Every finding on record at Bonita Hills Post Acute

Based on interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1 had a physician's order for podiatry appointment on 1/5/26. This failure had the potential for the resident to not receive the necessary care and services to maintain their highest physical well-being and potentially delay the necessary care and treatment.Findings: Review of the facility's P&P titled Transportation revised 1/23/24, showed the facility shall help arrange transportation for residents as needed. The Policy Explanation and Compliance Guidelines section showed the social services will help the resident as needed to obtain transportation. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The Policy Explanation and Compliance Guidelines showed the licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Closed medical record review for Resident 1 was initiated on 1/23/26. Resident 1 was admitted to the facility on [DATE], and discharged on 1/5/26. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 1's Progress Note dated 1/5/26, showed the resident walked out of the facility to the bus stop. Resident 1 stated she had an appointment and was leaving the facility. The bus picked up the resident from the facility, the physician was made aware. Review of Resident 1's Order Summary Report dated 1/23/26, failed to show a physician's order was obtained for a podiatry appointment on 1/5/26. On 1/28/26 at 1318 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with RN 2. RN 2 stated the licensed nurse would put the order for an appointment on behalf of the physician and find out if the resident needed transportation and a companion. RN 2 verified there was no physician's order for Resident 1's podiatry appointment on 1/5/26. RN 2 stated there should be an order for the resident's appointment for all the department personnel to be aware to see and coordinate, and for the resident not to miss the appointment. On 1/28/26 at 1522 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the Social Services Assistant. The Social Service Assistant stated Resident 1 scheduled her podiatry appointment on 1/5/26 at 1500 hours. The Social Services Assistant verified Resident 1 would need a physician's order to go to the appointment. On 1/28/26 at 1545 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified there was no physician's order for Resident 1's appointment for podiatry on 1/5/26, and acknowledged the Social Services Assistant knew Resident 1 had an appointment. The DON stated there should have been an order for Resident 1's podiatry appointment so everybody would know the appointment. On 1/28/26 at 1629 hours, a telephone interview was conducted with RN 1. RN 1 further stated she could not recall if the Social Services Assistant told her about Resident 1's podiatry appointment on 1/5/26. RN 1 further stated if there was an appointment for any resident, she usually put the physician's order in the electronic medical record, printed it, and gave it to the social services. RN 1 stated the physician would usually write the appointment in the physician's order. On 1/28/26 at 1659 hours, the DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was followed for one of five sampled residents (Resident 1). * The discharge section of the Resident's Clothing and Possessions form for Resident 1 was not completed. This failure had the potential to affect the ability of the resident or resident's responsible party to be informed of their belongings.Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/19/22, showed it is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The Policy Explanation and Compliance Guidelines showed the licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Closed medical record review for Resident 1 was initiated on 1/23/26. Resident 1 was admitted to the facility on [DATE], and discharged on 1/5/26. Review of Resident 1's Resident's Clothing and Possessions form dated 12/12/25, showed two sections on the form. The bottom section showed On Admission with various types of items the resident brought with them on admission. The top section of the form showed On Discharge. The On Discharge section showed a slash across the form with the words discharge AMA. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 1/28/26 at 1047 hours, an interview and concurrent closed medical document review for Resident 1 was conducted with CNA 5. CNA 5 verified Resident 1's Resident's Clothing and Possessions form showed the On Discharge section of the form was incomplete. CNA 5 stated Resident 1's belongings should have been counted and sorted by the licensed nurse or a CNA and placed in the bag with Resident 1's name. CNA 5 stated the licensed nurse or CNA should have given the resident's belongings to the social services. On 1/28/26 at 1318 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with RN 2. RN 2 verified Resident 1's Resident's Clothing and Possessions form was incomplete. RN 2 stated the licensed nurse or the CNA team lead should have filled the form to make sure there were no items missing. On 1/28/26 at 1545 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON acknowledged the above findings. The DON stated Resident 1's Resident's Clothing and Possessions form should have been filled out when the staff packed everything. The DON stated whoever packed the belongings should have specified the items on the form so the facility would have an accurate account of Resident 1's belongings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 1's physician was notified when Resident 1's urine color changed from yellow to dark amber. This failure had the potential for not providing the necessary care and services when the resident had a change in condition. Findings: Review of the facility's P&P title Notification of Changes revised dated [DATE], showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's progress note dated [DATE], showed a nursing entry regarding Resident 1's dark colored urine output. However, further review of Resident 1's medical record failed to show if Resident 1's physician was notified when Resident 1 had dark colored urine output. On [DATE] at 1445 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated at the beginning of her shift on [DATE], she assessed Resident 1's urine color, which was yellow and clear. However, at the end of the shift LVN 1 observed Resident 1 had dark amber colored urine. LVN 1 stated she documented her observation on the resident's progress notes but did not report the resident's change in condition to the physician. LVN 1 stated she should have reported the change in the color of the urine of the resident to Resident 1's physician. LVN 1 verified there was no documentation to show Resident 1's physician was notified of Resident 1's dark amber colored urine. On [DATE] at 0937 hours, an interview was conducted with the PA . The PA was asked if he was notified of Resident 1's dark colored urine on [DATE]. The PA stated he could not recall if he was notified or not. The PA stated if he was notified then it would be documented in the Resident 1's medical record. On [DATE] at 1530 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified there was no documented evidence to show Resident 1's physician was notified about the resident's dark colored urine on [DATE]. The DON was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of three sampled residents (Resident 1). * The facility failed to ensure the medications were administered as ordered by the physician for Resident 1. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications. Findings: Review of the facility's P&P title Medication Administration revised [DATE], showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's MAR for [DATE] showed two tablets of Tylenol (medication to treat pain and/or fever) was administered to Resident 1 on [DATE], for a temperature of 99 degrees Fahrenheit. Review of Resident 1's Order Summary Report dated [DATE], showed a physician's order dated [DATE], to administer acetaminophen (Tylenol-medication to treat pain and/or fever) 325 mg two tablets via GT every six hours as needed for fever, if the temperature was greater than 100.5 Fahrenheit. On [DATE] at 1445 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified Resident 1 was administered two tablets of Tylenol 325 mg medication on [DATE], for a temperature of 99 degrees Fahrenheit. On [DATE] at 1257 hours, an interview and concurrent closed medical record for Resident 1 was conducted with the QA Nurse. The QA Nurse was informed and verified LVN 1 failed to follow the physician's order when LVN 1 administered two tablets of the Tylenol medication to Resident 1 for a temperature of 99 degrees Fahrenheit. On [DATE] at 1530 hours, an interview was conducted the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed in the kitchen when: * Pasteurized eggs were not available for one resident (Resident 62) who requested fried over easy eggs daily with breakfast. * Four fry pans were not clean and had excessively worn surfaces.* Three steam table pans were stacked and stored wet.* One food prep sink did not have a backflow prevention. * Four cereal bins were outdated. These failures had the potential to cause food borne illnesses in a highly susceptible resident population who received food prepared in the facility kitchen. Findings: Review of the facility's matrix dated 8/5/25, showed 62 residents were on an oral diet. 1. Review of the facility P&P titled Egg Cookery and Storage revised 5/2020 showed the food and nutrition department should ensure that eggs are prepared in a manner to preserve quality, maximize nutritional retention and to be free of salmonella. Do not use raw eggs as an ingredient in the preparation of uncooked, ready-to-eat menu items unless using pasteurized eggs. Pasteurized eggs should be substituted for such items as scrambled eggs, omelets, French toast. During the initial tour of the kitchen on 8/5/25 at 0820 hours, an observation of Refrigerator A and concurrent interview was conducted with the DSS. One opened case of shell eggs labeled SEFS (California Shell Egg Food Safety) Complaint eggs were observed. The DSS stated the shell eggs were used for fried egg requested by the residents. When asked if the SEFS eggs were pasteurized, the DSS stated the food purveyor told him the SEFS eggs were pasteurized. On 8/5/25 at 0956 hours, a follow-up interview was conducted with the DSS. The DSS provided the invoice for the shell eggs dated 7/21/25, which showed the shell eggs were not pasteurized. The DSS stated he would try to purchase pasteurized eggs from a different purveyor. On 8/5/25 at 1542 hours, an interview was conducted with the DSS and RD. The DSS shared an email from a purveyor which stated pasteurized eggs would be delivered to the facility on 8/6/25 at 0500 hours. The DSS stated there were residents who requested fried eggs every morning. Medical record review for Resident 62 was initiated on 8/5/25. Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's physician's order dated 6/11/25, showed an order for a regular texture CCHO (carbohydrate controlled) diet. Review of Resident 62's breakfast meal ticket dated 8/6/25, showed Resident 62 preferred over easy fried eggs with breakfast. On 8/6/25 at 1052 hours, an interview was conducted with Resident 62. Resident 62 was alert and oriented. Resident 62 verified she preferred two over easy fried eggs every morning with breakfast. On 8/7/25 at 0930 hours, an interview was conducted with the RD. The RD was asked about her oversight of the kitchen. The RD stated the pasteurized eggs should always be available. When asked if the RD had checked to ensure pasteurized eggs were available as part of her monthly kitchen audit, she stated the pasteurized eggs were not included in the monthly audit of the kitchen. 2. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils A. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. B. The food-contact surfaces of cooking equipment and pans shall be free of encrusted grease deposits and other soil accumulations. On 8/5/25 at 0820 hours, during the initial tour of the kitchen, an observation of multiple fry pans and concurrent interview was conducted with the DSS. Four fry pans were observed with a greasy, black residue and food debris on the cooking surfaces. The DSS verified the findings and stated he would replace the fry pans. 3. Review of the facility's P&P titled Dry Storage- Dishes and Utensils revised 2/1/12, showed the dishes must be stored and to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. On 8/5/25 at 0820 hours, during the initial tour of the kitchen, an observation of three small steamtable pans and concurrent interview was conducted with the DSS. Three small steamtable pans were observed stacked together with water residue between the pans. The DSS verified all the equipment should be air dried. 4. According to the USDA Food Code 2022 Section 5-402.11 Backflow Prevention (A) .A direct connection may not exist between the sewage system and a drain originating from equipment in which food, .is placed. On 8/5/25 at 0950 hours, an observation of a food preparation sink located next to the dish machine and concurrent interview was conducted with the Maintenance Director. The food preparation sink drainpipe was plumbed directly into the wall. When asked if the food preparation sink had an air gap, the Maintenance Director verified the food preparation sink had no air gap. 5. Review of the facility P&P titled Dry Storage Chart revised 4/6/22, showed dry cereal, once opened was good for two to three months at a temperature of 70 degrees Fahrenheit (F). On 8/5/25 at 0820 hours, during the initial tour of the kitchen, an observation of the dry storeroom and concurrent interview was conducted with the DSS. The thermometer located in the dry storeroom read 90 degrees F. Four plastic bins containing dry cereal were observed with a use by date of 8/1/25. The DSS stated the cereal was good for three months once opened. The DSS verified the findings and stated the cereal would be discarded.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure accurate controlled medication records for one nonsampled resident (Resident 87). * Resident 87's MAR for October and November 2024 failed to show the Oxycodone/APAP (a controlled pain medication) documented on the Antibiotic or Controlled Drug Record were administered to the resident when the medication was removed from the medication supply. This failure resulted in inaccurate accounting of a controlled medication and the potential for drug diversion. Findings: Closed medical record review for Resident 87 was initiated on 8/8/25. Resident 87 was readmitted to the facility on [DATE], and discharged on 11/25/24. Review of Resident 87's Antibiotic or Controlled Drug Record for Oxycodone/APAP (a controlled pain medication) 5-325 mg tablets initiated on 10/28/24 at 1853 hours, showed the following:- On 10/31/25 at 1330 hours, one tablet was removed from the medication supply.- On 11/4/24 at 1030 hours, one tablet was removed from the medication supply.- On 11/22/24 at 0811 hours, one tablet was removed from the medication supply.- On 11/22/24 at 0900 hours, one tablet was removed from the medication supply. Review of Resident 87's MARs for October and November 2024 failed to show documentation if the above tablets were administered to the resident to account for why the tablets were removed from the medication supply. On 8/8/25 at 1011hours, an interview and concurrent closed medical record review for Resident 87 was conducted with the DON. The DON verified the above findings. The DON stated when the controlled medications were removed from the supply, they should be documented on the Antibiotic or Controlled Drug Record and on the MAR to show it was administered to the resident.

Based on interview, medical record review, and facility P&P review, the facility failed to clarify and follow up regarding the residents' rights to formulate the advance healthcare directives for two of six final sampled residents (Residents 28 and 85) reviewed for advance directive. * The facility failed to ensure Resident 28 and 85's information about advance directive were accurate. In addition, the facility failed to obtain a copy of Resident 28 and 85's advance directive to be placed in the residents' medical record. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directive dated 12/19/22, showed the following:- On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. Should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.- The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 1. Medical record review for Resident 28 was initiated on 8/5/25. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28' s POLST ( Physician Orders for Life-Sustaining Treatment) dated 5/7/25, under section D Information and Signatures, showed Resident 28 had no advance directive. Review of Resident 28's Advance Directive Acknowledgement form date 5/5/25, showed Resident 28 had executed an advance directive. Further review of Resident 28's medical record failed to show documented evidence of Resident 28's copy of the advance directive. 2. Medical record review for Resident 85 was initiated on 8/5/25. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85' s POLST dated 7/21/25, under section D Information and Signatures, showed Resident 85 had no advance directive. Review of Resident 85's Advance Directive Acknowledgement form date 7/27/25, showed Resident 85 did not executed an advance directive. On 8/11/2025 at 0913 hours, an observation and concurrent interview was conducted with Resident 85. Resident 85 was observed in bed eating breakfast. Resident 85 was asked if she had an advance directive. Resident 85 stated she had an advance directive and she formulated the advance directive when she was admitted at the facility before. Resident 85 stated her daughter had the copy of the advance directive. Resident 85 was asked if she provided a copy to the facility, she stated she did not remember. On 8/11/2025 at 0933 hours, a telephone interview was conducted with Family Member 1. Family Member 1 was asked about Resident 85's advance directive. Family Member 1 verified and acknowledged Resident 85 had an advance directive. Family Member 1 stated her mother was in and out of the facility and she had formulated an advance directive before. When asked if the facility staff had asked her about the advance directive, Family Member 1 stated no. Family member 1 added if the facility asked for the advance directive, she could give them a copy. On 8/11/2025 at 0959 hours, an interview and concurrent medical record review for Residents 28 and 85 was conducted with the SSD. The SSD was informed about Residents 28 and 85's advance directive documentation information and the conflicting information on the residents' medical record. The SSD verified and acknowledged he was not aware about the conflicting information about the advance directive of Residents 28 and 85. On 8/11/2025 at 1139 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 28, 65, and 69) reviewed for unnecessary medications were monitored for the identified manifested episode of behavior and provided with the non-pharmacological interventions for the use of psychotropic medications. * The facility failed to ensure Resident 28's target behavior for the use of the mirtazapine (antidepressant) was monitored accurately. In addition, the facility failed to ensure Resident 28's monthly behavior monitoring summary was completed for the use of the antidepressant medication. * The facility failed to ensure Resident 65 received accurate monitoring for the behavioral episodes and provided with the appropriate non-pharmacological interventions while being administered the Remeron (antidepressant), Risperdal (antipsychotic), and Trazodone (antidepressant) medications. Additionally, the facility failed to provide the monthly behavior monitoring summaries for June and July 2025 for the Risperdal and Trazodone medications. * The facility failed to ensure Resident 69's medical record showed the physician's clinical rationale for continuing the PRN Ativan (antianxiety) medication beyond a 14 day treatment period. In addition, the facility failed to implement the non-pharmacological interventions and complete the monthly behavior monitoring summary for the resident's Ativan use. These failures had the potential to negatively impact the residents' health outcomes and well-being.Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) dated 3/17/25, showed the psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. 1. Medical record review for Resident 65 was initiated on 8/5/25. Resident 65 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 65's Order Summary Report dated 8/6/25, showed a physician's order dated 6/30/25, to monitor the Remeron medication for depression manifested by poor PO intake, and record the number of times the behavior was manifested every shift. Review of Resident 65's Monitor Record form for July 2025 showed the following entries for the Remeron medication for depression manifested by poor PO intake: - on 7/2/25, from 2300 to 0700 hours, the documentation was left blank. - on 7/4/25, from 0700 to 1500 hours, the documentation was left blank. - on 7/6/25, from 0700 to 1500 hours and from 1500 to 2300 hours, the documentation was left blank. Review of Resident 65's Follow-Up Question Report dated 8/6/25, showed the following specific resident intake percentages: - on 7/5/25 at 0800 hours, 7/9/25 at 1309 hours, 7/10/25 at 1109 hours, 7/14/25 at 1438 hours, 7/15/25 at 1217 hours, and 7/16/25 at 1323 hours: 40%; - on 7/8/25 at 1132 hours: 35%; - on 7/21/25 at 1249 hours and 7/22/25 at 1105 hours: 20%; - on 7/22/25 at 2110 hours: 25%; - on 7/24/25 at 2234 hours: 10%; and - on 7/30/25 at 1246 hours: 30%. b. Review of Resident 65's Order Summary Report dated 8/6/25, showed a physician's order dated 5/15/25, to monitor the risperidone medication for schizophrenia manifested by auditory hallucinations (hearing voices), and record the number of times the behavior is manifested every shift. Review of Resident 65's Psychopharmaceutical Summary Sheet for the risperidone medication showed: - on 5/25/25, one episode of the behavior was documented. However, there was no documentation for the number of episodes of manifested behavior for June and July 2025. c. Review of Resident 65's Order Summary Report dated 8/6/25, showed a physician's order dated 6/20/25, to monitor the trazodone medication for depression manifested by verbalizations of inability to sleep, and record the number of times the behavior is manifested every shift. Review of Resident 65's Psychopharmaceutical Summary Sheet for the trazodone medication showed: - on 5/25/25, zero episodes were documented. However, there was no documentation for the number of episodes of manifested behavior for June and July 2025. On 8/6/25 at 0945 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 was asked how he monitored the residents for the use of the Remeron medication. LVN 3 stated the licensed nurses counted an episode of poor PO intake when a resident consumed less than 30% of the meal. LVN 3 stated the CNAs documented the percentage of the residents' meal intake, and the licensed nurses would count one episode if the resident ate less than 30%. LVN 3 was asked if Resident 65 had verbalized any auditory hallucinations or reported hearing voices to the facility staff. LVN 3 stated Resident 65 had not verbalized auditory hallucination or hearing voices during his shift. In addition, LVN 3 stated the resident had not reported having trouble sleeping during his shift. On 8/6/25 at 1000 hours, an interview was conducted with CNA 7. CNA 7 was asked when she would consider Resident 65 to have poor PO intake. CNA 7 stated she would report to the licensed nurse if Resident 65 ate less than 50% of the meal. CNA 7 verified Resident 65 had a episodes of eating less than 50% of the meal, as documented above. On 8/6/25 at 1015 hours, an interview and concurrent medical record review was conducted with the Quality Assurance Nurse (QA Nurse). When asked, the QA Nurse stated the licensed nurses monitored and documented for the poor PO intake episode when the residents' meal intake was less than 50%. When asked how the licensed nurses monitored for the residents' poor PO intake, the QA Nurse stated the CNAs documented the residents' meal intake for breakfast, lunch, and dinner, and the licensed nurses reviewed the CNAs' documentation and recorded the episodes on the residents' Monitoring Record form. The QA Nurse reviewed Resident 65's Follow-Up Question Report dated 8/6/25, and stated the licensed nurses should have documented all the episodes where the resident's meal intake was less than 50% on Resident 65's Monitor Record form. The QA Nurse verified the CNAs' documentation (Follow-Up Question Report) for the resident's meal intake did not match the behavior monitoring form for the use of the Remeron medication. In addition, the QA nurse was asked if there was documentation to show the non-pharmacological interventions were provided prior to the use of Remeron, trazodone, and Risperdal medication but the QA Nurse was unable to provide the documentation. The QA Nurse stated there was no monthly behavior monitoring summary for June and July 2025 for the trazodone and risperidone medications, and no monthly behavior monitoring summary for July 2025 for the Remeron medication. The QA Nurse verified the above findings. On 8/6/25 at 1240 hours, an interview was conducted with RN 1. RN 1 stated the licensed nurses documented an episode of poor PO intake when the residents' meal intake was less than 60%. On 8/7/25 at 1140 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 69 was initiated on 8/5/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's physician's orders showed the following:- dated 7/11/25, to administer Ativan 0.5 mg via GT every six hours PRN for anxiety manifested by the inability to relax, with an order duration of 14 days.- dated 7/30/25, to administer Ativan 0.5 mg via GT every six hours PRN for anxiety manifested by the inability to relax, with an order duration of 14 days. Review of Resident 69's MAR for July and August 2025 showed the following:- Resident 69 received 28 doses of the Ativan medication in July 2025.- Resident 69 received 12 doses of the Ativan medication in August 2025. Further review of Resident 69's medical record failed to show the physician's clinical rationale for continuing the Ativan medication beyond the 14-day period, the monthly behavior monitoring summary for the targeted behavior of the Ativan medication for July 2025,and if the non-pharmacological interventions were implemented prior to administering PRN Ativan medication. On 8/7/25 at 1437 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 69's medical record and verified the resident's medical record failed to show the physician's rationale for the continued PRN Ativan use, July's monthly behavior monitoring summary for the targeted behavior, and if the non-pharmacological interventions were attempted prior to administering PRN Ativan. 3. Medical record review for Resident 28 was initiated on 8/6/25. Resident 28 was admitted to the facility on [DATE], with a diagnosis of depression. Review of Resident Order Summary Report dated 8/7/25, showed the following physician's orders: - dated 6/3/25, and discontinued on 8/6/25, to administer mirtazapine 0.5 mg tablet by mouth at bedtime for depression manifested by poor intake less than 50% of each meal. - dated 6/3/25, to monitor poor intake less than 50% of meals and record the number of times the behavior was manifested every shift. Review of Resident 28's Nutrition Amount Eaten record for the last 30 days showed on 7/10, 7/11, 7/18, 7/22, 7/26, 7/27, 7/28, 8/2, 8/4, and 8/5/25, Resident 28 consumed less than 50% of his meals. Review of Resident 28's Monitor Record form from 7/1 to 7/31/25, showed the monitoring of the poor intake less than 50% of meals showed zero number of times the behavior manifested every shift. Further review of Resident 28's medical record failed to show documented evidence the monthly behavior monitoring summary was completed for the mirtazapine medication. On 8/7/25 at 1043 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified and acknowledged Resident 28 was on an antidepressant medication and was monitored for poor intake less than 50% of the meals. RN 1 was asked who determined the meal percentage of Resident 28. RN 1stated the CNAs recorded the meal percentage on the residents' meal percentage record. RN 1 was able to show Resident 28's meal percentage record for the past 30 days and verified there were episodes where the resident consumed less than 50% of the meal. When RN 1 was asked about the monitoring of the behavior for the resident, RN 1 was able to show the Monitor Record form for July 2025 and verified there were zero behavior episodes documented for the poor intake less than 50%. RN 1 verified and acknowledged the monitoring of the behavior for poor intake was inaccurate. RN 1 was asked if there was a monthly behavior monitoring summaries documented for Resident 28's poor intake for the past months. RN 1 reviewed the resident's medical record and verified there was no monthly behavior monitoring summaries documented and completed for the use of the mirtazapine medication. On 8/7/25 at 1125 hours, an interview and concurrent medical record review for Resident 28 was conducted with the DON. The DON was asked about the residents on antipsychotic medications. The DON stated the facility staff monitored the residents and made sure the medication was being given to resident and the targeted behavior was monitored. The DON was informed of the inconsistency and inaccurate monitoring for the behavior of the poor intake for Resident 28's use of the mirtazapine medication. In addition, the DON was informed the monthly behavior monitoring summaries were not completed. The DON verified and acknowledged the above findings. Cross Reference F756, example # 2.

Based on observation, interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 21 final sampled residents (Residents 3, 5, 8, and 59). * The facility failed to develop a care plan problem for Resident 3's use of the central line and IV antibiotic medication. * The facility failed to develop a care plan problem for Resident 5's use of the midline IV and maintenance care. * The facility failed to implement a care plan specific to the administration of oxygen. Resident 8 received continuous oxygen at a rate of 4 LPM, however, physician's order was for 3 LPM. * The facility failed to develop a care plan problem for the use Resident 59's right upper arm PICC line. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans dated 12/19/22, showed the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 1. Medical record review for Resident 3 was initiated on 8/6/25. Resident 3 was admitted to the facility on [DATE]. On 8/6/25 at 1117 hours, an observation and concurrent interview for Resident 3 was conducted with LVN 1. LVN 1 was asked at Resident 3's bedside about the resident's IV access. LVN 1 donned the disposable gloves and asked Resident 3 if LVN 1 could check his IV access and Resident 3 agreed. LVN 1 was observed lifting Resident 3's clothing and exposed the resident's chest. Two lumen central line with dry dressing was observed on the resident's left upper chest. LVN 1 stated the central line was the resident's PICC line. Review of Resident 3's Order Summary Report dated 8/5/25, showed the following physician's orders: - dated 7/30/25, to measure the external catheter length of the PICC line and measure the arm circumference upon admission and every seven days for site maintenance and as needed. - dated 7/30/25, to change the PICC transparent dressing by sterile technique upon admission and every day shift every seven days for site maintenance as needed. - dated 8/1/25, to administer piperacillin (antibiotic) solution reconstituted 3.375 gm intravenously every 12 hours for wound infection. Review of Resident 3's plan of care failed to show documented evidence a care plan problem was developed to address Resident 3's use of the IV central line and IV antibiotic. On 8/6/25 at 1112 hours, an interview for Resident 3 was conducted with LVN 5. LVN 5 stated Resident 3 was on IV antibiotic medication for the foot wound infection. LVN 5 stated Resident 3 had an IV access to his left upper chest. On 8/6/25 at 1335 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. When RN 1 was asked about the plan of care for Resident 3's use of the central line and IV antibiotic medication, RN 1 reviewed the resident's care plan and verified there was no care plan developed for the use of central line and the IV antibiotic medication. On 8/11/2025 at 1125 hours, an interview for Resident 3 was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F694, example # 4. 2. Medical record of Resident 5 was initiated on 8/5/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's Order Summary Report dated 8/5/25, showed a physician's order dated 7/14/25, to measure the external catheter length of the midline and measure the arm circumference upon admission and as needed for site maintenance. Review of Resident 5's plan of care showed a care plan dated 7/23/25, addressing Resident 5's skin alteration to the right lateral heel area, left lateral malleolus area, and right lower abdominal area. The interventions included administering the intravenous antibiotic as ordered and to monitor for side effects. However, the resident's plan of care failed to show a care plan problem was developed to address the resident's use and maintenance of the IV midline. On 8/6/25 at 1230 hours, an interview and concurrent medical record review was conducted with RN 1. When RN 1 was asked to show the care plan to address the resident's use and maintenance of the midline IV, RN 1 was unable to show the documentation. RN 1 verified the above findings. 3. Medical record review for Resident 8 was initiated on 8/5/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's physician's order dated 12/17/24, showed an order to administer continuous oxygen via nasal cannula at a rate of three LPM. Review of Resident 8's care plan titled Risk for Difficulty Breathing, End Stage CHF revised 1/8/25, showed to administer oxygen via nasal canula as ordered. On 8/5/25 at 0900 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was observed lying in bed and receiving continuous oxygen via a nasal cannula at a rate of four LPM. Resident 8 stated the licensed nurses at the facility had set the rate of her oxygen. On 8/5/25 at 0952 hours, an observation, interview, and concurrent medical record review was conducted with LVN 2. Resident 8 was observed lying in bed and receiving continuous oxygen via a nasal cannula at a rate of four LPM. LVN 2 reviewed Resident 8's current physician's orders and verified Resident 8's physician's order showed to administer continuous oxygen via nasal cannula at a rate of three LPM. LVN 2 then reviewed Resident 8's care plan titled Risk for Difficulty Breathing, End Stage CHF revised 1/8/25, which showed to administer oxygen via nasal canula as ordered. LVN 2 was then observed lowering Resident 8's continuous oxygen to a rate of three LPM, in accordance with the physician's order and comprehensive care plan for the use of oxygen. 4. Medical record review for Resident 59 was initiated on 8/5/25. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's progress notes dated 7/9/25, showed Resident 59 was admitted to the facility with a right upper arm PICC line with two-lumens. Review of Resident 59's Order Summary Report dated 8/6/25, showed the following physician's orders: - dated 7/10/25, to change the PICC/midline transparent dressing per sterile technique upon admission, every Sunday, and as needed every day shift. - dated 7/10/25, to measure the external catheter length of the PICC/midline and measure the arm circumference upon admission and with every dressing change on Sunday and PRN, for site maintenance. Review of Resident 59's plan of care failed to show a care plan problem to address the use of Resident 59's right upper arm PICC line. On 8/5/25 at 0824 hours, Resident 59 was observed with a PICC line with two-port external catheters to the right upper arm (RUA). The transparent dressing over the PICC line was dated 7/30/25. On 8/6/25 at 1324 hours, an interview and concurrent medical record review for Resident 59 was conducted with RN 2. RN 2 stated Resident 59 had a PICC line in the RUA and was currently receiving intravenous antibiotics. RN 2 reviewed Resident 59's medical record and verified the above findings. RN 2 stated there should be a care plan to address the use, care, and management of Resident 59's RUA PICC line. On 8/11/25 at 1207 hours, an interview was conducted with the DON. The DON stated for the residents admitted to the facility with a PICC line, there should be a care plan developed to address the management of the residents' PICC line. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON and Nurse Consultant. The Administrator, DON and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to to ensure feeding assistance was provided per the physician's order for one of 21 residents (Resident 5) observed during the dining observation. * During the dining observation, the facility failed to provided one to one feeding assistance for Resident 5. Resident meal card showed the resident required total assistance with feeding. This failure has the potential to negatively affect the resident's health outcomes and well-being. Findings: Review of the facility's P&P titled Meal Supervision and Assistance dated 12/19/22, showed the resident will be prepared for a well-balanced meal in a calm environment, location of his / her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: Identifying hazard(s) and risk(s), Evaluating and analyzing hazard(s) and risk(s), Implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary assemble equipment and supplies needed. Do not serve the meal until the attendant is ready to assist the resident. Medical record review for Resident 5 was initiated on 8/5/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's plan of care showed a care plan dated 7/31/25, addressing the resident's potential for nutritional problem. However, there was no care plan addressing the resident's need for total assistance with feeding and/or interventions to provide Resident 5 with one to one assistance with feeding during meals. Review of the Resident 5's Order Summary Report dated 8/5/25, showed a physician's order dated 7/14/25, for one to one feeder. Review of Resident 5's meal card dated 8/5/25, showed Resident 5 required total assistance with feeding. On 8/5/25 at 1300 hours, Resident 5 was observed sitting up in the middle of the bed with a bedside table in front of her. A closed lunch tray and utensils were placed in front of her. Resident 5 stated she was hungry and had been waiting for the facility staff for 10 minutes to assist her with her lunch. Resident 5 stated she needed assistance because she could not see her meal. Resident 5 stated the facility staff had delivered her meal tray but did not inform her whether they would return or provided assistance to her with setting up the meal tray and the utensils. Resident 5 was observed feeling around the meal tray with her hands, lifting the cover, and locating the utensils. Resident 5 was observed using the utensils to scoop the carrots and potatoes with difficulty, and eventually used her hands to eat a few pieces of the food. Resident 5's meal card showed the resident required total assistance. On 8/5/25 at 1310 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 stated she needed help with feeding and could not eat the rest of her food. Resident 5 was observed using the call light to request for facility staff assistance. On 8/5/25 at 1320 hours, an observation and concurrent interview was conducted with the IP. Resident 5's call light remained on and there was no facility staff present in the hallway. The IP was summoned to Resident 5's room. Resident 5 then asked the IP if any of the facility staff could help to feed her. Resident 5 was observed attempting to get the food with her hands. The IP was informed of the above observation. The IP stated Resident 5 always required the facility staff assistance with feeding and stated she would find a facility staff to help the resident. The IP verified the findings. On 8/5/25 at 1330 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 was observed assisting Resident 5 with her meal. CNA 3 stated she was asked by the IP to help feed Resident 5 and she thought the assigned sitter (CNA 4) would provide assistance with Resident 5's meals. On 8/5/25 at 1335 hours, an interview was conducted with the DSD. The DSD stated CNA 4 was assigned to Resident 5, however, CNA 4 had arrived late this morning and had gone on a break at a later time. The DSD stated CNA 4 was expected to return from her break in 10 minutes. On 8/5/25 at 1600 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 was informed of the above findings. LVN 6 stated Resident 5 was totally blind and required total assistance with feeding. LVN 6 reviewed Resident 5's plan of care and verified there was no care plan and/or interventions addressing the resident's need for total assistance with feeding.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 10) reviewed for accidents remained free from accident hazards. * Resident 10 sustained three falls while the sitter (facility staff who provides direct supervision to those residents requiring close monitoring) was distracted, and/or had left the room. * Resident 10's post fall neurological assessments were incomplete for the falls sustained on 3/3 and 8/5/25. * Resident 10's post fall, fall risk assessments were inaccurate for 7/27/25 and incomplete for 8/5/25. * The facility failed to ensure Resident 10 remained within the sitter's eyesight for 11 minutes. These failures resulted in the resident sustaining subsequent falls had the potential to place the resident at risk for serious injury and negative health outcomes. Findings: Medical record review for Resident 10 was initiated on 8/5/25. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's eINTERACT Change in Condition Evaluation - V 5.1 assessments showed the resident had falls on the following dates: 3/22, 4/1, 4/3, 6/27, 7/12, 7/27, and 8/5/25. Review of Resident 10's Care Plan Report showed a care plan problem addressing the resident's actual fall revised on 7/17/25. The interventions included to monitor the resident more frequently. The report also showed care plan problem addressing the resident's risk for falls dated 7/1/25. The interventions included to anticipate and meet the resident's needs, and to follow the facility's fall protocol. 1. a. Further review of Resident 10's eINTERACT Change in Condition Evaluation - V 5.1 assessment dated [DATE], showed the resident's sitter left the resident's room while the resident was sleeping and when the sitter returned, the resident was found lying on the floor, and stated he tried to get to the bathroom. Review of Resident 10's Interdisciplinary Care Conference - V 5 dated 7/2/25, showed the team met to discuss the resident's fall on 6/27/25. The recommendations showed the sitter was instructed on the importance of not leaving the resident's room except in an emergency. b. Further review of Resident 10's eINTERACT Change in Condition Evaluation - V 5.1 assessment dated [DATE], showed a sitter was assigned to Resident 10 and his roommate, the sitter reported Resident 10 was agitated and when the sitter went to assist the roommate, Resident 10 had a fall. c. Review of Resident 10's progress notes dated 8/5/25 at 2101 hours, showed the resident had an unwitnessed fall and was found on the floor. On 8/8/25 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated a sitter was assigned to Resident 10 and his roommate. Resident 10 had a sitter since he was readmitted to the facility on [DATE]. The DON stated the sitter was supposed to monitor the residents for safety, and not to provide resident care, so both the residents could be monitored. The DON stated for Resident 10's falls on 6/27 and 8/5/25, he had the falls when his sitter had left the room. The DON also stated for the resident's fall on 7/12/25, the sitter was assisting Resident 10's roommate, when Resident 10 had his fall. The DON stated the sitter's role was to monitor the residents for safety, and if the residents needed assistance, the sitter should have requested for the facility staff to assist them. 2. a. Review of Resident 10's post-fall Neurological Flowsheet - V 3 dated 4/3/25 at 1330 hours, showed a neurological assessment #14 was completed on 4/4/25 at 0930 hours, and the assessment #15 was scheduled four hours later at 1330 hours. The neurological assessment #15 was not completed. Review of Resident 10's progress notes dated 4/4/25 at 1448 hours, showed the resident was discharged to the community. b. Review of Resident 10's post-fall Neurological Flowsheet - V 3 dated 8/5/25 at 2045 hours, showed the following incomplete neurological assessments:- Assessment # 15, due to be completed on 8/6/25 at 1625 hours.- Assessment # 16, due to be completed on 8/7/25 at 0025 hours.- Assessment # 18, due to be completed on 8/7/25 at 1745 hours. On 8/8/25 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 10's medical record and verified the post fall Neurological Flowsheet - V 3 dated 4/3/25 at 1330, was incomplete and the final neurological assessment should have been completed on 4/4/25 at 1330, since the resident's medical record showed the resident was still in the facility at the time. The DON also verified the post-fall Neurological Flowsheet - V 3 dated 8/5/25, had an incomplete assessments for Numbers 15, 16, and 18. 3. Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed after a resident fall, the facility will complete post-fall assessment. Review of Resident 10's Fall Risk - V 4 dated 7/27/25, incorrectly showed the resident had no falls in past three months, which resulted in a fall risk score of nine. Review of Resident 10's Fall Risk - V 4 dated 8/5/25, showed assessment was blank, and no information documented. On 8/8/25 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 10's medical record and stated the above Fall Risk - V 4 assessments were completed post fall. The DON verified the assessment dated [DATE], was incorrectly completed and the assessment dated [DATE], was blank but should be completed immediately after the resident's fall. 4. On 8/8/25 at 0923 hours, while LVN 1 was preparing for Resident 10's wound care treatment, LVN 1 was standing at the treatment cart outside of Resident 10's doorway. LVN 1 went into the resident's room, washed her hands and came back out to her treatment cart in the hallway. Resident 10 was not visible from the doorway as his privacy curtain was completely closed. CNA 1 was observed standing inside the resident's room by the doorway and by the roommate's (Resident 69) bed. LVN 1 remained at her treatment cart gathering supplies. On 8/8/25 at 0934 hours, after 11 minutes later, LVN 1 went to Resident 10's bedside for a wound care treatment observation. Upon walking around to the other side of Resident 10's privacy curtain, Resident 10 was observed sleeping on the bed, with no other facility staff observed at the resident's bedside or visible from the resident's bedside with the privacy curtain in place. On 8/8/25 at 1014 hours, an interview was conducted with CNA 1 who was still standing inside the doorway next to Resident 69's bedside. CNA 1 stated she was the sitter for Residents 10 and 69. When asked how she was able to monitor Resident 10 with his privacy curtain pulled and blocking her view of him for the 11 minutes, while LVN 1 was at the treatment cart in the hallway, CNA 1 was unable to give an appropriate answer and stated she was waiting for the LVN to come into the room. On 8/8/25 at 1014 hours, an interview was conducted with the DON. The DON stated since Residents 10 and 69 were both fall risks and Resident 10 had frequent falls, the facility decided to assign a sitter to monitor the residents for safety. The DON stated the facility decided to utilize a sitter when the resident was readmitted to the facility on [DATE]. The DON stated the CNA should not have the privacy curtain pulled, obstructing her view of the resident while monitoring him.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT (gastrostomy tube- a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications) for one of three final sampled residents (Resident 4) reviewed for the GT feeding and one of three residents (Resident 2) observed for the medication administration. * The facility failed to ensure LVN 3 checked for the gastric residual (volume of fluid remaining in the stomach) prior to the administration of the GT medications for Resident 2 and failed to flush the GT between the administration of each medication. * LVN 6 failed to verify Resident 4's GT placement prior to administering the tube feeding. These failures posed the risk of complications related to the use of the GT for Residents 2 and 4.Findings: Review of the facility's P&P titled Appropriate Use of Feeding Tubes revised 12/19/22, showed the feeding tubes will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The plan of care will address the use of feeding tubes, including strategies to prevent complications. 1. Medical record review for Resident 2 was initiated on 8/6/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report dated 8/6/25, showed the following physician's orders: - dated 6/10/25, to flush the enteral feeding tube with 15-30 ml of water before and after the medication administrations; and - dated 6/10/25, to check the residual volume every shift. To hold the enteral feeding if the residual exceeds 100 ml. To recheck the residual in one hour and notify the physician if the residual volume is more than 100 ml on the second check. Review of Resident 2's plan of care showed a care plan problem dated 6/12/25, addressing Resident 2's use of the GT feeding. The interventions included to check for the GT placement and gastric contents/residual volume per the facility protocol and record, to hold the enteral feeding if the residual volume was greater than 100 ml aspirated, and to provide water flushes with medications per the nursing policy. On 8/6/25 at 0800 hours, a medication administration observation was conducted with LVN 3. LVN 3 was observed preparing the following GT medications: - one packet of Juven (wound healing supplement) mixed in six-ounces of water; - one tablet of vitamin C (supplement) 500 mg; - two tablets of docusate sodium (stool softener) 100 mg; - one table of simethicone (gas relief) 125 mg; - 30 ml of LiquaCel (liquid protein); - 5 ml of MultiVite Liquid (supplement); and - 17gm of polyethylene glycol (laxative) 3350. LVN 3 was observed checking for the GT placement by injecting air and auscultating the resident's abdomen. LVN 3 was observed flushing the GT with 30 ml of water prior to the GT medication administration. LVN 3 was not observed checking Resident 2's gastric residual volume. LVN 3 then proceeded to administer the above GT medications to Resident 2. LVN 3 was not observed flushing the GT with water in between each of the medications. On 8/6/25 at 0844 hours, an interview was conducted with LVN 3. LVN 3 was asked about the facility's protocol for the administration of a medication via the GT. LVN 3 stated for the administration of the medications via the GT, the enteral feeding should be placed on hold, and the licensed nurse should check for the GT placement by pushing 5-10 ml of air and auscultating for the sound. LVN 3 stated the licensed nurse should then aspirate to check for the gastric residual. LVN 3 further stated the GT medications were administered by gravity and in between each medications, the licensed nurse should flush the GT with 5 ml of water. LVN 3 verified during the medication administration observation, he did not check for the gastric residual prior to the administration of the medications, and he did not flush the GT with water in between each of the medications. On 8/11/25 at 0841 hours, an interview was conducted with the DON. The DON stated for the administration of the medications via the GT, the licensed nurses were expected to check for the GT placement and check for the gastric residual. The DON stated the licensed nurse should flush the GT with 10-30 ml of water before and after the medication administration, and in between each medications, the licensed nurse should flush the GT with 5 to 10 ml of water. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON and Nurse Consultant. The Administrator, DON and Nurse Consultant were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Verifying Placement of Feeding Tubes dated 12/19/22, showed before a feeding, flushing the tube, or administering medications via a feeding tube, proper placement should be verified. Verify tube placement by auscultating the abdomen while giving an air bolus into the tube. Medical record review for Resident 4 was initiated on 8/6/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 6/6/25, to administer the Osmolyte1.2 (type of enteral feeding) via GT daily at 1300 hours. On 8/6/25 at 1350 hours, LVN 6 was observed initiating Resident 4's GT feeding. LVN 6 checked the GT for residuals, and no residuals was observed. LVN 6 then flushed the GT with water and started the tube feeding. LVN 6 was not observed verifying Resident 4's GT placement with auscultation prior to flushing the GT and starting the tube feeding. LVN 6 verified she did not verify the resident's GT placement because placement only needed to be verified once a shift and she verified the placement when she administered the resident's morning medication. On 8/6/25 at 1514 hours, an interview was conducted with the DON. The DON verified the facility P&P showed to verify GT placement with auscultation before administering water flushes, tube feeding, and GT medications.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for four of four final sampled residents (Residents 3, 5, 59, and 83) reviewed for IV care. * The facility failed to ensure there was a physician's order for the use of Resident 3's central line. * The facility failed to ensure Resident 5's midline dressing was dated and failed to ensure for complete documentation of the maintenance flushes, as per the physician's orders. * The facility failed to ensure Resident 59's right upper arm PICC line was changed as per the physician's orders and failed to ensure Resident 59's PICC line external catheter and arm circumference measurements were obtained and documented in the resident's medical record. * The facility failed to ensure there was a physician's order for the care and maintenance of Resident 83's left upper arm midline and failed to ensure Resident 83's midline dressing was changed weekly. These failures had the potential to delay the identification of a catheter related complications for the residents.Findings: Review of the facility's P&P titled PICC/Midline/CVAD Dressing changed revised 12/19/22, showed it is the policy of this facility to change the peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease the potential for infection and/or cross contamination. To use sterile measuring tape to measure the external length of the catheter from the hub to skin entry to ensure that it has not migrated. To apply a transparent semi-permeable dressing to the insertion site. To label the dressing with the date, time and initials; and to document the procedure. 1. On 8/5/25 at 0824 hours, Resident 59 was observed with the two port external catheters PICC line to the right upper arm. The transparent dressing over Resident 59's right upper arm PICC line was dated 7/30/25. Medical record review for Resident 59 was initiated on 8/5/25. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's progress notes dated 7/9/25, showed Resident 59 was admitted to the facility with a right upper arm PICC line, with two-lumens. However, further review of the resident's progress note failed to show any documentation of Resident 59's baseline PICC line external catheter length and arm circumference measurements. Review of Resident 59's Order Summary Report dated 8/6/25, showed the following physician's orders: - dated 7/10/25, to change the PICC/midline transparent dressing per sterile technique upon admission, every Sunday, and as needed every day shift. - dated 7/10/25, to measure the external catheter length of the PICC/midline and measure the arm circumference upon admission and with every dressing change on Sunday and PRN, for site maintenance. Review of Resident 59's PICC Insertion Record dated 7/18/25, showed Resident 59 had a new PICC line with two-lumens (external ports) inserted in the right upper extremity. The document showed the external length measurement was 3 cm and the arm circumference was 40 cm. Review of Resident 59's IV Administration Report for July 2025 showed the following documentation: - On Sunday 7/20 and 7/27/25, the documentations for the external catheter length and arm circumference measurements for Resident 59's PICC line, and for the PICC line transparent dressing change, upon admission and every Sunday were left blank. - On 7/30/25 (the date observed on Resident 59's PICC line dressing), the IV Administration Record failed to show the documentation of Resident 59's PICC line external catheter length and arm circumference measurements. Further review of Resident 59's progress notes failed to show the licensed nurses' entry of the measurements for Resident 59's arm circumference and PICC line external catheter length. On 8/6/25 at 1324 hours, an interview and concurrent medical record review for Resident 59 was conducted with RN 2. RN 2 stated Resident 59 had a PICC line in the RUA and was currently receiving intravenous antibiotics. RN 2 stated the PICC line dressings were changed weekly and as needed and documented in the IV Administration Record. RN 2 stated during the PICC line dressing change, the external catheter length and the resident's arm circumference were measured and compared to the previous measurements. RN 2 reviewed Resident 59's medical record and verified the above findings. 2. On 8/5/25 at 0910 hours, Resident 83 was observed with a left upper arm midline with the dressing dated 7/23/25. Medical record review for Resident 83 was initiated on 8/5/25. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's N ADV-Clinical admission dated 7/25/25, under the Special Care section, the licensed nurse documented Resident 83 had a midline in the left upper arm. Review of Resident 83's progress notes dated 7/25/25, showed Resident 83 was admitted to the facility with a midline in the left upper arm for the continuation of the antibiotics. However, further review of the progress notes failed to show any documentation of Resident 83's midline measurements. Review of Resident 83's Order Summary Report failed to show a physician's order for the use and maintenance of Resident 83's midline in the left upper arm. Review of Resident 83's IV Administration Record failed to show documentation Resident 83's midline dressing was changed. On 8/5/25 at 1616 hours, an interview, observation, and concurrent medical record review for Resident 83 was conducted with RN 1. RN 1 stated the dressing changes for the midlines and PICC lines should be done weekly. RN 1 reviewed Resident 83's medical record and verified the above findings. RN 1 verified Resident 83's midline dressing in the left upper arm was dated 7/23/25 (before her admission to the facility) and had not been changed since her admission to the facility. On 8/11/25 at 0841 hours, an interview was conducted with the DON. The DON stated for the residents admitted to the facility with a PICC line or midline, the dressing should be changed upon admission and weekly. The DON stated upon admission to the facility, the licensed nurse should obtain the baseline measurements, which included the external catheter length, to ensure the catheter did not dislodge during the transfer. and the arm circumference measurement, to assess for swelling of the access site. The DON stated the PICC line and midline dressing should be changed weekly and as needed, and the licensed nurses were expected to measure the external catheter length and arm circumference, document the measurements in the IV Administration Record, and compare the measurements with the previous measurements. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Intravenous Therapy dated 12/19/22, showed all the intravenous tubing is to be labeled with date, time and initials. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. Medical record for Resident 5 was initiated on 8/5/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/5/25 at 0830 hours, Resident 5 was observed with a midline in the left arm and undated dressing. Review of Resident 5's Order Summary Report dated 8/5/25, showed a physician's orders dated 7/14/25: - to measure external catheter length of the midline and measure arm circumference upon admission and as needed for site maintenance. - Normal saline (sterile solution of 0.9% sodium chloride in water) flush intravenous solution 0.9 %: use 10 ml intravenously every shift for line maintenance. Flush the midline with 10 ml of normal saline before and after medication administration. - Site checks: monitor for signs and symptoms of complications or adverse reactions from IV therapy every shift. - To administer cefepime hydrochloride (antibiotic) intravenous solution 2 gram/100 milliliter: use 2 gram intravenously every 12 hours for abdomen wall abscess for two weeks . Review of Resident 5's IV Administration Report for July 2025 showed the following: - Missing documentation for the cefepime HCl 2 gram intravenously every 12 hours for abdominal wall abscess for two weeks on 7/18, 7/19, and 7/26/25 at 2100 hours. - Missing documentation for the normal saline flush 0.9%:10 ml intravenously every shift for line maintenance and before and after medication administration, and monitoring for the signs and symptoms of complications from the IV therapy for the 3 -11 shifts on 7/18, 7/19, and 7/26/25, and for the 11-7 shifts on 7/24, 7/25, 7/29, and 7/31/25. - No measurements were documented for the midline external catheter length and arm circumference on 7/15, 7/22, and 8/29/25. Review of Resident 5's IV Administration Report for August 2025 showed the following: - Missing documentation for the monitoring for signs and symptoms of complications and adverse reactions for the 7-3 shifts on 8/2, 8/3, and 8/4/25. - No measurements were documented for the midline external catheter length and arm circumference on 8/5/25. - Missing documentation for the normal saline flush for the 7–3 shifts on 8/2 and 8/3/25. On 8/5/25 at 0930 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 5's midline dressing was undated. RN 1 stated he flushed the resident's midline earlier in the morning and did not notice the missing date on the midline dressing. RN 1 acknowledged the midline dressing should be dated and the label. RN 1 verified the above findings. On 8/5/25 at 0945 hours, a follow up interview and concurrent medical record review was conducted with RN 1. When asked about the resident's midline care, external catheter length and arm circumference measurements, RN 1 stated the licensed nurse had measured the midline's external catheter length but did not document the actual measurements on the resident's medical record. RN 1 acknowledged the actual measurements for the external catheter length and arm circumference should have been documented to monitor for any shifting of the midline. When RN 1 was asked regarding Resident 5's midline maintenance for July and August 2025, which included the normal saline flushes, site checks, and antibiotic administration, RN 1 stated the licensed nurses should have documented the midline maintenance and IV medication administration on the resident's IV MAR. RN 1 stated if the resident refused the treatment/ medication or if there were any issues regarding the midline maintenance and IV antibiotic administration, then it should have been documented in the resident's progress notes. RN 1 acknowledged the missing documentation listed above and was unable to provide supporting documentation. RN 1 verified the above findings. 4. Medical record review for Resident 3 was initiated on 8/6/25. Resident 3 was admitted to the facility on [DATE]. On 8/6/2025 at 1117 hours, an observation and concurrent interview for Resident 3 was conducted with LVN 1. LVN 1 was asked at Resident 3's bedside about the resident's IV access. LVN 1 donned disposable gloves and asked Resident 3 to check his IV access and Resident 3 agreed. LVN 1 was then observed lifting Resident 3's clothing and exposing the resident's chest. Resident 3 was observed with a two-lumen central line on the left upper chest with dry dressing. LVN 1 stated the central line on the left upper chest was the resident's PICC line. Review of Resident 3's Order Summary Report dated 8/5/25. showed the following physician's orders: - dated 8/1/25, to administer piperacillin (antibiotic) solution reconstituted 3.375 gm intravenously every 12 hours for wound infection. - dated 7/30/25, to measure the external catheter length of PICC line and measure arm circumference upon admission and every seven day(s) for site maintenance and as needed. - dated 7/30/25, to change the PICC line transparent dressing per sterile technique upon admission and every day shift every seven day(s) for site maintenance as needed. However, further review of Resident 3's Order Summary Report for August 2025 failed to show for a physician's order for the IV central line, care, maintenance, and monitoring. On 8/6/25 at 1112 hours, an interview for Resident 3 was conducted with LVN 5. LVN 5 stated Resident 3 was on an IV antibiotic medication for the foot wound infection. LVN 5 stated Resident 3 had an IV access to his left upper chest. On 8/6/25 at 1335 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 was asked about Resident 3' IV antibiotic medication and IV access. RN 1 verified Resident 3 was on IV antibiotic medication for the wound infection. RN 1 was asked where Resident 3's IV access was located. RN 1 stated the resident's IV access was the PICC line on the left upper chest. When RN 1 was asked if the IV central line was placed from the acute care hospital, RN 1 verified the resident's central line was placed at the acute care hospital. RN 1 was asked for the documentation for the placement of the resident's central line. RN 1 accessed the resident's electronic medical record, verified and acknowledged there was no documentation for the IV access central line. RN 1 verified and acknowledged the physician's order for the resident's IV access site was incorrect and inaccurate. On 8/11/25 at 1125 hours, an interview for Resident 3 was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F656, example # 1.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of two final sampled residents (Resident 1) reviewed for tracheostomy services, and four of five residents (Residents 8, 22, 69, and 85) reviewed for oxygen therapy. * The facility failed to ensure only qualified staff managed the resident's oxygen delivery equipment. The SSD was observed turning Resident 1's oxygen concentrator off and on, in an attempt to troubleshoot a potential malfunction. * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 8. Resident 8 had an order to receive continuous oxygen at three LPM, however, Resident 8 received continuous oxygen at a rate of four LPM. * The facility failed to ensure Resident 22's nasal cannula tubing was dated and remained off of the floor. * The facility failed to document on the resident's MAR the administration of the oxygen to Resident 69. * The facility failed to obtain a physician's' order for the administration of continuous oxygen to Resident 85. These failures had the potential to result in negative resident health outcomes. Findings: Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under the orders of a physician. 1. Medical record review for Resident 1 was initiated on 8/5/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's order dated 5/25/25, showed to administer oxygen via tracheostomy collar, at a rate of five LPM, may titrate the oxygen to maintain the oxygen saturation greater or equal to 92%. Review of Resident 1's Care Plan Report revised 5/22/25, showed Resident 1 had altered respiratory status and was at risk for difficulty breathing related to tracheostomy, CHF, and chronic respiratory failure. The interventions included administering the oxygen at a rate of five LPM via tracheostomy. On 8/6/25 at 1110 hours, an observation and concurrent interview was conducted with the SSD. The SSD was observed in Resident 1's room turning Resident 1's oxygen concentrator off and on. The SSD was asked what he was doing, to which he replied, the machine was beeping, so I turned it off and on. The SSD was asked if he had the training specific to managing the oxygen concentrator functionality, to which he replied, no. The SSD was asked if he should turn the oxygen concentrator off and on, to which he replied, no, I should have contacted the nurse. Resident 1 was then observed motioning with his hand and indicating he needed to be suctioned. This observer then contacted the DON. On 8/6/25 at 1123 hours, an observation and concurrent interview was conducted with the DON. The DON entered Resident 1's room and performed the suctioning for Resident 1. The DON was informed the SSD was observed in Resident 1's room having turned Resident 1's oxygen concentrator off and on. The DON stated the SSD's action was not within the SSD's scope of practice. The DON stated the SSD having turned off the oxygen concentrator could result in negative health outcomes for Resident 1. Cross Reference F940, example # 1. 2. Medical record review for Resident 8 was initiated on 8/5/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's physician's order dated 12/17/24, showed an order to administer continuous oxygen via nasal cannula at a rate of three LPM. Review of Resident 8's care plan titled Risk for Difficulty Breathing, End Stage CHF revised 1/8/25, showed to administer the oxygen via nasal canula as ordered. On 8/5/25 at 0900 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was observed lying in bed and receiving continuous oxygen via a nasal cannula, at a rate of four LPM. Resident 8 stated the licensed nurses at the facility had set the rate of her oxygen. On 8/5/25 at 0952 hours, an observation, interview, and concurrent medical record review was conducted with LVN 2. Resident 8 was observed lying in bed and receiving continuous oxygen via a nasal cannula, at a rate of four LPM. LVN 2 was observed having obtained Resident 8's oxygen saturation (while receiving oxygen at a rate of four liters per minute). Resident 8's oxygen saturation level was 99%. LVN 2 then reviewed Resident 8's current orders and verified Resident 8's physician's order showed to administer continuous oxygen via nasal cannula, at a rate of three LPM. LVN 2 then lowered Resident 8's continuous oxygen to a rate of three LPM, in accordance with the physician's order. LVN 2 then obtained Resident 8's oxygen saturation (while receiving oxygen at a rate of three liters per minute). Resident 8's oxygen saturation level was 97%. Cross reference F656 example #3. 3. Review of the facility's Medication Administration P&P dated 12/19/22, showed to sign the MAR after administering medication. Medical record review for Resident 69 was initiated on 8/5/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69 Order Summary Report showed a physician's order dated 7/9/25, for the oxygen to be administered at two LPM PRN, may titrate to maintain the oxygen saturation greater than or equal to 95%. Review of Resident 69's progress notes showed the following:- dated 7/13/25 at 0325 hours, showed the oxygen was administered at two LPM via nasal cannula. - dated 7/14/25 at 1638 hours, showed the resident received the oxygen via nasal cannula.- dated 7/15/25 at 1620 hours, showed the resident received the oxygen via nasal cannula.- dated 7/17/25 at 1310 hours, showed the resident received the oxygen via nasal cannula.- dated 7/21/25 at 0233 hours, showed the resident received the oxygen via nasal cannula.- dated 7/21/25 at 1556 hours, showed the resident received the oxygen via nasal cannula.- dated 7/22/25 at 1505 hours, showed the resident received the oxygen via nasal cannula.- dated 7/23/25 at 1325 hours, showed the resident received the oxygen via nasal cannula.- dated 7/27/25 at 1245 hours, showed the resident received the oxygen via nasal cannula.- dated 7/28/25 at 1444 hours, showed the resident received the oxygen via nasal cannula.- dated 7/29/25 at 1340 hours, showed the resident received the oxygen via nasal cannula.- dated 7/31/25 at 1633 hours, showed the resident received the oxygen via nasal cannula.- dated 8/1/25 at 1400 hours, showed the resident received the oxygen via nasal cannula.- dated 8/2/25 at 1558 hours, showed the resident received the oxygen via nasal cannula.- dated 8/3/25 at 0710 hours, showed the resident was administered the oxygen via nasal cannula. - dated 8/5/25 at 1644 hours, showed the resident received the oxygen via nasal cannula.- dated 8/6/25 at 1638 hours, showed the oxygen was administered at two LPM via nasal cannula. Review of Resident 69's MAR for July and August 2025, failed to show the oxygen was administered to the resident. On 8/5/25 at 0921 hours, Resident 69 was observed lying in bed and receiving the oxygen via nasal cannula. On 8/5/25 at 1500 hours, an observation and interview was conducted with LVN 2 at Resident 69's bedside. LVN 2 checked Resident 69's oxygen concentrator and stated the resident was on three LPM. On 8/6/25 at 0801 hours, and on 8/7/25 at 0821 hours, Resident 69 was observed lying in bed and receiving the oxygen via nasal cannula. On 8/7/25 at 1524 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated he was Resident 69's licensed nurse. LVN 3 stated the resident had been on oxygen all day, and was usually on oxygen. LVN 3 reviewed Resident 69's MAR for August 2025 and verified the record did not show the resident received the oxygen. On 8/8/25 at 0903 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the oxygen administration should be documented in the residents' MAR. The DON stated Resident 69 had a PRN order for the oxygen and verified the resident's progress notes showed the resident was on oxygen on the above dates, however, the resident's MAR failed to show the oxygen was administered to the resident. 4. On 8/5/25 at 0835 hours, during the initial tour of the facility and at 1521 hours, an observation and concurrent interview for Resident 22 was conducted with LVN 5. Resident 22 was observed in bed awake with the oxygen on via nasal cannula, which attached to the oxygen concentrator machine and the rate set at two LPM. The nasal cannula was unlabeled and undated. In addition, the oxygen tubing was observed touching the floor. LVN 5 verified and acknowledged Resident 22's oxygen tubing was unlabeled and touching the floor. LVN 5 stated the oxygen tubing should have been labeled and kept off the floor. LVN 5 stated she would change the resident's oxygen tubing. Medical record review for Resident 22 was initiated on 8/5/25. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary Report dated 8/5/25, showed a physician's order dated 7/14/25, to administer the oxygen via nasal cannula at two LPM. On 8/11/25 at 1139 hours, an interview for Resident 22 was conducted with the DON. The DON was informed and verified the above findings. 5. Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed oxygen was administered under the orders of a physician, except in the case of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the residents assessment and orders such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. On 8/5/25 at 0914 hours, an interview and concurrent observation was conducted with Resident 85. Resident 85 was observed in bed receiving the oxygen via the nasal canula at 1.5 LPM. Resident 85's nasal canula tubing was not observed labeled with a date. Resident 85 stated she was administered the continuous oxygen via nasal cannula for about four to five days. Medical record review for Resident 85 was initiated on 8/5/25. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 85's H&P examination dated 7/26/25, showed Resident 85 had the capacity to understand and make decisions. Review of Resident 85's Order Summary Report dated 8/5/25, failed to show a physician's order for the administration of the oxygen via nasal canula. Review of Resident 85's plan of care failed to show a care plan problem addressing Resident 85's use of the oxygen via nasal canula. On 8/5/25 at 1504 hours, Resident 85 was observed sitting in her wheelchair and receiving the oxygen via nasal cannula at two LPM. On 8/5/25 at 1532 hours, an observation, interview and concurrent medical record review for Resident 85 was conducted with RN 1. RN 1 stated there should be a physician's order for the administration of the oxygen. RN 1 stated the oxygen tubing should be changed weekly and labeled with the date. RN 1 stated Resident 85 had been on continuous oxygen via nasal cannula for a few days. RN 1 reviewed Resident 85's medical record and verified the above findings. RN 1 was observed at Resident 85's bedside and verified Resident 85 was receiving oxygen via the nasal cannula at two LPM. RN 1 verified the nasal canula tubing was not dated. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for three of three final sampled residents (Residents 10, 59, and 85) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's order and failed to ensure the non-pharmacological pain interventions were implemented prior to the administration of the PRN pain medications for Resident 59. * The facility failed to ensure the non-pharmacological pain interventions were implemented and documented prior to the administration of the PRN pain medications to Residents 10 and 85. These failures had the potential to put Residents 10, 59, and 85 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.Findings: Review of the facility's P&P titled Pain Management revised 3/17/25, showed based upon the pain evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. Non-pharmacological interventions will include but are not limited to: a. Environmental comfort measures (e.g., adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning), b. Loosening any constrictive bandage, clothing or device, c. Applying splinting (e.g., pillow or folded blanket), d. Physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning), e. Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility, f. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain). Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. 1. Medical record review for Resident 59 was initiated on 8/5/25. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's Plan of Care showed a care plan problem dated 7/29/25, addressing Resident 59's risk for pain related to his disease process. The interventions included to administer the analgesia as per the physician's orders. Review of Resident 59's Order Summary Report dated 8/6/25, showed the following physician's orders: - dated 7/10/25, to administer oxycodone (narcotic pain medication) 5 mg one tablet by mouth every four hours as needed for moderate pain (pain level of four to six, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst), and -dated 7/10/25, to administer oxycodone10 mg one tablet by mouth every four hours as needed for severe back pain (pain level of eight to 10, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst). Review of Resident 59's MAR for 7/2025 and 8/2025 showed Resident 59 was administered the PRN pain medications on the following dates and times, and for the following documented pain levels, outside of the ordered pain parameters: * For the oxycodone 5 mg one tablet every four hours as needed for moderate pain (pain level of 4 to 6, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) - on 7/12/25 at 2026 hours, for a pain level of 7. - on 7/14/25 at 2016 hours, for a pain level of 7. - on 7/15/25 at 2018 hours, for a pain level of 8. - on 7/19/25 at 1715 hours, for a pain level of 7 * For the oxycodone 10 mg one tablet every four hours as needed for severe pain (pain level of 8 to 10, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) - on 7/13/25 at 1630 and 2100 hours, for a pain level of 7. - on 7/14/25 at 0440 hours, for a pain level of 7. - on 7/30/25 at 0638 and 2233 hours, for a pain level of 7. - on 8/6/25 at 1302 hours, for a pain level of 7. - on 8/7/25 at 0839 hours, for a pain level of 7. Additionally, review of Resident 59's medial record failed to show documentation of the non-pharmacological pain interventions were implemented and its effectiveness prior to the administration of the oxycodone 5 mg or 10 mg PRN pain medications for the above dates and times. On 8/7/25 at 1428 hours, an interview and concurrent medical record review for Resident 59 was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the PRN pain medications should be administered as per the physician's order for the ordered pain parameters. LVN 4 stated Resident 59 did not have a physician's order for the pain medication for a pain level of seven of 10. LVN 4 further stated the physician's order for the PRN pain medications should have been clarified with the physician. LVN 4 further reviewed Resident 59's medical record and stated there was no documentation the non-pharmacological interventions for pain were implemented and its effectiveness prior to the administration of PRN pain medications for the above dates. 2. Medical record review of Resident 85 was initiated on 8/5/25. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 85's Order Summary Report dated 8/5/25, showed a physician's order dated 7/24/25, to administer hydrocodone-acetaminophen (a controlled pain medication) 5-325 mg, one tablet every six hours PRN for moderate (pain level 4 to 6, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst ) to severe (pain level of 7 to 10, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) pain. Review of Resident 85' s MAR for 7/2025 and 8/2025 showed the hydrocodone-acetaminophen 5-325 mg pain medication was administered to Resident 85 on the following dates and times: - on 7/26/25 at 1208 hours, - on 7/27/25 at 1152 hours, - on 7/28/25 at 1627 hours, - on 7/29/25 at 2014 hours, - on 7/31/25 at 2023 hours - on 8/1/25 at 2021 hours, and - on 8/4/25 at 2003 hours. Review of Resident 85's medial record failed to show documentation the non-pharmacological interventions for pain were implemented and its effectiveness prior to the administration of the hydrocodone-acetaminophen 5-325 mg pain medication for the above dates and times. On 8/7/25 at 1343 hours, an interview and concurrent medical record review for Resident 85 was conducted with LVN 4. LVN 4 reviewed Resident 85's medical record and verified the above findings. LVN 4 stated the nonpharmacological pain interventions were not documented and should be documented in the nurse's progress notes. On 8/11/25 at 0841 hours, an interview was conducted with the DON. The DON stated when the resident complained of pain, the licensed nurse should assess the resident's pain and should implement the non-pharmacological pain interventions. The DON stated if the non-pharmacological interventions for pain were ineffective then the licensed nurse should administer the PRN pain medications as ordered by the physician. The DON further stated if the non-pharmacological interventions for pain were effective, then the pharmacological intervention would not be needed. The DON stated, the non-pharmacological interventions implemented should be documented in the MAR and if the licensed nurses were not able to document in the MAR, the licensed nurse should document the non-pharmacological interventions in the progress notes. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. Medical record review for Resident 10 was initiated on 8/5/25. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed a physician's order dated 6/11/25, for hydrocodone-acetaminophen (a controlled pain medication) 5-325 mg, to be administered every six hours PRN for moderate to severe pain. Review of Resident 10's MAR for August 2025 showed the hydrocodone-acetaminophen medication was administered to the resident on 8/2/25 at 2121 hours, and 8/4/25 at 0936 hours. Review of Resident 10's medical record failed to show the non-pharmacological interventions were attempted prior to administering the hydrocodone-acetaminophen medication. On 8/7/25 at 1442 hours, an interview and concurrent record review for Resident 10 was conducted with the DON. The DON reviewed Resident 10's MAR for 8/2025 and verified the resident received the hydrocodone-acetaminophen medication twice for moderate to severe pain. The DON stated the non-pharmacological interventions should be attempted prior to administering the PRN pain medications and verified Resident 10's medical record failed to show non-pharmacological interventions were attempted prior to administering the hydrocodone-acetaminophen medication to the resident.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of three final sampled residents (Resident 28) reviewed for dialysis. * The facility failed to ensure a physician's order for the peritoneal dialysis was obtained including the care of the dialysis access site of Resident 28. These failures had the potential for medical complications related to not obtaining the physician's order for dialysis care.Findings: Review of the facility's P&P titled Peritoneal Dialysis dated 12/19/22, showed the physician's order for the individualized prescriptions must include at least the number of exchanges or cycles to be done during each dialysis session, the volume of fluid with each exchange, duration of fluid in the peritoneal cavity, the concentration of glucose or other osmotic agent to be used for fluid removal, and the use of automated, manual or combined techniques. Before, during and after receiving the peritoneal dialysis, the facility staff must, based on the physician's orders and professional standards of practice, do the following: obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress; monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension; report identified or suspected complications immediately to the attending physician and dialysis staff to enable timely interventions; documentation of ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection, and bleeding at the site; and monitor for complications such as peritonitis. On 8/5/2025 at 0909 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 28. Resident 28 was observed awake on his left side position in bed. A dialysate bag was observed hung on the IV pole infusing via gravity connected to Resident 28's peritoneal dialysis access site on the abdomen, and the drainage bag was on the floor with a towel underneath. Resident 28 stated his dialysis was ongoing and doing it two times a day everyday in the morning and in the afternoon for approximately three to four hours. Medical record review for Resident 28 was initiated on 8/5/25. Resident 28 was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease and dependence on dialysis. Review of Resident 28's Order Summary Report for 8/2025 failed to show a physician's order for peritoneal dialysis at the bedside, including the assessment of the peritoneal dialysis access site before, during, and after dialysis. Further review of Resident 28's medical record failed to show documented evidence of Resident 28's assessment before, during, and after dialysis. On 8/6/2025 at 1335 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 was asked about Resident 28's peritoneal dialysis. RN 1 verified Resident 28 had peritoneal dialysis. RN 1 stated there was a kit for peritoneal dialysis which with the dialysate and the drainage bag. RN 1 stated and verified the peritoneal dialysis was given to Resident 28 two times a day, everyday. RN 1 was asked about the physician's order for administering the peritoneal dialysis to Resident 28. RN 1 accessed Resident 28's electronic medical record, verified and acknowledged there was no physician's order for the peritoneal dialysis. When RN 1 was asked about the documentation for the ongoing peritoneal catheter care monitoring and assessment, RN 1 was not able to show any documentation. On 8/11/2025 at 1139 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the consultant pharmacist performed a monthly Medication Regimen Review to identify potential medication irregularities for two of five sampled residents (final sampled residents, Residents 28 and 65) reviewed for unnecessary medications. * The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist in June and July 2025 for Resident 65 addressed the use of two antidepressant medications (mirtazapine and trazodone) and antipsychotic medication (Risperidone). *The facility failed to ensure the Medication Regimen Review conducted by the consultant pharmacist for July 2025 for Resident 28 addressed the irregularities and inaccurate monitoring of the poor meal intake of less than 50% of his meals, as ordered by the physician. These failures placed the residents at risk for adverse outcomes related to the medications they were receiving.Findings: Review of the facility's P&P titled Medication (Drug) Regimen Review (MRR) dated 6/2021 showed the consultant pharmacist is required to perform a comprehensive Medication Regimen Review at least monthly. The Medication Regimen Review includes evaluating the resident's response to medication therapy to ensure the resident maintains the highest practicable level of functioning and to prevent or minimize adverse consequences related to medication therapy. 1. Medical record for Resident 65 was initiated on 8/5/25. Resident 65 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 65's Order Summary Report dated 8/6/25, showed physician's order dated: -5/13/25, for risperidone (antipsychotic) oral tablet 0.5 mg give by mouth two times a day for Schizophrenia manifested by auditory hallucinations, hearing voices. On hold from 7/17 to 7/20/25; -5/13/25, for risperidone oral tablet 1 mg give one tablet by mouth at bedtime for Schizophrenia manifested by auditory hallucination, hearing voices. On hold from 7/17 to 7/20/25; -6/20/25, for trazodone (antidepressant) HCL tablet 100 mg give one tablet by mouth at bedtime related to depression, unspecified manifested by inability to sleep. On hold from 7/17 to 7/20/25; and -6/30/25, for mirtazapine (antidepressant) tablet 7.5 mg give one tablet by mouth at bedtime for depression manifested by poor PO intake. On hold from 7/17 to 7/20/25 Review of the facility's June and July 2025 Medication Regimen Review Current Resident Listings showed a list of the residents whose medication regimens were reviewed by the consultant pharmacist. However, review of the facility's Medication Regimen Review binder failed to show the consultant pharmacist conducted a Medication Regimen Review for Resident 65 to include the use of the psychotropic medications for June and July 2025. On 7/25/25 at 1030 hours, an interview and concurrent medical record review for Resident 65 was conducted with the DON. The DON stated that the consultant pharmacist was expected to conduct a Medication Regimen Review for all the residents at the facility every month. The DON verified Resident 65 should have had a Medication Regimen Review conducted by the consultant pharmacist for June 2025 and July 2025, specifically for the use of the psychotropic medications which included Trazodone, Risperidone, and Remeron. The DON confirmed the findings. 2. Medical record review for Resident 28 was initiated on 8/5/25. Resident 28 was admitted to the facility on [DATE], with a diagnosis of depression. Review of Resident 28's Order Summary Report dated 8/7/25, showed a physician's order dated 6/3/25, and discontinued on 8/6/25, to administer mirtazapine 0.5 mg tablet by mouth at bedtime for depression manifested by poor intake less than 50% of each meal. Another physician's order dated 6/3/25, showed to monitor poor intake less than 50% of meals and record the number of times the behavior was manifested every shift. Review of Resident 28's Nutrition Amount Eaten record for the last 30 days dated 7/10, 7/11, 7/18, 7/22, 7/26, 7/27, 7/28, 8/2, 8/4, and 8/5/25, showed Resident 28 consumed less than 50% of his meals. Review of Resident 28's Monitor Record from 7/1 through 7/31/25, for the monitoring of poor intake less than 50% of meals, showed zero number of times the behavior manifested every shift. The information documented on the Monitor Record was inconsistent with the information documented on the Nutrition Amount Eaten, on the specified dates. Further review of Resident 28's medical record failed to show evidence of the monthly behavior monitoring summary was completed. Review of Resident 28's consultant pharmacist's Medication Regimen Review for July 2025 showed no recommendation or any irregularities. However, the review of Resident 28's medical record showed documentation of irregularities and inaccurate monitoring of the poor intake of less than 50% of Resident 28's meals, as a behavior manifestation for the use of the antidepressant medication. On 8/7/2025 at 1043 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified and acknowledged Resident 28 was on antidepressant medication and was monitored for poor intake less than 50%. RN 1 was asked on who determined the meal percentage of Resident 28 and stated the CNAs recorded the meal percentage on the meal percentage record. RN 1 was able to show the meal percentage record of the resident for the past 30 days and verified there were episodes the resident had less than 50% meal percentage. RN 1 was asked about the monitoring of the behavior of the resident. RN 1 was able to show the monitoring of behavior for July 2025 and verified there was zero behavior documented of poor intake less than 50%. RN 1 verified and acknowledged the monitoring of the behavior for poor intake was inaccurate. RN 1 was asked if there was a monthly summary of behavior documented for Resident 28's poor intake for the past months. RN 1 reviewed Resident 28's medical record and verified there was no monthly summary of behavior documented and completed. On 8/7/2025 at 1125 hours, an interview and concurrent medical record review for Resident 28 was conducted with the DON. The DON was asked about the resident's antipsychotic medications. The DON stated they monitored the resident and made sure the medication was being given to the resident, and the behavior was being monitored. The DON was informed of the irregularities about the medication monitoring of Resident 28 for the use of mirtazapine medication, and of inconsistent and inaccurate monitoring for the behavior of poor intake of the resident. The DON was also informed of the monthly summary not completed and the consultant pharmacist Medication Regimen Review for the past month did not identify any irregularities. The DON verified and acknowledged the monitoring behavior of poor intake was inaccurate and there was no monthly summary of the resident's behavior. Cross reference F605, example # 3.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 21 final sampled residents (Resident 59) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the metoprolol (blood pressure medication) medication when Resident 59's SBP (Systolic Blood Pressure) was less than 120 mmHg. This failure had the potential for Resident 59 to develop significant adverse and side effects from the medication. Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications were administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. Further review of the P&P showed to obtain and record the vital signs, when applicable or per the physician's orders. When applicable, hold the medication for those vital signs outside the physician's prescribed parameters. To administer the medication as ordered in accordance with manufacturer specifications and sign the MAR after the administration. For those medications requiring vital signs, to record the vital signs onto the MAR. Medical record review for Resident 59 was initiated on 8/5/25. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's plan of care showed a care plan problem dated 7/17/25, addressing Resident 59's risk for complications related to hypertension. The interventions included to administer the anti-hypertensive medications as ordered and to observed the blood pressure and/or pulse monitoring parameters prior to the medication administration. Review of Resident 59's Order Summary Report dated 8/6/25, showed a physician's order dated 7/22/25, to administered metoprolol 25 mg one tablet by mouth every 12 hours for hypertension (high blood pressure) and to hold if the SBP was less than 120 mmHg or the heart rate was less than 60 beats per minute. Review of Resident 59's MAR for August 2025 showed Resident 59 was administered the metoprolol 25 mg medication on the following dates and times when Resident 59's SBP was less than 120 mmHg:- On 8/1/25 at 2100 hours, when Resident 59's SBP was 118/60 mmHg;- On 8/2/25 at 2100 hours, when Resident 59's SBP was 110/68 mmHg;- On 8/3/25 at 2100 hours, when Resident 59's SBP was 118/72 mmHg; and - On 8/5/25 at 0900 hours, when Resident 59's SBP was 116/75 mmHg; and at 2100 hours, when Resident 59's SBP was 118/66 mmHg. On 8/7/25 at 1428 hours, an interview and concurrent medical record review for Resident 59 was conducted with LVN 4. LVN 4 stated Resident 59 had the diagnosis of hypertension and was administered the blood pressure (BP) medications. LVN 4 stated when administering the BP medications, the resident's BP and heart rate were obtained prior to administering the BP medication. LVN 4 stated if the BP reading and heart rate were within the parameters ordered by the physician, the BP medication would be administered. LVN 4 stated a checkmark in the MAR indicated the medication was administered to the resident. LVN 4 reviewed Resident 59's MAR for August 2025 and verified the above findings. LVN 4 stated the metoprolol medication should have been held as per the physician's order. On 8/11/25 at 0841 hours, an interview was conducted with the DON. The DON stated for the administration of the BP medications with ordered parameters, the licensed nurses were expected to take the appropriate vital signs and compare the vital signs with the ordered parameters prior to the administration of the medication. The DON stated the checkmarks on the MAR meant the licensed nurse had documented the licensed nurse administered the medication to the resident. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 29.63%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration observations. * LVN 3 failed to administer the complete dose for six of Resident 2's medications when significant residual of the medications were observed in the medication cups and nebulizer cup. In addition, LVN 3 combined two GT medications and failed to administer the two medications as per the physician's order. * LVN 5 failed to obtain Resident 33's heart rate prior to the administration of the carvedilol (blood pressure medication). These failures had the potential to negatively affect the residents' health.Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications were administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. Further review of the P&P showed to obtain and record vital signs, when applicable or per the physician's orders. When applicable, hold the medication for those vital signs outside the physician's prescribed parameters. To review the MAR to identify the medication to be administered and to compare the medication source (bubble pack, vial, etc.) with the MAR to verify the resident name, medication name, form, dose, route, and time. 1. On 8/6/25 at 0800 hours, a medication administration observation for Resident 2 was conducted with LVN 3. LVN 3 prepared and administered the following medications to Resident 2:- one packet of Juven (wound healing supplement) mixed in six-ounces of water;- one tablet of vitamin C (supplement) 500 mg;- two tablets of docusate sodium (stool softener) 100 mg;- one table of simethicone (gas relief) 125 mg;- 30 ml of LiquaCel (liquid protein);- 5 ml of Multivite Liquid (supplement);- 17 gm of polyethylene glycol (laxative) powder 3350;- one vial of budesonide (inhaled corticosteroid used to manage and prevent symptoms like difficulty breathing, chest tightness, wheezing, and coughing associated with asthma) inhalation suspension 0.5 mg/2 ml; and- 1 ml of heparin (anticoagulant) 5000 units. During the medication administration observation for Resident 2, LVN 3 was observed pouring the MultiVite liquid medication into the irrigation syringe. LVN 3 was then observed adding the polyethylene glycol mixture to the MultiVite liquid medication before it was fully administered through the GT. After the administration of the GT medications, the following was observed:- three medication cups with significant white-colored medication residue;- one medication cup with brown-colored liquid; and- one cup with orange-colored powder mixture remaining in the cup. On 8/6/25 at 0844 hours, an interview and concurrent observation was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 identified the above medications were the Juven, LiquCel, docusate sodium, simethicone, and vitamin C. LVN 3 stated for the administration of the medications through the GT, the medication should be administered via gravity and flushed in between each medication. LVN 3 stated each medication should be completely administered before adding the next medication. On 8/6/25 at 0851 hours, an interview and concurrent observation was conducted of LVN 3. LVN 3 was observed removing Resident 2's nebulizer mask and placing the nebulizer set up inside the clear bag. LVN 3 was not observed checking the nebulizer cup to ensure there was no medication left in the nebulizer cup. When asked, LVN 3 verified he did not check the nebulizer cup to see if the complete dose was administered. An observation of the nebulizer cup was conducted with LVN 3. LVN 3 verified there was medication left inside the nebulizer cup. LVN 3 stated if there was still medication observed in the nebulizer cup, he should continue the breathing treatment until the dose was completely administered. Review of Resident 2's Order Summary Report dated 8/6/25, showed the following physician's orders dated 6/6/25:- to administer simethicone 80 mg via GT three times a day for gastroesophageal reflux disease (chronic digestive disorder where stomach acid frequently flows back into the esophagus). However, LVN 3 was observed administering simethicone 125 mg to Resident 2 during the medication administration observation.- to administer polyethylene glycol powder 1450 17 gm via GT one time a day for bowel management. However, LVN 3 was observed administering polyethylene glycol powder 3350 to Resident 2 during the medication administration observation. On 8/6/25 at 1108 hours, a follow-up interview and concurrent medical record review for Resident 2 was conducted with LVN 3. LVN 3 reviewed the physician's order and verified he administered the wrong doses for the simethicone and polyethylene glycol powder medications. When asked, LVN 3 stated he did not have the simethicone medication 80 mg in his medication cart. On 8/6/25 at 1135 hours, an interview and concurrent observation was conducted with LVN 5. LVN 5 stated she did not have the simethicone medication 80 mg in her medication cart. On 8/6/25 at 1140 hours, an interview and concurrent observation was conducted of Medication Cart A and Medication Room A with LVN 6. LVN 6 stated she did not have the simethicone medication 80 mg in her medication cart and stated Medication Room B only had the simethicone 125 mg medication bottles available. On 8/6/25 at 1145 hours an interview was conducted with the DON. The DON stated the over-the-counter facility stock supply of medications were all kept inside Medication Room B. 2. On 8/6/25 at 0902 hours, a medication administration observation was conducted for Resident 33 with LVN 5. LVN 5 obtained Resident 33's blood pressure reading, then prepared and administered the following medications to Resident 33:- one tablet of carvedilol (blood pressure medication) 12.5 mg;- one tablet of valsartan (blood pressure medication) 320 mg;- one tablet of spironolactone (diuretic medication) 100 mg;- one tablet of chlorthalidone (diuretic and blood pressure medication) 25 mg;- one tablet of amlodipine (blood pressure medication) 10 mg;- one tablet of Nephro-Vite (Vitamin supplement); and- one 4% lidocaine patch (pain reliever). Medical record review for Resident 33 was initiated on 8/6/25. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's Order Summary Report dated 8/6/25, showed a physicians' order dated 7/23/25, to administer carvedilol 12.5 mg one tablet by mouth two times a day for hypertension. To hold if the SBP was less than 100 mmHg or the heart rate was less than 60 beats per minute. However, LVN 5 was not observed obtaining Resident 33's heart rate prior to the administration of the carvedilol medication. On 8/6/25 at 1018 hours, an interview and concurrent medical record review for Resident 33 was conducted with LVN 5. LVN 5 verified she did not check Resident 33's heart rate prior to the administration of the carvedilol medication. LVN 5 stated she went back to check Resident 33's heart rate after the administration of the carvedilol medication and Resident 33's heart rate was 70 beats per minute. On 8/11/25 at 0841 hours, an interview was conducted with the DON. The DON stated during the administration of the medication via the GT, if the licensed nurse observed residual medication in the medication cups, the licensed nurse should add more water, stir the content, and administer the complete dose of the medication. The DON stated for the administration of the medications, the licensed nurses were expected to compare the physician's order with the medication available on hand to ensure the medication, route and dose were correct. The DON stated the licensed nurses should review the ordered parameters and hold the medication if the ordered parameters were not met. On 8/11/25 at 1124 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of six residents (nonsampled Resident 29) reviewed for resident council. * The facility failed to ensure Residents 29's call light was functioning properly. This failure had the potential to negatively impact Resident 29's psychosocial well-being or result in a delay to provide care.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 12/19/22, showed the facility is adequately equipped with a call light and the facility staff ensure the call light will be accessible to residents while in bed within the resident's room. On 8/6/25 at 1035 hours, a resident council meeting was conducted with the selected residents of the facility. Resident 29 attended the resident council meeting and expressed her concern about her call light not functioning. Resident 29 stated about two weeks ago, the facility were made aware about her call light not functioning and she was provided a call bell to use to call the facility staff when she needed assistance. Resident 29 stated she needed to wait a longer period of time for the nurses when she needed assistance. Medical record review for Resident 29 was initiated on 8/6/25. Resident 29 was admitted to the facility 5/24/25. Review of Resident 29's plan of care showed a care plan problem dated 8/3/23, addressing Resident 29's risk for falls. The interventions included to keep the call light within reach at all times. On 8/7/25 at 0848 hours, an observation and concurrent interview with Resident 29, LVN 3, and the Social Services Assistant was conducted. LVN 3 was in the hallway near Resident 29's room and stated Resident 29's bedroom door remained closed all the time because it was the residents' preference to have the door closed at all times. Resident 29 was observed in bed with the call bell on top of the over bed table in front of her. Resident 29 stated she was informed by the maintenance staff about her call light and there was a sound at the nurse's station but there was no light flashing on the panel to indicate her call light was turned on. Resident 29 tested her call light and pressed the red button. Resident 29's call light indicator above the door was not flashing and the call light indicator panel in the nurse's station was observed with an audible sound (beeping). However, there was no light indication to show what room call light was turned on to determine which room/resident needed assistance. During the interview with the Social Services Assistant who was at the nurse's station, the Social Services Assistant was asked which room had the call light on and needed assistance. The Social Services Assistant was unable to tell which room had the call light on and was observed going to the hallways and asking the other facility staff to ask their assigned residents who turned on their call light. The Surveyor returned to Resident 29's room and Resident 29 was asked how she felt about her call light not working. Resident 29 stated she was worried that if she needed urgent assistance, the facility staff might not come right away. Resident 29 stated the call bell did not work, specially when the door in her room was closed. Resident 29 added she needed to be turned and repositioned in the bed every two hours and sometimes she needed to remind and call the facility staff to reposition her in bed but sometimes the facility staff did not respond to her call bell right away. On 8/7/25 0859 hours, an observation and concurrent interview was conducted with CNA 6. CNA 6 was observed attending to Resident 29's need. CNA 6 was asked about the call light of the resident and stated she was aware Resident 29's call light was not working. CNA 6 stated she was made aware about two weeks ago, and she provided the call bell to the resident. On 8/7/25 at 0915 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated he was made aware about Resident 29's call light not functioning. The Maintenance Director stated the contracted company technician was at the facility and fixed the bulb on the call light panel and in the hallway, which were both working well. The Maintenance Director was informed about the observation about the call light of Resident 29. The Maintenance Director verified and acknowledged the call light of the resident was not functioning well. The Maintenance Director was asked to show the work order documentation regarding the resident's call light malfunction. The Maintenance Director verified and acknowledged he was made aware about the call light problem verbally and there was documentation to show the work order for Resident 29's call light. 8/7/25 at 0924 hours, a follow up interview was conducted with the Maintenance Director. The Maintenance Director showed an email from the contracted company technician indicating the company was waiting for replacement parts to fix the call light for Resident 29. On 8/7/25 at 1355 hours, an interview was conducted with the Administrator. The Administrator acknowledged and verified he was aware about Resident 29's call light problem. The Administrator was asked on what other alternatives could be provided, while waiting for the parts for the call light system to be fixed besides providing the resident with a call bell in the room. The Administrator verified and acknowledged the IDT did not have any alternatives to provide for the resident besides the call bell, when she needed to call for assistance. The Administrator was asked about Resident 29's preferences for her bedroom door to be close at all times, and the ineffectiveness of the call bell when the bedroom door was closed. The Administrator verified and stated he was aware about Resident 29's preferences.

Based on interview, clinical record review, and facility document review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) to prevent a fall which resulted in injury. Resident 1 required assistance to ambulate; however, she was frequently observed by staff to ambulate without assistance. Resident 1 was in the dining room after dinner, without supervision, and sustained a fall from a wheelchair with a head injury. Resident 1 was transferred via 911 ambulance to the ED, evaluated, and treated for [REDACTED]. Failure to provide adequate supervision to reduce the risk for falls and meet the resident's needs for safety had resulted in avoidable harm. Findings: On 4/29/15 at 1205 hours, an interview was conducted with Resident 1's family member. The family member stated she took the resident to see an orthopedist in the morning of 4/15/15, for a swollen left thumb. An x-ray was taken of Resident 1's left thumb during the office visit and showed the resident's left thumb was fractured. The resident was treated with a spica splint closed thumb cast and then returned to the facility. On 4/29/15 at 0950 hours, an interview was conducted with the Administrator and Acting DON. The Administrator and Acting DON stated the resident was able to propel herself in the wheelchair and scooted with her feet. They both confirmed the resident got up and out of the wheelchair without assistance, and confirmed the resident should not be doing this. The facility was unable to determine the cause of the left thumb fracture. Clinical record review was initiated for Resident 1 on 4/29/15. Resident 1 was readmitted to the facility on [DATE], after being transferred to the ED for a fall sustained on 4/15/15, resulting in a forehead laceration, a hematoma on the right cheek, and a fracture of the nasal bone. According to the H&P dated 9/3/14 and 4/23/15, the resident did not have the capacity to understand and make decisions. According to the MDS dated [DATE], the resident required limited assistance for all ADL care. The resident ambulated with assistance using a walker, was frequently incontinent of urine, and had moderately impaired vision (indicating the resident's vision was limited but objects could be seen). Resident 1's cognitive assessment showed Resident 1 had severe cognitive impairment. Review of the physician's orders [REDACTED]. Review of the care plan problem dated 8/27/14, to address being at risk for unavoidable falls secondary to impaired mobility and other conditions showed the resident had episodes of getting up unassisted. Approaches listed included bed/chair alarms, instructing the resident not to get up unassisted, calling for help, and continuing to assist the resident to the bathroom as needed. The care plan did not address supervision of the resident. Review of a Fall Risk Evaluation conducted on 4/7/15, showed Resident 1 was assessed to be at high risk for falls with a score of 22 (high risk is identified when scores are 10 or higher). Documentation showed the resident had fallen within the past 90 days, had moderately impaired vision, required assistance with toileting, had ambulatory problems using devices, and gait (walk) was unsteady. Balance was not stable and the resident was identified to have existing health conditions which placed her at risk for falls. During an interview with Resident 1's family member on 4/29/15 at 1205 hours, the family member stated upon the resident's return from the orthopedic appointment on 4/15/15, for the fractured left thumb, she had met with the Administrator and DON. She stated she had asked them to keep a close eye on Resident 1 and her left thumb cast, and remind them the resident had urgency to go to the bathroom. On 4/30/15 at 1400 hours, during a telephone interview with the Ombudsman, the Ombudsman said Resident 1's family member had spoken with the Administrator and DON who had told her they would keep a close eye on the resident. However, review of the resident's plan of care showed no documented evidence the care plan was revised to address how staff were to adequately supervise the resident to prevent from falls even after staff had been asked to provide more supervision as the resident had just sustained a left thumb fracture on 4/15/15, with a spica splint closed thumb cast in place. On 4/29/15 at 0950 hours, an interview and concurrent facility document review was conducted to review the facility's investigation regarding Resident 1's fall with injury on 4/15/15 at 1815 hours. The investigation showed Resident 1 was unattended in the dining room, sitting in her wheelchair when she fell to the floor. Staff were not present to witness the resident's fall; however, there were two residents sitting near her who had witnessed the fall. Resident A stated the resident slipped off the chair, and Resident B stated the resident was trying to turn the wheelchair around toward the door. The investigation also showed CNA 1 was assigned to care for residents in the dining room; however, CNA 1 was assisting other residents in the hallway when Resident 1 fell . CNA 1 and LVN 4 heard a call for help. When they responded, they found Resident 1 lying face down on the floor in the dining room with blood coming from her nose and forehead. Staff called 911 at 1820 hours, and the resident was immediately transferred to the ED with paramedics for sustaining a fall with injury. The facility concluded Resident 1 takes herself to the bathroom without assistance from staff, despite multiple reminders to ask for assistance. And, the hard cast and limited mobility in the left hand probably contributed to the resident's fall. On 4/29/15 at 1110 hours, an interview was conducted with Resident A. Resident A stated Resident 1 was moving the wheel of her wheelchair to turn the wheelchair towards the door. Resident A stated Resident 1 stood up from her wheelchair. Resident A stated she immediately called out help! in an effort to get someone to keep Resident 1 from falling. Resident A was asked to describe what Resident 1 was attempting to do when she stood up. Resident A stated she did not recall if the resident stood straight up or if she was attempting to get up. Resident A stated, It all happened so fast! On 4/29/15 at 1200 hours, an attempt was made to interview Resident B; however, she was not able to be interviewed. Review of the H&P from the hospital dated 4/15/15, showed the resident experienced a mechanical fall and sustained a forehead laceration, a hematoma on the right cheek, and a fracture of the nasal bone. Documentation also showed the resident was legally blind in both eyes, had dementia, and was assessed to be wheelchair bound, unable to walk. Review of an IDT note dated 4/16/15 at 1610 hours, showed the IDT met regarding the resident's fall on 4/15/15. CNA 1 and LVN 4 went to the dining room when they heard an alarm going off and someone calling for help. Documentation showed pressure was applied to the resident's head and nose which were actively bleeding. Emergency 911 was called and the resident was transferred to the ED. On 5/5/15 at 1710 hours, a telephone interview was conducted with LVN 4. She was asked to describe Resident 1's behavior prior to the fall on 4/15/15. LVN 4 stated CNA 1 told her Resident 1 was upset, saying she did not want the cast on her left arm. LVN 4 determined the color, motion, and sensitivity to the left arm and hand were good, and she advised the resident about the importance of the cast to be left in place. LVN 4 stated the resident told her it (the cast) bothers me. LVN 4 stated she was in the hallway passing medications when she heard a loud call for help. She went to the dining room and found Resident 1 face down on the floor. She stated the wheelchair was turned slightly to the right side where the resident had been sitting at the table close to the television. LVN 4 stated she heard the alarm was going off at about 1815 hours. She went to the dining room and the resident was responsive, stating she was okay. LVN 4 observed blood suddenly coming out from the resident's head, so she applied pressure with a clean towel and stayed with the resident until the Paramedics came. The Paramedics arrived in approximately five minutes, and the resident was transferred to the ED. On 5/5/15 at 1720 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he did not observe any problems with Resident 1's behavior prior to the fall. He was asked to state when the resident was last assisted to the bathroom prior to the fall. He stated it was about 1800 hours. He stated, she has to go to the bathroom every 5-10 minutes. He denied the resident asked him to assist her to the bathroom after 1800 hours and prior to the fall. CNA 1 was asked if he left Resident 1 in the dining room unattended. He stated, Yes. I was the only staff person assigned to the dining room-just me-I'm the only one. I have to leave to take residents back to their nursing station. CNA 1 was asked if it was his usual routine to leave residents in the dining room in order to take other residents back to the nurses' station. CNA 1 said, Yes. I normally take residents back to the nursing station, even if there is no other staff available to stay with the residents. CNA 1 stated when he left the dining room, Resident 1 was having a conversation with other residents.

Based on interview and closed clinical record review, the facility failed to provide adequate supervision for one of one sampled residents (Resident 1) to prevent a fall which resulted in injuries. Resident 1 was found lying on the bathroom floor after the CNA (CNA 1) left the resident unattended. The resident sustained [REDACTED]. Failure to provide adequate supervision resulted in avoidable harm. Findings: Closed clinical record review for Resident 1 was initiated on 11/19/13, which showed Resident 1 was admitted to the facility on [DATE]. The admitting assessment showed the resident had difficulty walking due to muscle weakness and was receiving hospice care. Review of the MDS (assessment tool) dated 10/14/13, showed Resident 1 was alert, confused and required one persons assistance for all activities of daily living, including transfers and toileting. Review of a care plan problem dated 8/25/13, titled "At risk for further unavoidable falls secondary to history of falls, decreased mobility, poor safety awareness" related to dementia and difficulty walking, showed the interventions included one person assistance with all transfers and bed/chair alarm to alert the resident and staff when she tries to get up unassisted. On 10/17/13, Resident 1 sustained an unwitnessed fall when she was left unattended in the bathroom. Review of the facility's investigation dated 10/17/13, showed Resident 1 was assisted to the bathroom by CNA 1 on 10/17/13 at 0925 hours. CNA 1 was called to assist another resident and left Resident 1 unattended, sitting in her wheelchair in the bathroom. At approximately 0930 hours, a housekeeper entered Resident 1's room and found Resident 1 lying on the bathroom floor. The housekeeper immediately notified nursing staff. Review of a licensed nurse's note dated 10/17/13, showed at 0930 hours, the license nurse was summoned to Resident 1's room by a CNA. The resident was assessed to have a skin tear to her left forehead (measuring 5 cm x 4 cm), which was bleeding. The resident was assisted back to bed and a neuro-check (assessment of cognition, sensory and reflexes) was performed. At 0940 hours, the resident was observed to be restless and complaining of pain. The physician and family were notified but denied transferring the resident to the acute hospital for evaluation. At 1200 hours, Resident 1's forehead skin tear was noted to have increased bleeding ("dressing of skin tear saturated with blood.") and had increased in size (9 cm x 6 cm with superficial depth). The hospice RN and physician were notified and ordered the resident be transferred to the acute hospital emergency department (ED). The family was at the resident's bedside and agreed. Resident 1 returned from the acute hospital ED the same day. Staff identified she had nine staples closing the wound on her forehead and was wearing a neck brace. The resident had sustained a fracture at the odontoid process (base of the skull) and a fracture to her cervical spine (C1, immediately below the base of the skull) as a result of the fall. According to Medscape (on-line professional resource) a fracture at C1 has a high risk for death. Review of the ED Patient Discharge Instruction Summary dated 10/17/13, showed the resident's family member was advised of the resident's ondontoid fracture and possible fatal outcome. Additional review of the facility's documents showed CNA 1 assisted Resident 1 from the toilet to the wheelchair. While CNA 1 was looking for an incontinence brief (in the resident's room), another staff member passed by and informed the CNA another resident was trying to get out of bed. CNA 1 left Resident 1's room to check on the other resident. When she returned, a housekeeper told her Resident 1 was lying on the bathroom floor. The facility concluded CNA 1 left the resident in the bathroom unattended and Resident 1 sustained an unwitnessed fall resulting in a laceration on her forehead and fractures to her neck. On 11/21/13 at 1200 hours, a telephone interview was conducted with CNA 2. She was not assigned to care for Resident 1 on 10/17/13; however, she had provided care to Resident 1 on previous occasions. CNA 2 was asked if Resident 1 required assistance for transfers and toileting. She stated, yes. When asked if the resident was safe to be left alone in the bathroom, CNA 2 stated "I always stayed with her...sometimes she tried to get up on her own." On 11/21/13 at 1315 hours, a telephone interview was conducted with LVN 1. She stated she was passing medications when CNA 1 called her to come to Resident 1's bathroom. She stated, when she got to the resident's bathroom, she found the resident on the floor lying on her right side, in a fetal position, facing the sink, with her hand on her head. The wheelchair was on her right, just next to the toilet. On 11/21/13 at 1345 hours, a telephone interview was conducted with CNA 1. She stated the resident needed assistance with toileting and transfers. She stated Resident 1 was alert and she would call for assistance to go to the bathroom. CNA 1 stated she had taken Resident 1 to the bathroom on 10/17/13 at 0925 hours. After the resident finished voiding, she assisted her to get back to her wheelchair. She stated she briefly left the resident alone in the bathroom to retrieve an incontinence brief from the resident's room. She said she had left the bathroom door open so she could observe her. However, a staff member walking down the hall asked CNA 1 to assist another resident who was attempting to get out of bed unassisted. CNA 1 stated she was afraid the other resident could fall and chose to leave Resident 1 to check on the other resident. When asked if the bathroom floor was wet or slippery, CNA 1 stated, "No," and there was nothing on the floor to cause her to fall. During a telephone interview and concurrent closed clinical record review with the DON on 11/21/13 at 1400 hours, the DON confirmed Resident 1 was at risk for falls. The DON stated Resident 1 had a history of [REDACTED]. The DON stated the resident's care plan was current, and confirmed the approach for a bed/chair alarm was used by the resident. There was no alarm in place at the time when the resident fell .