sure if she is allowed to change a resident's colostomy. CNA 3 continued to state that she works 3:00 p.m.-11:00 p.m. and those competency trainings are conducted during the 7:00 a.m.-3:00 p.m. shift. During an interview on 4/27/2026 at 9:00 a.m., with the DSD, the DSD stated that it is important for all nursing staff from all three shifts to attend annual skills competency days because specific skills competencies are conducted to ensure the facility provides continued education for the facility staff. The DSD stated that moving forward, the DSD will be scheduling skills competency days throughout the year so that all nursing staff have the opportunity to attend. During an interview on 4/27/2026 at 4:15 p.m., with the Director of Nursing (DON), the DON stated that annual skills competency are important to be attended by all nursing staff because it is the way to check the knowledge of the facility staff. The DON stated annual skills competency provides the facility the opportunity to re-educate the facility staff on specific skills that will help the facility staff provide quality care to the residents. During a review of the facility's Facility Assessment Tool dated 4/9/2025, the Facility Assessment Tool indicated the facility provides sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care and considered the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment required. Competency evaluation is checked on hire and annually thereafter. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, reviewed 5/27/2025, the P&P indicated all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. In addition, licensed nurses and nursing assistants employed by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. Facility and resident-specific competency evaluations will be conducted upon hire, annually as needed based on the facility assessment. Facility and resident-specific competency evaluations will include: a. Lecture with return demonstration for physical activities; b. Demonstrated ability to use tools, devices, or equipment used to care for residents; c. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform.

Based on observation, interview, and record review, the facility failed to ensure staff were not standing over a resident while assisting with feeding for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's self-esteem, self-worth, and sense of independence.Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 8/15/2022 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (the worsening of a disease or an increase in the severity of its symptoms), heart failure (progressive medical condition where the heart muscle is too weak to pump blood efficiently, failing to meet the body's oxygen needs), and lack of coordination. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 1/7/2026, the MDS indicated Resident 3's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 3 was dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene. During a meal observation on 4/16/2026 at 12:31 p.m., in Resident 3's room, observed Certified Nursing Assistant 1 (CNA 1) assisting Resident 3 with feeding. Observed CNA 1 assisting Resident 3 with feeding, standing over and hovering over Resident 3. During a concurrent observation and interview on 4/16/2026 at 12:32 p.m., with the Infection Preventionist (IP), observed CNA 1 in Resident 3's room, assisting Resident 3 with feeding. The IP stated that CNA 1 is assisting Resident 3 with feeding and is standing over and hovering over Resident 3. The IP continued to state that CNA 1 should be sitting down while assisting Resident 3 for safety and respect. During an interview on 4/16/2026 at 1:21 p.m., with CNA 1, CNA 1 stated that CNA 1 was standing while assisting Resident 3 with lunch. CNA 1 continued to state that she knows she is supposed to sit down on a chair and be eye level with Resident 3 to assist Resident 3 properly for resident's safety and respect. During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity, review date 5/27/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall treat cognitively impaired residents with dignity and sensitivity.

Based on interview and record review, the facility failed to implement their policy on meal service by failing to ensure kitchen staff recorded food temperatures for three meal times on 4/11/2026 (Lunch), 4/12/2026 (Dinner), and 4/15/2026 (Lunch). This deficient practice had the potential to place 117 of 119 in-house residents at risk for foodborne illness (any illness resulting from eating contaminated/spoiled foods).Findings: During a review of the facility's food temperature log dated 4/11/2026, the food temperature log indicated the following missing documentation for lunch:Entree: BlankMechanical Soft (M/S- foods that are soft, moist, and chopped, or ground, to require minimal chewing) Entree: BlankPuree (a texture modified diet that consists of smooth, moist foods that are easy to swallow, food with soft pudding like consistency) Entree: Blank Vegetables: BlankPureed Vegetables: Blank Starch: Blank Pureed Starch: Blank Gravy: Blank Dessert: Blank Milk: Blank Juice: Blank Coffee: Blank During a review of the facility's food temperature log dated 4/12/2026, the food temperature log indicated the following missing documentation for dinner: Entree: BlankM/S Entree: BlankPuree Entree: BlankVegetables: Blank Pureed Vegetables: BlankStarch: BlankPureed Starch: BlankGravy: BlankDessert: BlankMilk: BlankJuice: BlankCoffee: Blank During a review of the facility's food temperature log dated 4/15/2026, the food temperature log indicated the following missing documentation for lunch: Entree: Blank M/S Entree: BlankPuree Entree: BlankVegetables: BlankPureed Vegetables: BlankStarch: BlankPureed Starch: BlankGravy: Blank During a concurrent interview and record review on 4/16/2026 at 12:12 p.m., with the Dietary Supervisor (DS), DS reviewed the facility's food temperature logs for 4/2026. The DS stated that there were no food temperatures documented on Saturday, 4/11/2026 for lunch, on Sunday, 4/12/2026 for dinner, and on Wednesday, 4/15/2026 for lunch. The DS stated that cooks are responsible for checking the temperatures of all food items prior to meal service. The DS continued to state that all food items served should be checked for appropriate temperatures and documented to ensure that all food items served are within food temperature regulations. The DS stated that food temperatures need to be checked to ensure that food temperatures are within food temperature regulation so that facility's residents do not get sick because bacteria can start growing if food is not at the right temperatures. The DS continued to state that it is important for the cooks to document the temperatures checked to show proof that checking temperatures was actually done. During a review of the facility's policy and procedure (P&P) titled, Meal Service, review dated 5/27/2026, the P&P indicated meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature. The Food and Nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer that has been sanitized. The food will be served on trayline at the recommended temperatures and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food.

Based on interview and record review, the facility failed to provide routine biologicals and pharmacy services including administering all drugs per physician's order in accordance with good nursing principles and practices by failing to administer Atorvastatin (medication to help lower cholesterol) and Semglee (glargine insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) on 1/6/2026 at 9:00 p.m. per physician's order for one of three sampled residents. (Resident 1)This deficient practice had the potential to result in health complications due to inconsistent medication levels, leading to decreased therapeutic benefit.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 to the facility on 1/6/2026 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting right dominant side, and unspecified glaucoma (an eye condition that damages the optic nerve [a bundle of over a million nerve fibers that acts as a communication cable, transmitting visual information from the back of the eye to the brain]). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/12/2026, the MDS indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 1 was dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 1's admission Note dated 1/6/2026 timed 7:06 p.m., the admission Note indicated Resident 1 was admitted from the general acute care hospital (GACH). The nurse practitioner and the physician were made aware of the resident's admission and the resident's medication orders were faxed to the pharmacy. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following orders:- Atorvastatin Calcium Oral Tablet 40 milligrams (mg- unit of measurement) give 1 tablet by mouth at bedtime for hyperlipidemia (high cholesterol- when the amount of fat circulating in the bloodstream is high) with start date of 1/6/2026.-Semglee Subcutaneous (under the skin) Solution 100 unit/Milliliter (mL- unit of measurement) Inject 8 units (unit of measurement) subcutaneously (under the skin) at bedtime for diabetes mellitus, with start date of 1/6/2026. During a review of the facility's pharmacy delivery manifest dated 1/7/2026, the delivery manifest indicated that Resident 1's Atorvastatin 40 mg and Semglee wer delivered on 1/7/2026 at 3:22 a.m. During a concurrent interview and record review on 1/2/2026 at 2:35 p.m. with Registered Nurse 2 (RN 2), Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of January 2026 and progress notes were reviewed. RN 2 stated that the facility receives pharmacy delivery of medications three times a day, once every shift. RN 2 stated that Resident 1's Atorvastatin was not administered on 1/6/2026 at 9:00 p.m. RN 2 stated that code 8 was documented for Atorvastatin, indicating the medication not available. RN 2 further reviewed Resident 1's MAR for the month of January 2026 and stated that Resident 1's Semglee 8 units was not administered on 1/6/2026 at 9:00 p.m. RN 2 stated that code 8 was documented for Semglee, indicating medication not available. RN 2 stated that because Resident 1 was admitted on [DATE] at 7:06 p.m., Resident 1's medications had not been delivered on time for the scheduled 9:00 p.m. dose and Resident 1 did not receive his medications as prescribed. RN 2 stated that the charge nurse assigned to Resident 1 should have called Resident 1's physician to inform the physician of the missed doses and clarified whether additional orders were needed. RN 2 reviewed Resident 1's progress notes for 1/6/2026 and stated that there was no documented evidence that Resident 1's physician was made aware that Resident 1 did not receive his Atorvastatin and Semglee 9:00 p.m. dose on 1/6/2026. During a concurrent interview and record review on 2/4/2026 at 2:07 p.m. with the Director of Nursing (DON), Resident 1's MAR and physician orders were reviewed. The DON stated that medication orders for newly admitted residents' order are sent to the pharmacy for dispensing, and once the medications are delivered, the licensed nurses administer the first dose of the medication in accordance with the physician's orders. The DON reviewed Resident 1's MAR for January 2026 and stated that the licensed nurse assigned to Resident 1 on admission should have called the physician to clarify the medication orders, including whether the medications could be initiated the following day after delivery, since the resident was admitted on [DATE] at 7:06 p.m. During a review of the facility's policy and procedure (P&P) titled Provider Pharmacy Requirements, last reviewed on 5/27/2025, the P&P indicated it is the policy of the facility that regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications services and related equipment and supplies. The provider pharmacy agrees to perform the following pharmaceutical services including but not limited to: 3) Providing medications package in accordance with the facilities needs and equipment requirements providing routine and timely pharmacy service 7 days per week and emergency pharmacy service 24 hours per day seven days a week. All other new medication or admission orders as ordered by the physician will be available for administration of the next dose. During a review of the facility's P&P titled Charting and Documentation, last reviewed on 5/27/2025, the P&P indicated All services provided to the resident progress toward the care plan goals or any changes in their residence medical physical functional condition shall be documented in the residence medical record. The medical records should facilitate communication between the interdisciplinary team regarding the residence condition and response to care.

Based on interview and record review, the facility failed to conduct a resident's nutritional assessment within seven (7) days upon readmission for one of four sampled residents (Resident 1), as per the facility's policy and procedure (P&P).This deficient practice had the potential to place the resident at risk for undetected nutritional status and at risk for medical complications related to impaired nutrition.Findings:During a review of Resident 1's admission Record indicated the facility originally admitted the resident on 8/28/2025 and readmitted the resident on 11/27/2025 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/3/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff for activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's physician orders, the physician orders indicated the following orders:- Transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) due to abnormal laboratory results, ordered 9/5/2025 timed at 3:10 p.m.,- Admit Resident 1 to the facility, ordered 9/10/2025 timed at 12:45 p.m.During a review of Resident 1's Weights and Vitals Summary, the Weight Summary indicated the following:- On 8/29/2025, Resident 1 weighed 103 pounds (lbs. - a unit of weight)- On 9/5/2025, Resident 1 weighed 98 lbs.- On 9/11/2025, Resident 1 weighed 98 lbs.During a concurrent interview and record review on 12/3/2025 at 10:20 a.m., with Registered Dietitian 1 (RD 1), reviewed Resident 1's Nutritional Risk Assessments (NRAs) dated 8/29/2025 and 9/22/2025, dietary progress notes from Resident 1's initial admission [DATE]), and Resident 1's Weights and Vitals Summary. RD 1 stated Resident 1's first nutritional assessment was done on 8/29/2025, and the second nutritional assessment was done on 9/22/2025, and no other comprehensive nutritional assessments were done after reviewing the dietary notes. RD 1 stated that Resident 1 lost five (5) lbs. from 103 lbs. (measured on 8/29/2025) to 98 lbs. before being transferred to the hospital on 9/5/2025. RD 1 stated Resident 1 returned to the facility on 9/10/2025 with the same weight of 98 lbs. RD 1 stated in general, a nutritional assessment should be done within seven (7) days of admission and readmission, but Resident 1's nutritional assessment was done on the 12th day of readmission (readmitted on [DATE]; nutritional assessment was done on 9/22/2025).During a concurrent interview and record review on 12/3/2025 at 11:40 a.m., with the Director of Nursing (DON), reviewed Resident 1's NRAs dated 8/29/2025 and 9/22/2025, dietary progress notes from Resident 1's initial admission [DATE]), and Resident 1's Weights and Vitals Summary. The DON stated that Resident 1 had a gastrostomy tube (G-tube - a soft tube placed through the belly wall directly into the stomach, creating a shortcut for food, fluids, and medicine when someone can't eat or drink normally through their mouth due to swallowing issues) and lost five (5) lbs. from 103 lbs. to 98 lbs. at the facility before being transferred to the hospital on 9/5/2025. The DON further stated that when Resident 1 returned to the facility, after five (5) days of hospitalization, on 9/10/2025, Resident 1 weighed 98 lbs. The DON stated that the comprehensive nutritional assessment should be done within seven (7) days of readmission to assess Resident 1's nutritional conditions, but it was not done in a timely manner and was done on the 12th day of readmission on [DATE].During a review of the facility's P&P titled, Nutrition & Weight Management Policy, last reviewed 10/2025, the policy indicated, The facility provides care and services to each Resident to ensure the Resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A comprehensive nutritional assessment shall be completed by a Dietitian within seven (7) days of admission, annually, and upon significant change in condition. Follow up assessments be completed as needed.During a review of the facility's P&P titled, Weight Change Protocol, last reviewed 6/2025, the policy indicated, The following criteria define weight changes significant or insidious weight changes: Slow and progressive weight change trending away from weight goal. This can refer to weekly or monthly weight. Five (5) lbs. weight loss or gain in one (1) month. The Facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions within seven (7) days of admission or re-admission. Goals. Consider possible negative health effects from the weight change and the discussion of this with the resident or decision maker.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for three of seven residents (Residents 62, 120, and 83) observed during medication pass by failing to ensure:1. Licensed Vocational Nurse (LVN) 4 pulled the curtain closed when checking Resident 62's blood sugar and during administration of insulin (a natural hormone that turns food into energy and manages your blood sugar level) via injection.2. Registered Nurse (RN) 4 pulled the curtain closed or shut the door to the hallway while administering oral medications to Resident 120.3. Registered Nurse (RN) 4 fully pulled the curtain closed while checking Resident 83's blood pressure and administering oral medications and eyedrops.This deficient practice violated Residents 62, 120, and 83's right to be treated with respect and dignity and had the potential to affect the residents' sense of self-worth and self-esteem.Findings: 1. During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted the resident on 10/19/2024 with diagnoses including muscle weakness and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood) During a review of Resident 62's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/04/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 62 was independent in performing activities of daily (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a review of Resident 62`s physician`s orders dated 10/19/2024, the physician`s order included an order for Humulin (a short-acting insulin used to help manage blood sugar levels in individuals with type 1 or type 2 diabetes) R Injection Solution 100 Unit/milliliter as per sliding scale (one way to determine how much insulin to take before each meal.). During a concurrent medication pass observation and interview on 07/29/2025 at 4:39 p.m., observed LVN 4 enter Resident 62`s room, where the resident was sitting in her wheelchair with the privacy curtain open, visible from her roommates and from the hallway. LVN 4 proceeded to take the resident`s blood sugar by fingerstick ( a common method for monitoring blood glucose levels, especially for individuals with diabetes. It involves pricking the fingertip with a lancet to obtain a small blood sample, which is then applied to a test strip and read by a glucose meter), without drawing the privacy curtain. LVN 4 then went back to the medication cart and prepared the insulin injection and went back to the resident`s room and administered the insulin injection without drawing the privacy curtain around Resident 62’s bed. When LVN 4 was asked if the resident’s dignity and privacy were maintained during the blood sugar checks and medication administration, LVN 4 stated that she should have provided privacy to the resident by drawing the curtain. LVN 4 stated not providing privacy to the resident could result in the resident feeling embarrassed and exposed. During a review of the facility`s policy and procedures titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures…” 2. During a review of Resident 120’s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 120’s Physician Progress Note dated 3/12/2025, the Physician Progress Note indicated the resident can make his needs known but cannot make medical decisions. During a review of Resident 120’s Minimum Data Set (MDS – a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 120 had moderate cognitive impairment (has trouble thinking, learning, and remembering clearly). The MDS further indicated Resident 120 was dependent on staff to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 8:47 a.m. with RN 4 at Resident 120’s bedside, RN 4 administered oral medications to Resident 120 while he was in bed. RN 4 did not pull Resident 120’s privacy curtain around his bed or shut the door to his room leaving Resident 120 visible inside his shared room and from the hallway while getting the resident’s medications. 3. During a review of Resident 83’s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, epilepsy (a brain disorder that causes seizures) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 83’s History and Physical (H&P) dated 10/4/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 83’s MDS, dated [DATE], the MDS indicated Resident 83 was cognitively intact (can think, learn, and remember clearly). The MDS further indicated Resident 83 was independent for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 9:00 a.m. with RN 4 at Resident 83’s bedside, RN 4 checked Resident 83’s blood pressure while he was in bed. RN 4 then administered oral medications, and eye drops to Resident 83 while he was in bed. RN 4 did not pull Resident 83’s privacy curtain around his bed leaving Resident 83 exposed to a common area at the foot of his bed inside his shared room. During an interview on 7/29/2025 at 9:28 a.m. with RN 4, RN 4 stated she should have pulled the privacy curtain around the residents while providing care and giving medications. RN 4 stated the residents should have their curtains pulled around them when getting care because they have a right to privacy and it is important for their dignity. During an interview on 7/31/2025 at 2:48 p.m. with the Director of Nursing (DON), the DON stated residents should be provided privacy when getting their blood pressure checked. The DON stated if a resident is exposed to the hallway while getting medications they should have privacy. The DON stated the purpose of closing the curtain is because of dignity issues and to provide privacy if the resident wants it. During a review of the facility`s policy and procedure (P&P) titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures….”