Every finding on record at Canyon Oaks Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one of two sampled residents (Resident 1), by failing to document the administration of Resident 1's medications on the Treatment Administration Record (TAR - a report detailing the physician ordered care and medications administered to a resident by the licensed nurse in the facility). This deficient practice had the potential to result in medication errors and/or confusion about the care provided.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/5/2026 with diagnoses that included gastrointestinal hemorrhage (any blood loss within the digestive tract, spanning from the mouth to the rectum), Barrett's esophagus (a condition where the flat lining of the lower food pipe gets damaged by long-term acid reflux [when stomach acid flows up into your food pipe]), and anemia (a condition characterized by a decrease in the normal number of red blood cells, which reduces the blood's ability to carry oxygen to body tissues). During a review of Resident 1's History and Physical (H&P - a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 8/6/2026, the H&P indicated Resident 1 had decision-making capacity. During a review of Resident 1's TAR for 8/1/2026 - 8/31/2026, the TAR indicated Resident 1 had scheduled topical (medicine meant to be put directly onto the surface of the body) medications that were due to be administered during the evening shift (3 p.m. - 11 p.m.) of 8/7/2026, which included:- Mupirocin (antibiotic used to treat skin infections) topical ointment (a thick, oil-based medicine or skin product) 2% (contains 20 milligrams [mg - unit of measurement] of active mupirocin for every 1 gram [g - unit of measurement] of ointment).- Pimecrolimus (medicine that calms an overactive skin immune system, which lowers inflammation, redness, and itching) topical cream 1% (contains 10 mg of active pimecrolimus for every 1g of cream).- Triamcinolone acetonide (medicine used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) topical cream 0.1% (contains 1 mg of active triamcinolone acetonide for every 1g of cream).Resident 1's TAR dated 8/7/2026 indicated the evening shift, 3 p.m. to 11 p.m., was left blank with no indication if Resident 1 received the scheduled topical medications. During an interview on 8/12/2026 at 3:38 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that during the 7 a.m. to 3 p.m. shift, there is usually a designated treatment nurse that is responsible for completing the TAR for the residents. LVN 3 further stated that there is no treatment nurse during the 3 p.m. to 11 p.m. shift and therefore the nurses passing out medications are also responsible for providing any wound care and/or topical medications on their assigned resident's TAR. LVN 3 stated that when administering any medication, each medication should be signed off right after it is given. During a concurrent interview and record review on 8/12/2026 at 4:10 p.m., with the Director of Nursing (DON), reviewed Resident 1's TAR for 8/1/2026 - 8/31/2026. The DON stated LVN 2 was assigned to administer Resident 1's medication and treatments on 8/7/2026 for the evening shift. The DON stated the 5:00 p.m. medications which included mupirocin, pimecrolimus, and triamcinolone acetonide for 8/7/2026 on Resident 1's TAR were left blank. The DON stated LVN 2 had most likely gave the medications, but had just forgotten to sign off on Resident 1's TAR. The DON stated that per facility protocol, the nurse administering the medication or treatment should document on the Medication Administration Record (MAR) and/or TAR immediately after administering the medication so there is no confusion about whether the medication was administered or not. During a review of the facility's policy and procedure titled, Administering Medications, last revised 4/2019, the policy indicated, it is the policy of the facility to ensure medications are administered in a safe and timely manner and as prescribed. The policy and procedure further indicated topical medications used in treatments are recorded on the resident's TAR. The individual administering the medication initials the resident's administration record on the appropriate line after giving each medication and before administering the next ones.

Based on interview and record review the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 1) by failing to ensure that only medications ordered by the physician for continued use after discharge were provided to Resident 1 upon discharge when on 6/16/2026 Resident 1 was discharged with a vial of Humulin Regular Insulin (medication used to assist with controlling blood sugars) that was not included on the physician-ordered discharge medication list. This deficient practice had the potential for Resident 1 or the responsible party (RP 1) to administer a medication that was not intended for continued use following discharge, placing Resident 1 at risk for hypoglycemia (a medical condition where your blood sugar drops to abnormally low levels, typically below 70 milligrams per deciliter [mg/dl - unit of measure]) resulting in dizziness, confusion, seizures (a sudden, uncontrolled burst of abnormal electrical activity in the brain), loss of consciousness (happens when a person is neither awake nor aware of their environment, and cannot respond to external stimuli) or death.During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 6/7/2026 with diagnoses that include type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and osteoarthritis (a progressive disorder of the joint, caused by a gradual loss of cartilage) of the right knee. During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a resident's medical condition) dated 6/8/2026, the H&P indicated Resident 1 had limited decision-making capacity. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/16/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated Resident 1 required supervision with eating and oral hygiene, and moderate assistance with toileting and showering. During a review of Resident 1's Discharge Medication List (a form used by the facility to list a resident's medications upon discharge) dated 6/15/2026, the Discharge Medication List did not include Humulin Regular Insulin as a medication to be continued following discharge. During a concurrent interview and record review on 7/6/2026 at 10:53 a.m., with RP 1, a photograph of a vial of Humulin Regular Insulin provided by RP 1 to the State Agency (SA) was reviewed. The vial of Humulin Regular Insulin was labeled with a prescription dated 6/7/2026 from the facility Medical Director. RP 1 stated that Resident 1 was discharged from the facility on 6/16/2026. RP 1 further stated that upon arriving at Resident 1's residence, RP 1 found the vial of Humulin Regular Insulin among the medications sent home with Resident 1 upon discharge. RP 1 stated Humulin Regular Insulin was not included on Resident 1's discharge medication regimen and expressed concern that the medication could have been inadvertently administered because it was sent home with the resident. During a concurrent interview and record review on 7/7/2026 at 12:15 p.m., with Registered Nursing Supervisor 1 (RNS 1), Resident 1's Discharge Medication List dated 6/15/2026 was reviewed. RNS 1 confirmed that Humulin Regular Insulin was not listed as a discharge medication on the Discharge Medication List. RNS 1 stated that RNS 1 reviewed the Discharge Medication List with RP 1 prior to discharge. RNS 1 further stated it was possible that RNS 1 provided Resident 1 with the vial of Humulin Regular Insulin upon discharge but was unable to confirm whether the medication had been provided to Resident 1. During a concurrent interview and record review on 7/7/2026 at 12:30 p.m., with the Director of Nursing (DON), Resident 1's Discharge Medication List dated 6/15/2026 was reviewed. The DON confirmed Humulin Regular Insulin was not listed on the Discharge Medication List. The DON reviewed a photograph of a vial of Humulin Regular Insulin prescribed by the facility Medical Director to Resident 1. The DON stated Resident 1 should not have been given the vial of Humulin Regular Insulin upon discharge on [DATE] because it was not included on the physician-ordered discharge medication regimen. The DON further stated this failure had the potential to compromise a safe transition of care and could have resulted in a significant medication error following discharge. During a review of the facility policy and procedures (P&P) titled Discharge Medications last reviewed on 1/21/2026, the P&P indicated that unless otherwise specified by facility policy, or contrary to current laws, medications shall be sent with the resident upon discharge. Controlled substances may not be released to the resident upon discharge.The charge nurse shall verify that the medications are labeled consistent with the current physician orders.The nurse reconcile pre-discharge medications with the resident's post discharge medications. The medication reconciliation will be documented. The nurses shall review medication instructions with the resident, family member or representative before the resident leaves the facility.

Based on observations, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 152 of 152 facility residents. Findings: During a concurrent observation and interview on 5/5/2026 at 8:15 a.m. with the Dietary Supervisor (DS), observed dry and black sticky substance on the grounds in front and to the right of both dumpsters. The left dumpster had black substance dripping from it. The DS stated she cannot identify the source or nature of the black stains and sticky substances. During an interview on 5/5/2026 at 8:58 a.m. with the Director of Maintenance (DOM), the DOM stated the black dumpster is for disposal of regular, non-hazardous trash. The DOM stated he observed there was wet, black substance on the ground in the right front corner of the two black dumpsters. The DOM stated the dumpster area should be clean and without spillage from the dumpsters. The DOM stated the spillage odor can be unpleasant. The DOM stated it was important for the dumpster area to be free from spillage because spills can attract insects, cockroaches, rats that could enter the facility and potentially cause or spread infection to residents. During a review of the facility's P&P titled, Sanitation last reviewed 1/26/2026, the P&P indicated, Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in the dumpster/compactors with kids (or otherwise covered).Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of seven residents (173, 160, and Resident 2) investigated under the accident care area by failing to: a. Provide upper bed rail padding for a resident with a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness) to Resident 173. This deficient practice placed Resident 173 at an increased risk for injuries. b. Ensure that vitamin A&D ointment (a topical skin protectant and moisturizer) and unknown white paste in an unlabeled medicine cup was not left at the Resident 160's bedside. This deficient practice had the potential to place Resident 160 and other residents at an increased risk for application or ingestion of unprescribed A&D ointment and unknown substance which can result allergic reaction or poisoning. c. Ensure that Resident 2 had bilateral floor mats while in bed as ordered by the physician. This failure had the potential to result in injury to Resident 2. Findings: a. During a review of Resident 173's admission Record, the admission Record indicated the facility admitted Resident 173 on 4/29/2026 with diagnoses including traumatic subdural hemorrhage (bleeding between the brain and the tough outer membrane that covers it, caused by a head injury) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 173's History and Physical (H&P), dated 1/26/2026, the H&P indicated Resident 44's had diagnoses including seizures and tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe). The H&P further stated Resident 44 was unable to make his own decisions. During a review of Resident 173's Minimum Data Set (MDS – a resident assessment tool) dated 5/14/2026, the MDS indicated the resident understood others and made himself understood. The MDS further indicated Resident 173 needed supervision/touch assistance (helper provides verbal cues and/or touch assistance) from facility staff for activities such as eating, oral hygiene, and upper body dressing. During a review of Resident 44's Physician's Order, the Physician's order dated 4/29/2026, indicated an order for levetiracetam oral tablet (medication to help prevent seizures) 500 mg (milligrams – a unit of measurement) give 1 tablet by mouth two times a day for seizure prophylaxis (prevention). During an observation on 5/4/2026 at 8:26 a.m. in Resident 173's room, Resident 173 was sitting up in bed. The upper bed rails on Resident 173's bed were made of metal and were not padded. During a concurrent observation and interview on 5/4/2026 at 8:31 a.m. in Resident 173's room with Licensed Vocational Nurse (LVN 7), LVN 7 stated Resident 173's bed did not have the needed padding on his bedrails to keep him safe during a potential seizure. LVN 7 stated the padding is to protect the resident's head and body from the uncontrolled shaking from seizures. During a concurrent interview and record review on 5/7/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON reviewed Resident 173's physician's orders. The DON stated Resident 173 was taking the medication levetiracetam as a seizure precaution and facility staff should have applied padding to his siderails to protect his head and body in the event Resident 173 had a seizure. During a review of the facility provided Policy and Procedure (P&P) titled, Seizure Precautions last reviewed on 1/21/2026, the P&P indicates to provide a safe environment and pad side rails as indicated. b. During a review of Resident 160's admission Record, the admission Record indicated the facility admitted Resident 160 on 9/8/2026 with diagnoses that included atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the walls that carries blood away from the heart), chronic pain syndrome (long lasting pain), and anxiety disorder (chronic, uncontrollable, and excessive worrying about everyday things that interferes with daily life, far beyond normal stress). During a review of Resident 160's MDS dated [DATE], the MDS indicated Resident 160 makes self-understood and able to understand others. The MDS indicated Resident 160 required substantial/maximal assistance (helper does more than half the work) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing, and required supervision or touching assistance with eating. During review of Resident 160's History and Physical (H&P), dated 9/11/2023, the H&P indicated Resident 160 had the capacity to make own decisions. During a concurrent observation and interview on 5/4/2026 at 10:19 a.m., in Resident 160's room, with Licensed Vocational Nurse (LVN) 1, observed two open individually packaged A&D ointment and half-filled unlabeled medication cup with white paste substance, with a spoon held up by the white paste on Resident 160's right side bedside table. LVN 1 stated that the vitamin A&D and medicine cup with unknown substance should not be at the bedside. LVN 1 stated that once opened, the unused vitamin A&D in the individual packet should be disposed of and not re-used because of potential contamination that could result in spread of infection. LVN 1 stated that the unknown substance in the medication cup posed a risk for Resident 160, other residents and everyone who enters Resident 160's room for potential harm. LVN 1 explained that the unlabeled, unidentified substance in the medication cup can be ingested on accident if mistaken for something edible. During an interview on 5/7/2026 at 10:39 a.m. with the Director of Nursing (DON), the DON stated that the vitamin A&D and unlabeled unknown substance in the medication cup left at Resident 160's bedside was inappropriate. The DON stated the items should have been disposed after if they were excess supply from what was applied to Resident 160. The DON stated the unknown substance left at the bedside could be mistaken as food by another resident who finds it at the bedside and ingests it which could result in harm. The DON also stated that an allergic reaction could occur if the vitamin A&D left at the bedside were used by another resident who may be confused and do not know they are allergic to it. During a review of the facility's policy and procedure (P&P) titled, Safety Plan and Supervision of Residents last reviewed 1/26/2026, the P&P indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated polices and procedures. These risk factors and environment hazards include the following:.poison control. During a review of the facility's P&P titled, Administering Medications last reviewed 1/26/2026, the P&P indicated Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services.Medications should only be removed from the cart at the time of administration and must not be left unattended. c. During a review of Resident 2's admission Record, the Admission Record indicated the facility admitted Resident 2 to the facility on 8/5/2024 with diagnoses including but not limited to acute kidney failure (a sudden inability of the kidneys to filter waste from the blood), muscle weakness, and unspecified dementia (a progressive state of decline in mental abilities). During a review of the MDS dated [DATE], the MDS indicated Resident 2 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 2 (a score of 0 - 7, severely impaired cognition), functional impairment affecting daily functions on upper and lower extremities, and use of wheelchair. During a review of Resident 2's History and Physical (H&P), dated 4/11/2026, the H&P indicated Resident 2 had history and diagnosis of leg weakness, and did not have capacity to make own decisions due to senile (decline in mental or physical abilities associated with old age) dementia. During a review of Resident 2's physician's order, dated 12/11/2024, the physician's order indicated a low bed with bilateral landing mat when in bed. During a review of Resident 2's Care Plan (CP), revised 3/10/2026, the CP indicated Resident 2 had risk for falls related to generalized weakness, history of multiple falls, and dementia. The CP indicated an intervention to place a floor pad next to Resident 2's bed. During an observation on 5/4/2026 at 2:00 p.m. in Resident 2's room, Resident 2 was lying in bed positioned on right side with no bilateral floor mats on either side of the bed. During an interview on 5/6/2026 at 3:31 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 2 is not on high fall risk precautions, that was a long time ago. CNA was not aware of an order for bilateral landing floor mat when Resident 2 was in bed. During a concurrent observation and interview on 5/6/2026 at 3:36 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 2's room, Resident 2 was lying in bed with no bilateral landing floor mats. LVN 2 stated if there is a physician's order for bilateral landing floor mats, they should be in place. During a concurrent interview and record review on 5/6/2026 at 3:42 p.m. with LVN 6, Resident 2's physician order dated 12/11/2024 was reviewed. The physician's order indicated low bed with bilateral landing mats when in bed. LVN 6 stated Resident 2 had been free of falls for about 6 months; the order should have been discontinued. During a concurrent interview and record review on 5/7/2026 at 11:25 a.m. with the Director of Nursing (DON), Resident 2's physician order dated 12/11/2024 was reviewed. The physician order indicated the use of low bed with bilateral landing mat when in bed. The DON stated the facility staff should have followed and implemented the physician order. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated in collaboration with physician the staff will identify and implement relevant interventions .to try to minimize serious consequences of falling, and re-evaluate fall risk interventions for current relevance.

Based on observation, interview, and record review the facility failed to: 1.Administer a form of multiple vitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) to one (1) of six (6) observed residents (Resident 69) during medication administration task, as ordered by Resident 69's physician. 2. Replace one open used medication emergency kit ([ekit] - storage container for emergency use medications) within 72 hours of opening the kit on 4/27/2026, in one (1) of three (3) inspected medication carts (Medication Cart 1 Station 2.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication ekits containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for May 2026, in two (2) of two (2) inspected medication rooms (Medication Room Station 2 and Medication Room Station 4.) As a result, medication administration, control and accountability of CM and availability of medications did not follow state and federal regulations and facility policy and procedures. These failures had the potential to result in Resident 69 receiving suboptimal (less than standard) care and experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have), in addition to increasing the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. Findings: During an observation on 5/4/2026 at 10:02 a.m., in Medication Cart 2 Station 3, Licensed Vocational Nurse (LVN) 1 was observed administering multi-vitamin with minerals tablet orally to Resident 69. Resident 69 was observed swallowing the multivitamin with mineral tablet with a bottle of Boost (a nutritional drink.) During an observation on 5/4/2026 at 12:15 p.m., with LVN 3, in Medication Room Station 4 there was: -One (1) medication ekit containing CMs, labeled [NAME].REF-53 with a date indicating pharmacy prepared the kit on 3/5/2026, without an accountability log for the reconciliation of CM inventory at every shift change for May 2026. During a concurrent interview, LVN 3 stated that all CMs, including medication ekits containing CMs, should be reconciled at every shift. LVN 3 stated that the ekit labeled [NAME].REF-53 contained CMs in Medication Room Station 4 and was not reconciled at every shift in May 2026. LVN 3 stated it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 5/4/2026 at 12:35 p.m., with Registered Nurse (RN) 1, in Medication Room Station 2 there was: -One (1) medication ekit containing CMs, locked with a green tag imprinted with 05291598, and labeled with a date indicating pharmacy prepared the kit on 2/10/2026, without an accountability log for the reconciliation of CM inventory at every shift change for May 2026. During a concurrent interview, RN 1 stated that all CMs, including medication ekits containing CMs, should be reconciled at every shift. RN 1 stated that the ekit locked with a green tag imprinted with 05291598 contained CMs in Medication Room Station 2 and was not reconciled at every shift in May 2026. RN 1 stated it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 5/4/2026 at 12:50 p.m., with LVN 4, in Medication Cart 1 Station 2, there was: -One (1) open medication ekit labeled S18 with a document indicating the ekit was opened on 4/27/2026 at 11:39 p.m. During a concurrent interview, LVN 4 stated the medication ekit labeled S18 was opened on 4/27/2026, used and awaiting replacement for a new one from pharmacy. LVN 4 stated the mediation ekit should have been replaced with a new one from pharmacy within 24 hours of opening the kit. LVN 4 stated the medication ekit was not replaced with a new one within 24 hours and this failure could lead to negative consequence for residents by not having emergency medications readily available during emergency situations causing resident harm and potential hospitalization. During an interview 5/4/2026 at 1:15 p.m., with LVN 1, LVN 1 acknowledged the physician order for Resident 69 indicated to give multivitamin not containing minerals. LVN 1 stated LVN failed to administer the correct multivitamin as prescribed by Resident 69's physician. LVN 1 stated administering multivitamins with minerals to Resident 69 may not be beneficial to their health and may cause adverse effects. LVN 1 stated this was not according to physician orders and considered a medication error. During an interview 5/4/2026 at 1:35 p.m., with the Director of Nursing (DON), the DON stated LVN 1 failed to administer multivitamin without minerals to Resident 69, according to physician orders. The DON stated this was considered a medication error. The DON stated Resident 69 may be at risk of not being able to tolerate the additional minerals from the multivitamin. The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered to residents. During the same interview, the DON stated that medication ekits containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the two (2) eKits containing CMs in Medication Room Station 2 and 4 were not reconciled at each shift change in May 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of ekits at each shift change in Medication Room Station 2 and Station 4. During the same interview, the DON stated that open and used medication ekits should be replaced with a new one within 72 hours. The DON stated the medication ekit in Medication Cart 1 Station 2 was open and used on 4/27/2026 and not replaced within 72 hours. The DON stated this failure can create potential harm for residents by not having critical medication readily available during emergency situations. During a review of Resident 69's admission Record (a document containing demographic and diagnostic information,) dated 5/4/2026, the admission Record indicated Resident 69 was originally admitted to the facility on [DATE] with a diagnosis including anemia (a condition often caused by iron deficiency where the body doesn't have enough healthy red blood cells to carry oxygen to tissues, resulting in fatigue, weakness, and shortness of breath) and dysphagia (difficulty swallowing often leading to malnutrition.) During a review of Resident 69's (Medication Administration Record ([MAR] - a record of mediations administered to residents), for May 2026, the MAR indicated Resident 69 was prescribed multiple vitamin tablet orally once a day for supplementation, to give at 9 a.m. During a review of the facility's policy and procedures (P&P), titled Emergency Pharmacy Service and Emergency Kits (E-KITS), last reviewed 1/21/2026, the P&P indicated: In states that allow replacing used doses of medication, the nurse replaces the medication in the appropriate area of the kit within 24 hours of opening or next scheduled delivery, or as required by state regulation. During a review of the facility's P&P titled Controlled Substances, last reviewed 1/21/2026, the P&P indicated that CMs are substances that have an accepted medical use (medications which fall under U.S Drug Enforcement (DEA) Schedules II-V,) have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and recordkeeping at the nursing care center, in accordance with federal and state laws and regulations. 7. At each shift change, a physical inventory of all CMs as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record. During a review of the facility's P&P titled Controlled Medication Storage, last reviewed 1/21/2026, the P&P indicated: Medications included in the DEA classification as CSs are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. 6. At each shift change, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the CS accountability record or verification of CS count report. During a review of the facility's P&P titled Medication Administration General Guidelines, last reviewed 1/21/2026, the P&P indicated that Medications are administered as prescribed . Medication Preparation 3. Prior to administration, review and confirm medication orders for each individual resident on the MAR. Compare the medication and dosage schedule on the resident's MAR with the medication label. Medication Administration 1.Medications are administered in accordance with written orders of the prescriber. 9 Verify medication is correct three (3) times before administering the medication. a. When pulling the medication package from med cart b. When dose is prepared c.Before dose is administered.

Based on observation, interview, and record review the facility failed to: a.Not store food items with medications in the medication refrigerator for one (1) of two (2) inspected medication rooms (Medication Room Station 4.) b. Label the Neosporin (over-the-counter triple antibiotic ointment used to prevent infections in minor cuts, scrapes, and burns) ointment and properly store the ointment for resident self-administration in accordance with the facility policy and procedure on Medication Labeling and Storage, for one (1) of one (1) sampled resident (Resident 160). These deficient practices increased the risk of unsafe medication administration for Resident 60 and the cross contamination (the physical transfer of harmful bacteria, viruses, or allergens from one surface or food item to another) between food and medications for residents in the facility, resulting in health complications such as infections and medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have.) Findings: a.During an observation on 5/4/2026 at 12:15 p.m., in Medication Room Station 4, in the presence of Licensed Vocational Nurse (LVN) 3, the medication refrigerator contained several medications for the residents in Station 4 together with one (1) carton of orange juice and one (1) carton of apple juice. During a concurrent interview, LVN 3 stated the medication refrigerator should only be used to store medications and not to store food items together with medications. LVN 3 stated there was a risk of cross contamination when storing food with medications. During an interview on 5/4/2026 at 1:35 p.m., with the Director of Nursing (DON,) the DON stated that the facility failed to not store two (2) juice carton boxes together with medications stored in the medication refrigerator in Medication Room Station 4. The DON stated the refrigerator was intended to be used for medication storage only, and storing food with medications together in the same refrigerator was not according to facility policy and procedures and increased the risk of cross contamination. During a review of the facility's policy and procedures (P&P), titled Storage of Medication, dated 1/21/2026, the P&P indicated: Medications and biologicals are stored safely, securely, and properly.to support safe effective drug administration. 13. Refrigerated medications should be kept in closed and labeled containers.and all medications segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods.should not be stored in this refrigerator. b. During a review of Resident 160's admission Record, the admission Record indicated the facility admitted Resident 160 on 9/8/2026 with diagnoses that included atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the walls that carries blood away from the heart), chronic pain syndrome (long lasting pain), and anxiety disorder (chronic, uncontrollable, and excessive worrying about everyday things that interferes with daily life, far beyond normal stress). During a review of Resident 160's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 160 makes self-understood and able to understand others. The MDS indicated Resident 160 required substantial/maximal assistance (helper does more than half the work) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing, and required supervision or touching assistance with eating. During review of Resident 160's History and Physical (H&P), dated 9/11/2023, the H&P indicated Resident 160 had the capacity to make own decisions. During a concurrent observation and interview with Resident 160 on 5/7/2026 at 11:52 a.m. in Resident 160's room with Registered Nurse (RN) 1, observed an unlabeled box of Neosporin on a tray table (a height-adjustable rolling table designed to slide over a bed or chair) placed in front of Resident 160. Resident 160 stated she applies the Neosporin on sores she would get and pointed to a marked redness on the left side of her face, near her right ear, as one of the sites she applies the ointment. When asked of other sites she applies the medication, Resident 160 responded with elevated voice and stated, I don't know where else I put it on, but I have many. Resident 160 could not specify when or how frequent she applies the medication, only able to state that she applies the medication to prevent her sores from becoming infected. During a concurrent observation and interview with Resident 160 on 5/7/2026 at 1:37 p.m. in Resident 160's room with the Director of Nursing (DON), observed Resident 160 lying in bed with the tray table placed in front of Resident 160. On the tray table is the unlabeled Neosporin box. Resident 160 emptied the unlabeled Neosporin tube from the Neosporin box. Resident 160 stated she applies the Neosporin she applies it herself when she needs it. Resident 160 stated she needed a new supply since it was almost empty. During an interview on 5/7/2026 at 1:45 p.m. with the DON, the DON stated that the Neosporin in Resident 160's room should have a label. The DON stated that medications for resident self-administration are provided by the facility and are supposed to have a label with the resident's name, the name of the drug and other pertinent information per physician orders. The DON stated medication without a label should never be left at the bedside. The DON stated that if a medication was brought in by the resident or family member, the medication would be sent home and an order for the medication would be obtained from the physician and supplied by the pharmacy with a label. The DON stated that in situations where medication from outside was brought in the facility by the resident or family was approved by physician for the resident to have, it would also need to have a label from pharmacy. The DON stated medication label is important because it informs which resident the medication was ordered for and all the other information about the medication in accordance with the physician's order. The DON stated that unlabeled medication poses a safety issue. The DON explained that when unlabeled, a medication may be used by someone who could be allergic to it and have an allergic reaction. During a review of the facility's P&P titled, Medication Labeling and Storage last reviewed 1/26/2026, the P&P indicated Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name f. route of administration; and g. appropriate instructions and precautions. If medication containers have a missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. During a review of the facility's P&P titled, Medications Brought to the Facility by the Resident/Family last reviewed 1/16/2026, the P&P indicated, If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being, to be able to take the medication from outside, the director of nursing services, the nursing staff, with support of the attending physician and consultant pharmacist, shall check to ensure that.c. the contents of each container are labeled in accordance with established policies; and d. the contents of each container have been verified by a licensed pharmacist. During a review of the facility's P&P titled, Self-Administration of Medications last reviewed 1/26/2026, the P&P indicated, Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them.The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medication.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Oranges, tomatoes, broccolis and prepared juice were labeled with incorrect date. 2. Prepared juice was left stored in the refrigerator beyond the for-use date. 3. Surfaces of the cutting boards were scratched and had gouges along the edges. 4. Temperatures of food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) were not obtained in accordance with the facility policy and procedure on Meal Service, by failing to ensure: a. [NAME] 1 obtained the temperature of all food on the tray line. b. Dietary Aide 1 (DA 1) recorded the temperature of all food items on the breakfast/lunch Food Temperature monitoring log. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 151 of 152 medically compromised residents who received food from the kitchen. Findings: 1-3. During an initial kitchen tour observation on 5/4/2026 at 7:55 am., in the presence of the Dietary Supervisor (DS), observed oranges, tomatoes, and broccoli stored in a container with a sticker label dated 6/1/2026. Also observed cups filled with red liquid and single serving of pre-packaged prune juice on a tray with a label dated 5/3/2026 inside the reach in refrigerator #1 and observed separate cups filled with red liquid on a tray with a label dated 5/5/2026 inside reach in refrigerator #2. During an interview with the DS in the kitchen on 5/4/2026 at 8:10 a.m., the DS stated that produce container labels indicated when the produce delivery date. The DS stated the labels on the oranges, tomatoes, and broccoli storage container were incorrect and should have been labeled 5/1/2026 instead of 6/1/2026. The DS stated the person who created the label made a mistake. The DS stated that accurate labeling is important to track freshness, safety and quality of food. The DS stated that they follow First-In-First-Out (FIFO an inventory management where oldest produce are used first) method, so labeling the produce correct delivery dates is essential. During an interview with the DS in the kitchen on 5/4/2026 at 8:15 a.m., the DS stated the cups filled with red liquid in the reach in refrigerators were juice prepared to be served to the residents. The DS stated once juice is removed from its original container, it can be served until the following day. The DS stated prepared juices should be labeled with their use-by date. The DS stated the juices on the tray dated 5/3/2026 found in the reach in refrigerator #1 were prepared on 5/2/2026 and unserved juice should have been removed from the refrigerator and thrown away on 5/3/2026. The DS stated that leaving the juices in the refrigerator after the use-by date risked serving the juice to the residents. The DS stated serving juice by the designated use date is important to ensure the quality of the juice served to the residents. During a subsequent kitchen observation in the presence of the DS and interview with the DS on 5/5/2026 at 8:15 a.m. observed three (3) cutting boards, two (2) blue and one (1) green. The surfaces of the cutting boards were faded and white, scored with scratches and grooves all around the edges. The DS stated that food can get trapped in these areas, leading to bacterial growth that may contaminate the food prepared for the residents. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods last reviewed 1/26/2026, the P&P indicated, All food items in the storeroom, refrigerator, and freezer needs to be labeled and dated.Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product.Produce is to be dated with received date. During a review of the facility's P&P titled, Food Receiving and Storage last reviewed 1/26/2026, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.Beverages are dated when opened and discarded after twenty-four (24) hours. During a review of the facility's policy and procedure P&P titled, Sanitation last reviewed 1/26/2026, the P&P indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 4. During a kitchen tray line observation on 5/06/2026 at approximately 11:45 a.m., observed the kitchen's tray line. Observed [NAME] 1 checking the temperatures of the food on the tray line. Cook 1 took the following food temperatures: milk = 35 degrees Fahrenheit ( F, a unit of measure for temperature) juice = 35 plain yogurt = 35 puree (foods that are smooth with pudding like consistency) vegetable = 175 Puree chicken = 172 Puree pasta = 163 Minced and moist (diet featuring soft, cohesive foods that require minimal chewing) chicken = 171 Minced and moist cabbage = 159 Minced and moist vegetable = 162 Bite-sized (tender moist foods cut into small pieces that are easy to chew) chicken = 160 Regular (texture of food with no modifications and restrictions) chicken = 200 Regular noodles = 167 Regular vegetable = 170 Gravy = 150 Regular rice = 170 Regular fish = 210 Vegetarian entrée = 180 Observed three foods on the tray line that the temperatures were not taken. Asked [NAME] 1 about the following foods that [NAME] 1 had not taken the temperatures: Salad greens Tuna Egg salad Observed the Dietary Supervisor (DS) took the temperatures of those foods. During the tray line procedure, reviewed the Breakfast/Lunch Food Temperature logs. There were some entry lines that were blank, indicating a temperature was not documented for that item. During an interview with the DS on 5/06/2026 at 12:30 p.m., the DS stated all hot and cold food temperatures should be taken and recorded at the same time. The DS stated this was important for safety, for ensuring those items are within the required temperature range to prevent residents from getting sick. During an interview with [NAME] 1, Dietary Aide 1 (DA 1), and the Assistant [NAME] (Cook 2) on 5/06/2026 at 1:20 p.m., [NAME] 1 stated she is in charge of taking the temperature of the hot foods for the tray line. Cook 2 stated she is in charge of taking the temperature of the cold foods on the tray line. Cook 2 stated she should have recorded the temperatures of the lettuce, tuna, and egg salad. [NAME] 2 stated she usually does on other days. DA 1 stated she was recording temperatures for the hot foods that day. DA 1 stated she did not record all of the food temperatures at the time Cook 1 was checking the temperatures. DA 1 stated this is important to make sure food reaches the required temperatures, that the food is fully cooked and does not want any resident to get sick. During an interview with the Director of Nurses (DON) on 5/07/2026 at 8:32 a.m., the DON stated that the dietary staff should be checking the hot and cold food temperatures to ensure they are within the required temperature ranges. The DON stated this was to ensure food is safe for residents and to ensure that the food is palatable (pleasant to taste) to the residents. During a concurrent interview and record review with the DS on 5/07/2026 at 11:49 a.m., the DS reviewed the Breakfast/Lunch Food Temperature log. The DS confirmed that the following foods were not recorded until a later time after initially taking the food temperatures: Bite-sized noodles. Minced and moist noodles Fish Rice Bite-sized vegetable Milk Juice The DS stated the dietary staff keep a log, to ensure the hot and cold foods are served within the required temperatures. The DS stated the temperatures need to be recorded immediately after taking the temperatures to ensure staff do not forget the values in the case they are recording after the fact. The DS stated this is to ensure the hot and cold foods are within the required temperature range. During a review of the facility's policy and procedure titled, Meal Service, last reviewed 1/21/2026, indicated the food will be served on tray line at the recommended temperatures and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food served. The policy indicated hot food serving temperatures must be at or above minimum holding temperature of 140 . The policy indicated cold food items will be placed on the trays as close to serving time as possible to assure the temperature is below 41 .

Based on observation, interview, and record review the facility failed to provide a safe storage (refrigerator) designated for residents' food coming from outside sources. This failure had the potential to result in consumption of food that is unsafe and cause foodborne illness in residents who receive food from outside sources. Findings: During an interview with the Director of Nursing (DON) at 8:32 a.m., the DON stated there is no refrigerator for food brought in from families from outside the facility. During an interview with the Registered Dietician (RD) on 5/07/2026 at 1:31 p.m., the RD stated the facility cannot store food for residents brought in by their families (outside food) unless it is non-perishable such as packaged food or nuts. The RD stated, for hot and cold foods, they can be sitting out for two hours and then must be thrown out. When asked if it was an unreasonable request from residents to store their food, the RD stated the kitchen staff can store food from the outside for a one-time event later in the day such as a birthday. When asked why the facility does not have a separate refrigerator for residents outside food, she stated it is more liability if the facility does have a resident's refrigerator since the staff would have to check the food items and would need to monitor the refrigerator so other residents would not take other residents' food. The RD stated it is a lot of work to label the resident's food brought in from the outside. When asked how the facility's practice was not allowing residents to have a homelike environment, she stated the facility provides three meals and it is not necessary to have extra food items. During a review of Resident 97's admission Record (or face sheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident to the facility on 3/28/2023 with diagnoses that included acute kidney failure (the sudden loss of kidney function, typically developing within a few hours or days). During a review of Resident 97's Minimum Data Set (MDS- a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 97 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 97 required supervision (helper provides verbal cues as resident completes activity) with eating. The MDS indicated Resident 97 was on a therapeutic diet (specially created diet such as low salt or fortified). During a review of Resident 97's Physician's Orders, the Physician's Orders indicated an order dated 2/27/2026 for fortified diet (diet that have vitamins, minerals added to increase their nutritional value and prevent weight loss) regular texture. During an observation and interview with Resident 97 on 5/07/2026 at 1:51 p.m. she stated she would like to store outside food in the facility for a day or two. Resident 97 stated she thought everyone would like to have their food stored as well. During a review of Resident 134's admission Record, the admission Record indicated the facility originally admitted Resident 134 to the facility on 1/23/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 134 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. The MDS indicated Resident 134 was not on a therapeutic diet. During a review of Resident 134's Physician's Orders, the Physician's Orders indicated an order dated 3/23/2026 for regular diet, regular texture. During an interview with Resident 134 on 5/07/2026 at 1:52 p.m., Resident 134 stated he would like to have a refrigerator to store food brought in from the outside. During a review of Resident 106's admission Record, the admission Record indicated the facility originally admitted Resident 106 on 6/25/2021 and re-admitted on [DATE] with severe protein-calorie malnutrition (a life-threatening, advanced deficiency of essential protein and energy intake). During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 134 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 106 was independent with eating. The MDS indicated Resident 106 was on a therapeutic diet. During a review of Resident 106's Physician's Orders, the Physician's Orders indicated an order dated 3/2/2026 for fortified diet puree texture (foods that are smooth with pudding like consistency). During an interview on 5/07/2026 at 1:52 p.m., Resident 106's Family Member 1 (FM 1). FM 1 stated she wished to have food she brings in from the outside to be stored at the facility. During an interview with the Administrator (ADM) on 5/07/2026 at 1:59 p.m., the ADM stated the facility tells families that hot and cold foods brought in by family have to be eaten within a certain time frame because they do not store residents' food in the facility. When asked why the facility does not store food, he stated it would be an added step to check food temperatures. The ADM stated it is important for residents to have the meals they want. The ADM stated he would consider holding a resident council meeting and meet with his team to see if something such as a refrigerator to store outside food would be achievable. The ADM stated he wants the residents to have as much a homelike environment as is possible. During a second interview with the DON on 5/07/2026 at 2:08 p.m. he stated there is no space to place a refrigerator dedicated to resident's food brought in from the outside. When asked if that is a valid reason for not having a refrigerator, the DON stated he would investigate that. The DON stated it is a reasonable request if a resident asks to store outside food they do not want to eat at that time it was brought. During an interview with the Dietary Supervisor (DS) on 5/07/2026 at 2:55 p.m., she stated there is no refrigerator to store residents outside food. The DS stated after the Covid-19 pandemic (also called Covid-19, a global outbreak of an infectious disease caused by the severe acute respiratory syndrome coronavirus), the corporate said the facility will no longer hold food for residents. The DS stated before Covid-19, the facility had a refrigerator designated to store residents' food brought in from the outside. The DS stated the kitchen staff maintained the refrigerator, including refrigerator temperature checks, and removing food that had been stored past the required time allowed. When asked if this is a reasonable request to store food for residents, she stated regardless of what she thinks, the policy indicates there is no outside food storage. During a review of the facility's policy and procedure titled, Food Brought by Family/Visitors, last reviewed 1/21/2026, indicated the following: 1.Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. a. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods cannot be stored in the facility and should be consumed within 2 hours to ensure resident safety. 10.Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours are discarded.

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV - into the vein) insertion site (site on the body where IV is inserted through the skin) and the label indicating the date of insertion were visible and not covered with white tape for one of one sampled resident (Resident 172). This deficient practice had the potential to delay the identification of complications, including pain/redness, and infection at the IV insertion site. Findings: During a review of Resident 172's admission Record, the admission Record indicated the facility admitted Resident 172 on 4/26/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), bacteremia (the presence of bacteria in the bloodstream) and dementia (a progressive state of decline in mental abilities) During a review of Resident 172's History and Physical (H&P) the H&P indicated Resident 172 did not have the capacity to make his own medical decisions. During a review of Resident 172's Minimum Data Set (MDS- a resident assessment tool), dated 5/3/2026, the MDS indicated Resident 172 required substantial assistance (helper does more than half the effort) for activities such as eating. During a review of Resident 172's At Risk for IV Therapy Complications Care Plan (CP) initiated on 4/30/2026, the CP indicated the following interventions: -monitor and document signs and symptoms of infection at the site: drainage, inflammation, swelling, redness, warmth and notify physician. -monitor and document signs and symptoms of leaking at the IV site, edema (swelling caused by excess fluid trapped in your body's tissues) at the insertions site. During a review of Resident 172's Order Summary Report, active as of 5/7/2026, the Order Summary Report indicated an order dated 4/26/2026 to monitor IV site every shift for signs and symptoms of complications. During an observation on 5/4/2026 at 8:40 a.m. in Resident 172's room, Resident 172 was sitting up in his wheelchair watching television. Observed Resident 172 with white tape wrapped around his left antecubital (AC - the crook of the elbow or the inside bend of the arm). During a concurrent observation and interview 5/4/2026 at 8:46 a.m. in Resident 172's room with Registered Nurse 2 (RN 2), RN 2 looked at Resident 172's left arm and stated that the white tape was covering the IV insertion site. RN 2 stated that the IV insertion site and the label indicating the date of insertion could not be observed because they were covered with white tape. RN 2 stated she could not fully implement the order to monitor the IV site because it was not visible and any complications could have the potential to be missed. RN 2 stated IVs should be changed every seven days, and she could not visualize the date of insertion to validate when the IV was inserted. During an interview on 5/7/2026 at 11:50 a.m. with the Director of Nursing (DON), the DON stated the insertion site of an IV must be visible to monitor for complications. The DON stated the nurses should have never added that much white tape, instead if the dressing was loose, reinforce or change the dressing instead. The DON stated IVs should not be kept in longer than seven days. During a review of the facility's Policy and Procedure, (P&P) titled Peripheral and Midline IV Dressing Changes last reviewed 1/21/2026, the P&P indicated the purpose of the policy is to prevent complications associated with IV therapy. The P&P further indicated to document the date and time.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two of seven sampled residents (Resident 60, Resident 144) investigated under the environment task. This deficient practice had the potential to result in Resident 60 and Resident 144 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being. Findings: a. During a review of Resident 60's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 60 on 1/30/2024, re-admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD lung disease that causes shortness of breath and narrowing of the airways), acute (sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues) and need for assistance with personal care. During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026, the MDS indicated Resident 60 usually makes herself understood and usually understand others. The MDS indicated Resident 60 had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) function. The MDS further indicated Resident 60 was dependent (helper does all the effort) with toileting hygiene, personal hygiene, shower/bathe self, required partial/moderate assistance (helper does less than half the work) with oral hygiene, and required supervision or touching assistance (helper sets up or cleans up) with eating. During an observation on 5/4/2026 at 11:16 a.m., in Resident 60's room, observed Resident 60 in bed with the call light on the floor on the left side of Resident 60's bed. During an interview on 5/4/2026 at 11:19 p.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 60's room, CNA 1 stated that Resident 60's call light was on the floor. CNA 1 stated she did not use the clip to keep the call light in place which caused the call light to fall off the bed, making the call light out of reach for Resident 60. CNA 1 stated it is important that the call light is within reach for the resident to alert staff when Resident 60 needs assistance. CNA 1 stated that if call light is not within reach, Resident 60 would not be able to get the assistance the resident needs. During a review of Resident 60's care plan (a document that outlines a resi dent's healthcare needs, goals, and the interventions planned to achieve those goals) titled, [Resident 60] At risk for falls related to generalized weakness/decreased physical activity, side effects of medications, COPD. last revised 2/19/2026, the care plan indicated an intervention to ensure call light within reach and encourage the resident to use it for assistance as needed. b. During a review of Resident 144's admission Record, the admission Record indicated the facility originally admitted Resident 144 on 7/14/2022 and re-admitted on [DATE], with diagnoses that included hemiplegia (loss of muscle function and voluntary movement) and hemiparesis (partial weakness or reduced control of one side of the body) following cerebral infarction ( ischemic stroke, which is caused by a blockage of blood flow to the brain) affecting left non-dominant side, type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a condition that results in poor circulation of the blood) During a review of Resident 144's MDS dated [DATE], the MDS indicated Resident 144 was able to make self-understood and understand others. The MDS indicated Resident 144 had moderately impaired cognition. The MDS further indicated Resident 144 was dependent (helper does all the effort) with toileting hygiene, lower body dressing, required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, required partial/moderate assistance with oral hygiene and personal hygiene, and required supervision or touching assistance (helper sets up or cleans up) with eating. During a concurrent observation and interview on 5/4/2026 at 11:46 a.m., observed Resident 144 lying in bed with the call light dangling off Resident 144's right side upper bed rail. Resident 144 stated he uses the call light to alert facility staff when needing assistance. Resident 144 stated he did not know where his call light was. During an interview on 5/4/2026 at 11:56 a.m. with Care Partner 1 (CP 1) at Resident 144's room, CP 1 stated Resident 144's call light was dangling from Resident 144's bed where Resident 144 could not reach it. CP 1 stated that the call light should always be within Resident 144's reach for the resident to be able to call for assistance as needed. CP 1 stated added that not having call light within reach of the resident could potentially result in a resident fall. During a review of Resident 144's care plan titled, [Resident 144] At risk for falls related to generalized weakness/decreased physical activity, side effects of medications. last revised 4/23/2026, the care plan indicated an intervention to ensure call light within reach and encourage the resident to use it for assistance as needed. During an interview on 5/7/2026 at 10:39 a.m. with the Director of Nursing (DON), the DON stated that the call light should always be placed within reach of the residents to ensure they can request assistance as needed. The DON stated that failing to keep the call light accessible may delay the provision of care and services to residents. The DON further stated that when residents do not have access to the call light, there is an increased risk of falls if the resident attempts to get out of bed without assistance if resident has limited mobility. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light last reviewed 1/26/2026, the P&P indicated, Ensure that the call light is accessible to the resident while in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to ensure the bilateral heel protectors were on and the heels were floated (when the lower leg is elevated with a pillow, leaving the heel floating to air) according to the doctors order for one of three sampled residents (Resident 7) investigated under pressure injuries. This deficient practice had the potential for the worsening of or the development of PI/Pus in Resident 7. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 3/18/2026 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), falls and dysphagia (difficulty swallowing). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/5/2026, indicated Resident 7 was only sometimes understood by others and only sometimes understands others. The MDS further indicated Resident 7 required setup assistance (helper sets up or cleans up for the resident) for activities such as eating and oral hygiene and substantial assistance (when helper does more thana half the effort) for toileting, bathing, and lower body dressing. During a review of Resident 69's Physician's Orders, active as of 5/7/2026, the Physician's Orders indicated an order dated 4/26/2026 to float bilateral heels when in bed with heel protectors and/or wedge to offload pressure. During a concurrent observation and interview on 5/4/2026 at 9:33 a.m. with the Licensed Vocational Nurse (LVN 7) in Resident 7's room, LVN 7 looked at Resident 7's feet and stated only the right heel had a heel protector and neither of her feet were floated. During a concurrent interview and record review on 5/4/2026 ay 9:46 a.m. with LVN 7, LVN 7 reviewed Resident 7's physician's orders and stated both of Resident 7's heel should have been floated with heel protectors to prevent further skin breakdown. During an interview on 5/7/2026 at 1:37 p.m. with the Director of Nursing (DON), the DON stated Resident 7's heel must be floated and have protectors on at all times while in bed. The DON stated licensed nurses and certified nurse assistants (CNAs) work together to prevent worsening of Resident 7s heel pressure injury. During a review of the facility's Policy and Procedure, (P&P) titled Skin and Wound Monitoring and Management last reviewed 1/21/2026, the P&P indicated to prevent pressure injuries to residents by repositioning and using pressure relieving /reducing and redistributing devices including but not limited to pressure relieving mattresses, wedges and pillows.

Based on observation, interview, and record review, the facility's interdisciplinary team (IDT - a coordinated group of experts from several fields who work together) failed to ensure a resident's self-administration of medication was appropriate and safe for one of one sampled resident (Resident 160) by failing to conduct the Self-Administration Safety Screen for Resident 160, who was self-administering a medication. This deficient practice placed resident at increased risk for negative outcome from potential improper use of medication, inappropriate treatment and medication mismanagement. Findings: During a review of Resident 160's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 160 on 9/8/2026 with diagnoses that included atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the walls that carries blood away from the heart), chronic pain syndrome (long lasting pain), and anxiety disorder (chronic, uncontrollable, and excessive worrying about everyday things that interferes with daily life, far beyond normal stress). During a review of Resident 160's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 160 was able to make self-understood and able to understand others. The MDS indicated Resident 160 required substantial/maximal assistance (helper does more than half the work) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing, and required supervision or touching assistance with eating. The MDS indicated Resident 160 required substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet/tub/shower transfer. During review of Resident 160's History and Physical (H&P), dated 9/11/2023, the H&P indicated Resident 160 had the capacity to make own decisions. During a concurrent interview and record review on 5/7/2026 at 10:39 a.m., with the Director of Nursing (DON), Resident 160's physician's order dated 2/24/2025 was reviewed. The physicians order indicated, May have Neosporin (over-the-counter triple antibiotic ointment used to prevent infections in minor cuts, scrapes, and burns) at the bedside per patient's request, every shift for Neosporin use. The DON explained that before a resident can self-administer a medication, the IDT would conduct an assessment by completing the Self-Administration Safety Screen to determine whether the resident is capable of safely self-administering medications. The DON stated that Resident 160 had not been assessed for self-administration of medication, and there was no Self-Administration Safety Screen form found in Resident's 160's medical record. During a concurrent observation and interview with Resident 160 on 5/7/2026 at 11:52 a.m. in Resident 160's room with Registered Nurse (RN) 1, observed a box of Neosporin (over-the-counter triple antibiotic ointment used to prevent infections in minor cuts, scrapes, and burns) on Resident 160's bed tray table. Resident 160 stated she applies the Neosporin ointment on sores she would get and pointed to a marked redness on the left side of her face, near her right ear. When asked of other areas she applies the Neosporin, Resident 160 raised her voice and stated I don't know where else I put it on, but I have many referring to multiple sores where she uses the ointment. Resident 160 could not specify how often she applies Neosporin or all the locations she applies Neosporin, only that she applies it to prevent her sores from becoming infected. During a review of Resident's 160's 'Treatment Administration Record (TAR), dated April 2026, the TAR indicated licensed staff's initials in the box for everyday of the month for day, evening, and night for May have Neosporin at the bedside per patient's request, every shift for Neosporin use. During a review of Resident's 160's TAR, dated May 2026, the TAR indicated licensed staff's initials in the box for everyday from 5/1/2026-5/6/2027 for day, evening, and night for May have Neosporin at the bedside per patient's request, every shift for Neosporin use. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications last reviewed 1/26/2026, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self- administering medication is safe and clinically appropriate for the resident.If is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status.

Based on observation, interview, and record review, the facility failed to ensure one out of four sampled resident rooms (Resident 105 and 174's shared room) was within a comfortable temperature range of 71 degrees Fahrenheit ( F) to 81 F. This deficient practice placed Residents 105 and 174 at risk for being uncomfortable due to the low temperature in the facility. Findings: a. During a review of Resident 105's admission Record, the admission Record indicated the facility admitted the resident on 4/1/2026 with diagnoses including, but not limited to, fracture of the left humerus (upper arm bone), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 105's Physician Progress Note, dated 4/2/2026, the progress note indicated the resident was not capable of making her own medical decisions. During a review of Resident 105's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 105 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 105 was dependent (helper does all of the effort) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). b. During a review of Resident 174's admission Record, the admission Record indicated the facility admitted the resident on 4/23/2026 with diagnoses including, but not limited to, acute (severe, sudden onset) and chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) and difficulty in walking. During a review of Resident 174's Physician Progress Note, dated 4/24/2026, the progress note indicated the resident was capable of making her own medical decisions. During a review of Resident 174's MDS, dated [DATE], the MDS indicated Resident 17 was cognitively intact (able to think, learn, and remember clearly). The MDS indicated Resident 174 required substantial assistance (helper does more than half of the effort) with most ADLs. During an interview on 5/4/2026 at 12:11 p.m. with Resident 174 and Resident 174's family member (FM 2) at Resident 174's bedside, Resident 174 stated it gets too cold in the facility especially at night. FM 2 stated he brought extra blankets from home for Resident 174, but she tells him it is still too cold. During a concurrent observation and interview on 5/7/2026 at 8:37 a.m. with the Director of Maintenance (DOM) in the hallway outside of Resident 105 and Resident 174's shared room, the DOM took the temperature of the room with an infrared thermometer (a temperature gun, a device that measures an object's temperature from a distance by detecting infrared radiation emitted by the object). The temperature in the room was 70 F. During a concurrent observation and interview on 5/7/2026 at 8:56 a.m., the DOM took a second temperature in Resident 105 and Resident 176's shared room with an infrared thermometer. The temperature in the room was 68 F. The DOM stated their goal is to keep each resident room between 73-76 F for the residents' comfort unless they prefer the temperature to be at something different. During a concurrent interview and record review on 5/7/2026 at 1:00 p.m. with the Director of Nursing (DON), the DON stated the facility should be kept at a comfortable temperature for the residents to make sure they provide them a homelike environment. The DON stated if it's too cold it won't be comfortable for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment, last reviewed on 1/21/2026, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment. The P&P further indicated the facility staff, and management maximizes, to the extent possible, the characteristics of the facilty that reflect a personalized, homelike setting including a comfortable and safe temperature of 71-81 F.

Based on observation, interview and record review, the facility failed to ensure a resident's hand-held nebulizer (a device that turns liquid medicine into mist you breathe in) and tubing was dated for one of one sampled resident (Resident 172) investigated under respiratory care area. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: During a review of Resident 172's admission Record, the admission Record indicated the facility admitted Resident 172 to the facility on 4/26/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), bacteremia (the presence of bacteria in the bloodstream) and dementia (a progressive state of decline in mental abilities) During a review of Resident 172's History and Physical (H&P) the H&P indicated Resident 172 did not have the capacity to make his own medical decisions. During a review of Resident 172's Minimum Data Set (MDS, a resident assessment tool), dated 5/3/2026, the MDS indicated the Resident 172 required substantial assistance (helper does more than half the effort) for activities such as eating. During a review of Resident 172's Order Summary Report, active as of 5/7/2026, the Order Summary Report indicated an order dated 4/26/2026 for: - Ipratropium-Albuterol Inhalation Solution (medication to prevent and treat breathing difficulties). 1 (one) unit inhaled orally via nebulizer every 6 (six) hours as needed for SOB (shortness of breath) During a concurrent observation and interview 5/4/2026 at 8:51 a.m. in Resident 172's room with Registered Nurse (RN 2), Resident 172 was sitting up in his wheelchair watching television. Observed a hand-held nebulizer on top of Resident 172's bedside table. RN 2 stated the hand-held nebulizer did not have a label indicating the date it was last changed. RN 2 stated that any oxygen tubing or hand-held nebulizer must be labeled with the date and time it was last changed so staff would know when the hand-held nebulizer and tubing are due for a change to prevent the growth of bacteria and cross contamination. During an interview on 5/7/2026 at 11:57 a.m. with the Director of Nursing (DON), the DON stated all medical devices such as nasal cannulas, nebulizers and tubing must be dated with the date it was changed for other staff members to know when it was last changed and to prevent bacteria growth. The DON stated Resident 172's hand-held nebulizer should have had a label indicating the date it was last changed. During a review of the facility`s policy and procedure titled Oxygen Administration, last reviewed on 1/21/2026, the policy indicated that the purpose of this procedure is to provide guidelines for safe oxygen administration.review the physician`s orders or facility protocol for oxygen administration. The P&P further indicated the tubing must be changed every 7 (seven) days and the date and time changed must be documented.

Based on observation, interview, and record review the facility failed to maintain an environment free from accident hazards for one of seven residents (Resident 22) investigated for accidents when there was no informed consent obtained prior to the installation of left and right upper side rails (adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides). This deficient practice had the potential to result in adverse effects from the side rails including restriction of physical movement and entrapment (becoming caught between the rails and the mattress). Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 3/20/2025 with diagnoses including, but not limited to, acute (severe, sudden onset) and chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), dementia (a progressive state of decline in mental abilities), and difficulty in walking. During a review of Resident 22's History and Physicals (H&Ps), dated 5/6/2026 and 3/25/2025, the H&Ps both indicated the resident was not capable of making his own medical decisions. During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool), dated 3/24/2026, the MDS indicated Resident 22 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 22 required substantial assistance (helper does more than half of the effort) with showering, Resident 22 required partial assistance (helper does less than half of the effort) with toileting, lower body dressing, and putting on and taking off footwear, and Resident 22 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying) with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 22's Order Summary Report, the Order Summary Report indicated an active order for the following: Safety: Upper bilateral Quarter - 1/4 Rail.for increased mobility and transfers to promote resident independence and use as an enabler, dated 2/3/2026. During a review of Resident 22's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, [Resident 22] is at risk for impaired bed mobility., dated 6/25/2025, the care plan indicated the following interventions: Provide education to the resident/resident representative on the positioning bar/rail(s) intended purpose and potential risk. The care plan further indicated: Obtain informed consent from resident/resident representative for use of positioning bar/rail(s) to assist with moving within the bed, getting in and out of bed. During a concurrent interview and record review on 5/5/2026 at 3:51 p.m. with the Assistant Director of Nursing (ADON), Resident 22's Positioning Bar/Rail and Informed Consent, dated 3/20/2025, indicated Resident 22 was the individual educated on the risks and benefits of the side rails and did not indicate informed consent was obtained. The ADON stated Resident 22 has impaired cognition and she was not sure if he could have given consent at that time. The ADON stated there was no other documentation that an informed consent was obtained in the resident's side rail assessments. The ADON stated informed consent should be obtained so the resident and family are fully informed of the plan of care and the potential risks which could include entrapment or bumping himself on the side rail which could cause bruising or skin tears (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers). During an observation on 5/5/2026 at 4:01 p.m. with the ADON at Resident 22's bedside, Resident 22 was in bed, and two quarter-length side rails were attached and raised on the upper part of the resident's bed. During a concurrent interview and record review on 5/7/2026 at 1:00 p.m. with the Director of Nursing (DON), Resident 22's Positioning Bar/Rail and Informed Consent, dated 3/20/2025, was reviewed. The DON stated the resident was not fully oriented and the resident's family member (FM 3), who is his representative, should have been notified of the side rails and given education about the potential risks and benefits. The DON stated the informed consent for the side rails should have been obtained from the resident's family member. The DON stated the resident, and family should be aware there are potential risks from side rails including injury, fractures, and entrapment. During a review of the facility's Policy and Procedure (P&P) titled, Bed Safety and Bed Rails, last reviewed on 1/21/2026, the P&P indicated: Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 5) maintained a current CPR (cardio-pulmonary resuscitation - an emergency, life-saving technique performed when someone's breathing or heartbeat has stopped) certification from a CPR provider whose training includes a hands-on session in accordance with accepted national standards for one of five staff members investigated in the staffing facility task. The deficient practice had the potential for staff to perform substandard life-saving measures to residents which could result in negative outcomes including death.Findings: During an employee file audit of LVN 5 on [DATE] at 11:03 a.m. with Care Partner 1 (CP 1) and the Infection Preventionist (IP), the employee file contained a certificate of completion for CPR training through CPR Training Provider 1 (CPRTP 1). The IP stated they offer CPR training at the facility but if an employee takes an outside course they will accept it. CP 1 stated she was unsure if the CPR training LVN 5 completed included a hands-on component to it. During an interview on [DATE] at 11:48 a.m. with LVN 5, LVN 5 stated the CPR training she received was through a website recommended by a past instructor. LVN 5 stated the training consisted of online videos and a test on the website that asked questions about the online content. LVN 5 stated there was not an in-person hands-on component to the training. During an interview on [DATE] at 1:00 p.m. with the Director of Nursing (DON), the DON stated CPR training should have a hands-on component to ensure staff knows how to do CPR correctly. The DON stated if a staff member does not know how to do CPR correctly there is a risk of harming the resident or death. During a review of CPRTP 1's website, dated 2026, the webpage titled Support indicated: No, we do not offer hands-on training. During a review of the facility's Policy and Procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support, last reviewed on [DATE], the P&P indicated preparation for the administration of CPR during an emergency consists of the following facility practices: Maintain personnel CPR certification for healthcare providers through a CPR provider whose training includes hands-on practice an skills assessment, either in a physical or virtual instructor-led setting, in accordance with accepted national standards.

Based on interview and record review, the facility failed to develop and implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) addressing incontinence (the inability to control urination [the act of passing urine] or bowel movements) for three of five sampled residents (Resident 2, 3, and 4) when licensed nursing staff did not identify the type of bowel and bladder retraining program (a planned routine to help a resident regain or improve control of urination and bowel movements) to be implemented and failed to include specific approaches or interventions detailing how the B&B retraining program would be carried out based on the resident's assessment. This deficient practice had the potential to result in residents not receiving the necessary services and assistance to restore or maintain continence. Findings:1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including atherosclerosis (a condition in which plaque builds up inside the arteries) of aorta (the main artery that sends blood away from the heart to the rest of the body), the first lumbar (lower back areas consisting of five large, sturdy vertebrae [backbones]) vertebrae fracture (broken bone), low back pain, and mixed incontinence (the involuntary leakage of urine resulting from a combination of both stress and urge incontinence). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 2 required moderate assistance (helper does less than half of the effort) from staff with toileting hygiene, maximal assistance (helper does more than half the effort) with shower and lower body dressing, and was dependent (helper does all the effort) on staff with toilet transfer. The MDS further indicated Resident 2 was always incontinent with both bladder and bowel function. During a review of Resident 2's Bowel/Bladder Continence assessment, or the B&B assessment, dated 12/5/2025, the B&B assessment indicated that Resident 2 was a candidate for Prompted Voiding Program (PVP - a behavioral technique for managing incontinence, especially in seniors with cognitive issues, where caregivers ask them every two to three hours if they need to use the toilet), Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 2's Care Plan (CP) Report, initiated on 6/9/2025 and with target date of 3/9/2026, the Care Plan Report on Toileting Program: Bowel and Bladder Incontinence, indicated Resident 2 was at risk for incontinence associated dermatitis (a condition that causes swelling and irritation of the skin). The goal was for Resident 2 to have decreased episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident, nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:16 p.m., with Minimum Data Set Nurse (MDSN - a nurse who assesses, monitors and documents of residents' care in a long-term or skilled nursing facility) 1, Resident 2's B&B assessment dated [DATE] and care plans were reviewed. MDSN 1 stated Resident 2 was a candidate for a B&B retraining program, but the CP did not indicate the type of B&B retraining program and the approaches or interventions to be implemented for the resident. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 11/17/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and reduced mobility (movement). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were intact. The MDS indicated that Resident 3 required maximal assistance from staff with toileting hygiene, shower, and Resident 3 was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 3 was always incontinent with both bladder and bowel function. During a review of Resident 3's B&B assessment dated [DATE], the B&B assessment indicated that Resident 3 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 3's CP Report, initiated on 11/17/2021 and revised on 8/26/2025, the CP Report indicated Resident 3 was incontinent of bowel and bladder, and the goal was for Resident 3 to have decreased frequency of urinary episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a review of Resident 3's Care Plan Report, initiated on 8/9/2022 and revised on 8/26/2025, CP Report indicated Resident 3 was always incontinent with bowel, and the goal was for Resident 3 to have decreased episodes of bowel incontinence though the review; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. 3. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/18/2024 with diagnoses including atherosclerosis of aorta, left femur (thigh bone) fracture, and presence of left artificial hip joint. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were intact. The MDS indicated that Resident 4 required maximal assistance from staff with toileting hygiene, shower, and Resident 4 was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 4 was always incontinent with both bladder and bowel function. During a review of Resident 4's B&B assessment dated [DATE], the B&B assessment indicated that Resident 4 was a candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 4's Care Plan Report, with an initiated date of 6/19/2025 and the target date of 3/20/2026, the Care Plan Report indicated Resident 4 was incontinent of bladder and bowel, and the goal was for Resident 4 to have decreased episodes of incontinence during the retraining period through the review date; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:37 p.m., with MDSN 1, Resident 4's B&B assessment dated [DATE] and care plans were reviewed. MDSN 1 stated Resident 4 was a candidate for a B&B retraining program, and that the goal of the CP was to decrease episodes of incontinence. MDSD 1 stated that the CP did not indicate the type of B&B retraining program to be implemented nor did it include the specific approaches or interventions to be carried out for the resident. During a concurrent interview and record review on 2/17/2026 at 4:46 p.m., with the Assistant Director of Nursing (ADON), Resident 2, 3, and 4's B&B assessments and care plans were reviewed. The ADON stated that an individualized person-centered care plan addressing B&B retraining programs were not developed and implemented for Resident 2. 3, and 4. The ADON stated that it was important to develop and implement an individualized person-centered care plan for Resident 2, 3, and 4, who were assessed as candidates for a B&B retraining program to ensure the residents receive the necessary services and assistance to maintain or restore continence. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered last reviewed 1/21/2026, the P&P indicated, The comprehensive, person-centered care plan. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 2, 3 , and 4) who were incontinent (having no or insufficient voluntary control) of bladder (a hollow, muscular organ that stores urine before it is expelled from the body) and bowel (the long tube that carries solid waste from the stomach out of the body) function, received the appropriate services and assistance to maintain or restore continence for by failing to implement its policy and procedures (P&P) on the assessment and management of urinary and fecal incontinence. This deficient practice had the potential to result in residents not receiving the necessary services and assistance to maintain or restore continence, which could lead to ongoing incontinence and negatively affect self-esteem and dignity. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including atherosclerosis (a condition in which plaque builds up inside the arteries) of aorta (the main artery that sends blood away from the heart to the rest of the body), the first lumbar (lower back areas consisting of five large, sturdy vertebrae [backbones]) vertebrae fracture (broken bone), low back pain, and mixed incontinence (the involuntary leakage of urine resulting from a combination of both stress and urge incontinence). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 2 required moderate assistance (helper does less than half of the effort) from staff with toileting hygiene, maximal assistance (helper does more than half the effort) with shower and lower body dressing, and was dependent (helper does all the effort) on staff with toilet transfer. The MDS further indicated Resident 2 was always incontinent with both bladder and bowel function. During a review of Resident 2's Bowel/Bladder Continence assessment, or the B&B assessment, dated 12/5/2025, the B&B assessment indicated that Resident 2 was a candidate for Prompted Voiding Program (PVP - a behavioral technique for managing incontinence, especially in seniors with cognitive issues, where caregivers ask them every two to three hours if they need to use the toilet), Habit Training/Scheduled Voiding or Bladder Retraining program. The assessment did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a review of Resident 2's Care Plan (CP) Report, initiated on 6/9/2025 and with target date of 3/9/2026, the Care Plan Report on Toileting Program: Bowel and Bladder Incontinence, indicated Resident 2 was at risk for incontinence associated dermatitis (a condition that causes swelling and irritation of the skin). The goal was for Resident 2 to have decreased episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident, nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:16 p.m., with Minimum Data Set Nurse (MDSN - a nurse who assesses, monitors and documents of residents' care in a long-term or skilled nursing facility) 1, Resident 2's B&B assessment dated [DATE], care plans, and progress notes were reviewed. MDSN 1 stated Resident 2 was a candidate for a B&B retraining program but there was no documented evidence that the B&B retraining program was discussed with the resident, nor was there documentation whether the B&B retraining program was offered or whether Resident 2 declined participation. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 11/17/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and reduced mobility (movement). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were intact. The MDS indicated that Resident 3 required maximal assistance from staff with toileting hygiene, shower, and was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 3 was always incontinent with both bladder and bowel function. During a review of Resident 3's B&B assessment dated [DATE], the B&B assessment indicated that Resident 3 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 3's Care Plan Report, initiated on 8/9/2022 and revised on 8/26/2025, CP Report indicated Resident 3 was always incontinent with bowel, and the goal was for Resident 3 to have decreased episodes of bowel incontinence though the review; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. 2. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/18/2024 with diagnoses including atherosclerosis of aorta, left femur (thigh bone) fracture, and presence of left artificial hip joint. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were intact. The MDS indicated that Resident 4 required maximal assistance from staff with toileting hygiene, shower, and was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 4 was always incontinent with both bladder and bowel function. During a review of Resident 4's B&B assessment dated [DATE], the B&B assessment indicated that Resident 4 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 4's Care Plan Report, with an initiated date of 6/19/2025 and the target date of 3/20/2026, the Care Plan Report indicated Resident 4 was incontinent of bladder and bowel, and the goal was for Resident 4 to have decreased episodes of incontinence during the retraining period through the review date; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:37 p.m., with MDSN 1, Resident 4's B&B assessment dated [DATE] care plans, and progress notes were reviewed. MDSN 1 stated that Resident 4's B&B assessment indicated that Resident 4 was a candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. MDSN 1 stated that there was no documented evidence indicating whether Resident 4agreed to or declined participation in a B&B retraining program. MDSN 1 further stated that there was no documentation to show that a B&B retraining program had previously been implemented for the resident. During a concurrent interview and record review on 2/17/2026 at 4:46 p.m., with the Assistant Director of Nursing (ADON), Resident 2, 3, and 4's B&B assessments, care plans, and progress notes were reviewed. The ADON stated that the licensed nurse who assessed the residents' B&B continence status should interview the residents to determine whether the residents wish to participate in a B&B retraining program. The ADON stated that if the residents agreed to participate, a physician's order should be obtained and the residents' progress in a B&B retraining program should be documented in the medical record. The ADON stated that Resident 2, 3, and 4 were cognitively intact and had the capacity to communicate their preferences and verbalize whether they wish to participate in a B&B retaining program. The ADON further stated that she was unable to locate documented evidence indicating that B&B retraining programs had previously been implemented for the three residents, nor was there documentation indicating whether the residents had declined participation. During a review of the facility's P&P titled, Urinary Continence and Incontinence - Assessment and Management last reviewed 1/21/2026, the P&P indicated, The physician and staff that will provide appropriate services and treatment to help residents restore or improve or bladder function and prevent urinary tract infections to the extent possible. As appropriate, based on assessing the category and the causes of incontinence, the staff will provide scheduled toileting, prompted avoiding, or other interventions to try to manage incontinence. The staff will document the results of the toileting trial in the resident's medical records. During a review of the facility's P&P titled, Fecal Incontinence - Assessment and Management last reviewed 1/21/2026, the P&P indicated, The resident receives appropriate services and treatment to help or restore or improve bowel function and prevent complications of fecal incontinence to the extent possible. As appropriate, based on the assessed causes of incontinence and the resident/representative desire to participate, a scheduled bowel toileting program may be initiated. The staff document the results of the toileting program in the resident's medical record.

Based on observation, interview and record review, facility failed to ensure residents that are diabetic (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) were served sugar free gelatin and sugar free pudding for one of three sampled residents (Resident 1).This deficient practice had the potential for Resident 1 to experience hyperglycemic (occurs when glucose [sugar] levels in the blood become too high) episodes.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2025 with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain) due to occlusion (the blockage or closing of an opening, blood vessel) or stenosis (abnormal narrowing of a blood vessel) of small artery (tiny blood vessel), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and long term use of insulin (hormone that regulate the amount of glucose in the blood).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2025, the MDS indicated the resident had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, required substantial/maximal assistance from staff personal hygiene, and is dependent on staff with toileting hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for consistent carbohydrate/no added salt (NAS) diet (diet consistency that helps control blood sugar levels), ordered 8/11/2025.During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment), initiated 8/4/2025, the care plan indicated the resident has hyperglycemia related to DM. The care plan indicated an intervention to discuss meal times, portion size, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen and monitor compliance with diet and document any problems.During an observation on 8/25/2025 at 12:58 p.m., observed Resident 1's lunch tray with an orange gelatine cup that is unlabeled and observed a pudding cup with the letter R written on top of the pudding cup cover.During a concurrent observation and interview on 8/25/2025 at 12:59 p.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 1's room, observed Resident 1's lunch tray. LVN 1 stated that Resident 1's orange gelatine is regular gelatine and not sugar free. LVN 1 continued to state that the pudding served on Resident 1's lunch tray was regular pudding because there is an R written on the top cover of the pudding. LVN 1 stated that the orange gelatine is regular because there is no label that it is sugar free.During a concurrent observation and interview on 8/25/2025 at 1:15 p.m., with the Registered Dietician (RD), in Resident 1's room, observed Resident 1's lunch tray. The RD stated the RD was not sure if the orange gelatine was sugar free or regular because it is not labeled. The RD stated that the pudding served to Resident 1 is regular pudding because there is an R marked on the top cover. The RD stated that Resident 1's diet should be consistent carbohydrate diet and should have been served sugar free gelatine and sugar free pudding because Resident 1 is diabetic. The RD continued to state that serving residents with diabetes regular gelatine and/or regular pudding will affect the residents' blood sugar levels.During a review of the facility's policy and procedure (P&P) titled, Consistent Carbohydrate Diet, review date 1/15/2025, the policy indicated the consistent carbohydrate diet is indicated for residents with diabetes or prediabetes. It provides consistent meal patterns and portion sizes in order to assist residents in achieving blood glucose and weight goals. This diet is planned to meet the current dietary reference intakes within the limitations of the diet restrictions. Modifications of the diet may be necessary for complications of diabetes and associated diseases.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's insulin (hormone that regulate the amount of glucose [sugar] in the blood) as prescribed by the physician.This deficient practice resulted in the omission of insulin which could have resulted in a hyperglycemic (a condition where the blood sugar levels are abnormally high) episode.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/17/2025 with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain) due to occlusion (the blockage or closing of an opening, blood vessel) or stenosis (abnormal narrowing of a blood vessel) of small artery (tiny blood vessel), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and long term use of insulin. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2025, the MDS indicated the resident had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, required substantial/maximal assistance from staff personal hygiene, and is dependent on staff with toileting hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for insulin glargine solution 100 unit/milliliters (units/mL- unit of measurement), inject nine (9) units subcutaneously (under the skin) at bedtime for DM (hold if blood sugar [BS] less than 100 milligram/deciliter (mg/dL - units of measurement), ordered 8/7/2025.During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment), initiated 8/4/2025, the care plan indicated the resident has hyperglycemia related to DM. The care plan indicated an intervention for Lantus (brand name of insulin glargine) as ordered. During a concurrent interview and record review on 8/25/2025 at 12:06 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 1's Medication Administration Record (MAR, a report detailing the medication administered to a resident by the licensed nurses) dated 8/2025. RN 1 stated all medications should be given per physician's order. RN 1 stated that Resident 1 did not receive his glargine insulin on 8/14/2025. RN 1 stated that Resident 1's blood sugar on 8/14/2025 at 9:00 p.m. was 100 mg/dL. RN 1 stated Resident 1's blood sugar was within parameters (a set of defined limits) of administering Resident 1's glargine insulin and should have been administered.During a concurrent interview and record review on 8/25/2025 at 12:44 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's MAR dated 8/2025. The ADON stated that licensed nurses should be administering medication per physicians' orders and parameters given. The ADON stated since Resident 1's blood sugar on 8/14/2025 at 9:00 p.m. was 100 mg/dL, the licensed nurse should have administered Resident 1's glargine insulin. The ADON continued to state that if Resident 1 did not receive his glargine insulin, there could be a potential for Resident 1 to experience a hyperglycemic episode. During an interview on 8/25/2025 at 4:12 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that LVN 2 did not administer Resident 2's glargine insulin because LVN 2 overlooked the parameters of the order. LVN 2 stated that she (LVN 2) should have read the order in its entirety. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, review date 1/15/2025, the policy indicated medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer without unnecessary interruptions. Medications are administered in accordance with the prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had verbalized suicidal ideation (thoughts or ideas of ending one ' s own life), was provided with one-to-one staff supervision as per the psychiatrist (medical doctor who specializes in mental health) order. The one-to-one staff assigned to Resident 1 left the resident unsupervised for five (5) to 10 minutes. This deficient practice resulted in Resident 1 securing a knife and stabbing himself multiple times before being found by another facility staff member. On 10/24/22 at 6:14 p.m., the State Agency (the Department) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to provide adequate supervision. On 10/25/22 at 8:44 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On 10/24/22, in-services were given to Care Partner 1 (CP 1), Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) that it is mandatory for sitter/caregiver to remain with the resident at all times and should have reliever if taking a break to ensure they are not left alone. 2. On 10/24/22, the facility ' s Interdisciplinary Team (IDT) reviewed, evaluated, and assessed all residents in the facility to determine if any resident requires one-to-one supervision for risks of self-harm and/or protection from unsafe behavior. Facility IDT will perform/conduct the following for any resident identified having suicidal ideation: DON/designee will call primary MD and will notify resident ' s representative/responsible party DON/designee will obtain a doctor ' s order for one-to-one sitter/caregiver DON/designee will communicate to all staff (e.g. Point Click Care [PCC - electronic charting system] communication, memo, etc.) regarding list of identified residents A notification sticker will be placed on resident ' s door beside their name to identify residents who require one-to-one supervision to ensure every staff is made aware. DON/DSD will provide training to every one-to-one sitter/caregiver specific to tasks to protect resident from self-harm and/or protection from unsafe behavior or incident per plan of care. DON/DSD will provide a resident activity log for one-to-one sitter/caregiver to note observation of resident every 15 minutes for first 2 hours, then if uneventful Q 30 for next 2 hours, then if still uneventful Q1 hour Q shift. One-to-one sitter/caregiver will report to charge nurse/supervisor per scheduled observation above every shift - with or without any inappropriate behavior. One-to-one sitter/caregiver will stay with resident at all times and should have reliever if taking a break. DON/designee will review activity log Q shift the first 24 hours, then daily. IDT will review interventions and will evaluate/update resident ' s plan of care per result of one-to-one intervention 3. On 10/24/22 DON, Director of Staff Development (DSD) and Quality Assurance (QA) Nurse started facility-wide in-service training to all staff regarding policy & procedure on neglect, nursing supervision/one-to-one sitter/caregiver support on any identified resident with suicidal ideation. 4. Assessment of facility staff ' s knowledge and competency on neglect, safety/supervision, and care of residents with suicidal ideation behaviors will be performed and completed by 11/4/22. 5. DON/designee will discuss in morning stand up meeting regarding list of identified residents requiring one-to-one supervision. 6. DON/designee will communicate to all staff (e.g. Point Click Care [PCC - electronic charting system] communication, memo, etc.) regarding list of identified suicidal ideation residents requiring one-to-one supervision. 7. A notification sticker will be placed on resident ' s door by resident ' s name to identify residents who are one-to-one supervision to ensure every staff is aware. 8. DON/DSD will provide training to every one-to-one sitter/caregiver specific to tasks to protect resident from self-harm and/or protection from unsafe behavior per plan of care. 9. DON/DSD will provide a resident activity log for one-to-one sitter /caregiver to note observation of resident every 15 minutes for first 2 hours, then if uneventful Q 30 for next 2 hours, then if still uneventful Q1 hour Q shift. 10. Resident activity log will be reviewed/signed by charge nurse every two hours. 11. One-to-one sitter /caregiver will report to charge nurse/supervisor per scheduled observation above every shift - with or without any inappropriate behavior. 12. DON/designee will review activity log Q shift the first 24 hours, then daily until one to one has been discharged . 13. IDT will review interventions and will evaluate/update resident ' s plan of care per result of one-to-one intervention 14. One-to-one sitter/caregiver policy & procedure will be reviewed and revised within appropriately seven (7) days. Revision will be submitted to legal department for review. All staff will be provided in-service training on revised policy & procedure within 14 days. 15. Directed in-service to be conducted on 10/26/22 by Nurse Consultant with expertise on care of residents with suicidal ideation. 16. DON, DSD and other nursing leadership will conduct rounds throughout the facility to ensure safety and supervision to residents especially those with suicidal ideations are provided efficiently. 17. DON/designee will review list of residents identified needing one-to-one supervision, evaluate caregiver support, and plan of care daily. 18. ADM/designee will evaluate compliance of plan of correction on the following: Completion of all in-service training, proper identification of residents requiring one on one supervision, ensuring that sitter is always present and in room, proper identification and timely notification. Results of evaluation will be discussed in next QAPI committee meeting, monthly, and then after as determined by QAPI committee. On 10/26/22 at 12:10 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the Department accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] with a diagnosis that included major depressive disorder, malignant neoplasm (cancerous tumor) of the peritoneum (membrane that lines the inner abdominal wall and covers the organs within the abdomen), and dysphagia (difficulty swallowing). A review of Resident 1 ' s History and Physical dated 10/8/22 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Psychiatry Evaluation dated 10/11/22 indicated Resident 1 verbalized that he had been thinking of killing himself. The Psychiatry Evaluation further indicated the patient was acutely suicidal and the recommendation was to maintain strict suicide precautions with a one-to-one sitter and to transfer Resident 1 to an acute psychiatric hospital if possible. A review of Resident 1 ' s Progress Notes, noted as a late entry, dated 10/19/22 and timed 6:25 p.m., indicated on 10/18/22 at 7:30 p.m., LVN 1 was made aware by Certified Nursing Assistant 1 (CNA 1) that Resident 1 was bleeding and needed his attention. The Progress Notes also indicated LVN 1 went to Resident 1 ' s room and found Resident 1 with a knife in his hand and a laceration to his right thigh with active bleeding. The Progress Notes further indicated the knife was confiscated from Resident 1 and LVN 1 applied pressure to the actively bleeding right thigh wound until the paramedics took over at 7:40 p.m. A review of Resident 1 ' s Progress Notes, noted as a late entry, dated 10/19/22 and timed 8:10 p.m. indicated on 10/18/22 at 7:30 p.m., Registered Nurse 1 (RN 1) was made aware by LVN 1 that Resident 1 was bleeding. The Progress Notes also indicated RN 1 noted that Resident 1 had wounds on the left and right thighs and observed Resident 1 stabbing his abdomen multiple times. A review of Resident 1 ' s Change in Condition Evaluation dated 10/18/22 indicated Resident 1 had a large laceration on the front of the right thigh that was actively bleeding, multiple lacerations to the front of the left thigh, multiple lacerations to the left arm and multiple wound punctures to the abdomen. A review of Resident 1 ' s Care Plan indicated Resident 1 had a mood problem related to depression, manifested by suicidal ideation. Resident 1 ' s Care Plan indicated a one-to-one sitter would be provided. During an interview with the ADM on 10/24/22 at 2:28 p.m., the ADM stated Resident 1 had verbalized suicidal ideation and after being evaluated by the psychiatrist on 10/11/22, a recommendation was made for Resident 1 to have a one-to-one sitter. According to the ADM, on the evening of 10/18/22, around 7:20 p.m. to 7:30 p.m., the assigned one-to-one sitter, CP 1, left Resident 1 ' s room to assist with another resident who was a high fall risk and was trying to get out of bed. It was during this time when CP 1 was not in the room that Resident 1 secured a knife and started stabbing himself. The ADM stated Resident 1 was left unsupervised for approximately five (5) to ten minutes before he was found by CNA 1. The ADM stated there should have been a staff member in the room with Resident 1 at all times. During an interview with the DON on 10/24/22 3:46 p.m., the DON stated Resident 1 did not have a formal doctor ' s order for one-to-one supervision. The DON stated one-to-one supervision was the psychiatrist ' s recommendation, but the facility was treating it like a formal doctor ' s order. During an interview with CP 1 on 10/24/22 at 5:30 p.m., CP 1 stated her role as a care partner is to provide assistance where needed. CP 1 stated she had been assigned as a one-to-one sitter for Resident 1 before and knew that he needed constant monitoring because he wanted to kill himself. CP 1 stated on the evening shift of 10/18/22, she was instructed to keep an eye on both Resident 1 and Resident 2. CP 1 stated Resident 2 was a high fall risk and was actively trying to get out of bed. CP 1 stated she was sitting in Resident 1 ' s room, but placed her chair closer to the hallway so she could keep an eye on both Resident 1 and Resident 2. CP 1 stated at around 7:15 p.m. she could see Resident 2 attempting to get out of bed, so she left Resident 1 and went into Resident 2 ' s room. During an interview with the CNA 1 on 10/25/22 at 3:18 p.m., CNA 1 stated on 10/18/22 at around 7:30 p.m., he was passing by Resident 1 ' s room when he noticed blood on Resident 1 ' s gown. CNA 1 stated as he approached Resident 1, he noticed that Resident 1 had a knife in his right hand and that his right thigh was heavily bleeding. According to CNA 1, there was no other staff in the room. CNA 1 stated he immediately called for help and LVN 1 and RN 1 came right away. During an interview with the RN 1 on 10/25/22 at 3:35 p.m., RN 1 stated that at the start of the evening shift for 10/18/22, she checked on all her residents and did see CP 1 sitting with Resident 1. RN 1 stated around 7:30 p.m., she was alerted by LVN 1 that Resident 1 was bleeding. RN 1 stated when she arrived at Resident 1 ' s room, she observed Resident 1 stabbing himself repeatedly in the abdomen (belly) with a sharp knife. RN 1 stated that with the help of LVN 1, they were able to confiscate the knife and put pressure on the wounds until the paramedics arrived. RN 1 stated CP 1was not in the room during the incident. RN 1 stated she never instructed CP 1 to watch over both Resident 1 and Resident 2. RN 1stated that as the assigned one-to-one sitter, CP 1 should not have left Resident 1 and if she needed to leave for any reason, she should have called for another staff to relieve her. During an interview with ADM on 10/26/22 at 2:15 p.m., the ADM stated the facility should have a tighter system regarding one-to-one sitters to ensure the sitters are always with resident. The ADM stated Resident 1 should have had a sitter with him at all times. The ADM stated that moving forward, emphasis will be placed on making sure all facility staff understands the role and expectations of a one-to-one sitter to ensure the safety of their residents. A review of the Facility's Policy and Procedure titled, Safety Supervision of Residents, dated 7/1/20, indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was kept free from neglect. Resident 1, who had verbalized suicidal ideation (thoughts or ideas of killing themselves), and was under strict one-to-one supervision (one staff to remain with the resident at all times); was left unattended by Care Partner 1 (CP1) who was the resident ' s assigned sitter (person assigned to remain with a resident at all times) This deficient practice resulted in Resident 1 obtaining a knife and stabbing himself multiple times in the abdomen , cutting himself in both thighs, and cutting his left arm before being found by another facility staff member. On 10/24/22 at 6:14 p.m., the State Agency (the Department) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to provide constant one to one supervision to Resident 1, who verbalized suicidal ideation. On 10/25/22 at 8:44 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On 10/24/22, in-services were given to Care Partner 1 (CP 1), Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) that it is mandatory for a sitter/caregiver to remain with a resident at all times when ordered by a physician (a [MD]), and a sitter/caregiver should have a reliever (a person who will replace the sitter/caregiver when the assigned person needs a break) if taking a break to ensure a resident is not left alone. 2. On 10/24/22, the facility ' s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) reviewed, evaluated, and assessed all residents in the facility to determine if any resident requires one-to-one supervision for risks of self-harm and/or protection from unsafe behavior. Facility IDT will perform/conduct the following for any resident identified as having suicidal ideation: DON/designee will call the resident ' s MD and will notify resident ' s representative/responsible party DON/designee will obtain a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] DON/designee will communicate to all staff (Point Click Care [PCC - electronic charting system] communication, memo, etc.) regarding list of identified residents A notification sticker will be placed on resident ' s door beside their name to identify residents who require one-to-one supervision to ensure every staff is made aware. DON/Director of Staff Development (DSD) will provide training to every one-to-one sitter/caregiver specific to tasks to protect resident from self-harm and/or protection from unsafe behavior or incident per plan of care. DON/DSD will provide a resident activity log for one-to-one sitter/caregiver to note observation of resident every (Q) 15 minutes for first two (2) hours, then if uneventful Q 30 minutes for next two (2) hours, then if still uneventful Q one (1) hour Q shift. One-to-one sitter/caregiver will report to charge nurse/supervisor per scheduled observation above every shift - with or without any inappropriate behavior. One-to-one sitter/caregiver will stay with resident at all times and should have reliever if taking a break. DON/designee will review activity log Q shift the first 24 hours, then daily. IDT will review interventions and will evaluate/update resident ' s plan of care per result of one-to-one intervention 3. On 10/24/22 DON, DSD and Quality Assurance (QA) Nurse (QAN) started facility-wide in-service training to all staff regarding policy & procedure on neglect, nursing supervision/one-to-one sitter/caregiver support on any identified resident with suicidal ideation. 4. Assessment of facility staff ' s knowledge and competency on neglect, safety/supervision, and care of residents with suicidal ideation behaviors will be performed and completed by 11/4/22. 5. DON/designee will discuss in morning stand up meeting regarding list of identified residents requiring one-to-one supervision. 6. DON/designee will communicate to all staff (Point Click Care [PCC - electronic charting system] communication, memo, etc.) regarding list of identified suicidal ideation residents requiring one-to-one supervision. 7. A notification sticker will be placed on resident ' s door by resident ' s name to identify residents who are one-to-one supervision to ensure every staff is aware. 8. DON/DSD will provide training to every one-to-one sitter/caregiver specific to tasks to protect resident from self-harm and/or protection from unsafe behavior per plan of care. 9. DON/DSD will provide a resident activity log for one-to-one sitter /caregiver to note observation of resident every 15 minutes for first two (2) hours, then if uneventful Q 30 minutes for next two (2) hours, then if still uneventful Q one (1) hour Q shift. 10. Resident activity log will be reviewed/signed by charge nurse every two hours. 11. One-to-one sitter /caregiver will report to charge nurse/supervisor per scheduled observation above every shift - with or without any inappropriate behavior. 12. DON/designee will review activity log Q shift the first 24 hours, then daily until one to one has been discharged . 13. IDT will review interventions and will evaluate/update resident ' s plan of care per result of one-to-one intervention. 14. One-to-one sitter/caregiver policy and procedure will be reviewed and revised within appropriately seven (7) days. Revision will be submitted to legal department for review. All staff will be provided in-service training on revised policy and procedure within 14 days. 15. Directed in-service to be conducted on 10/26/22 by Nurse Consultant with expertise on care of residents with suicidal ideation. 16. DON, DSD and other nursing leadership will conduct rounds throughout the facility to ensure safety and supervision to residents especially those with suicidal ideations are provided efficiently. 17. DON/designee will review list of residents identified needing one-to-one supervision, evaluate caregiver support, and plan of care daily. 18. ADM/designee will evaluate compliance of plan of correction on the following: Completion of all in-service training, proper identification of residents requiring one on one supervision, ensuring that sitter is always present and in room, proper identification and timely notification. Results of evaluation will be discussed in next Quality Assurance and Performance Improvement (QAPI-data driven approach to quality improvement) committee meeting, monthly, and then after as determined by QAPI committee. On 10/26/22 at 12:10 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the Department accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical dated 10/8/22 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Psychiatry (branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) Evaluation dated 10/11/22 indicated Resident 1 verbalized that he had been thinking of killing himself. The Psychiatry Evaluation further indicated the resident was acutely (presently) suicidal, and the recommendation was to maintain strict suicide precautions with a one-to-one sitter and to transfer Resident 1 to an acute psychiatric hospital if possible. A review of Resident 1 ' s Progress Notes, noted as a late entry, dated 10/19/22 and timed 6:25 p.m., indicated that on 10/18/22 at 7:30 p.m., LVN 1 was made aware by Certified Nursing Assistant 1 (CNA 1) that Resident 1 was bleeding and needed his attention. The note indicated that LVN 1 went to Resident 1 ' s room and found Resident 1 with a knife in his hand and noted a laceration (cut) to his right thigh with active bleeding. The note further indicated that the knife was confiscated from Resident 1 and LVN 1 applied pressure to the actively bleeding right thigh wound until the paramedics took over at 7:40 p.m. A review of Resident 1 ' s Progress Notes, noted as a late entry, dated 10/19/22 and timed 8:10 p.m. indicated on 10/18/22 at 7:30 p.m., RN 1 was made aware by LVN 1 that Resident 1 was bleeding. The note indicated RN 1 noted that Resident 1 had wounds on the left and right thighs and observed Resident 1 stabbing his abdomen multiple times. A review of Resident 1 ' s Change in Condition Evaluation dated 10/18/22 indicated Resident 1 had a large laceration on the front of the right thigh that was actively bleeding, multiple lacerations to the front of the left thigh, multiple lacerations to the left arm and multiple wound punctures to the abdomen. A review of Resident 1 ' s Care Plan dated 10/10/22 indicated Resident 1 had a mood problem related to depression, manifested by suicidal ideation. Resident 1 ' s Care Plan indicated a one-to-one sitter would be provided. During an interview with the ADM on 10/24/22 at 2:28 p.m., the ADM stated Resident 1 had verbalized suicidal ideation and after being evaluated by the psychiatrist on 10/11/22. ADM stated that a recommendation was made for Resident 1 to have a one-to-one sitter. According to the ADM, on the evening of 10/18/22, at around 7:20 p.m. to 7:30 p.m., the assigned one-to-one sitter, CP 1, left Resident 1 ' s room to assist with another resident who was a high fall risk and was trying to get out of bed. ADM stated that it was during that time when CP 1 was not in the room that Resident 1 obtained a knife and started stabbing himself. The ADM stated Resident 1 was left unsupervised for approximately five (5) to ten minutes before he was found by CNA 1. The ADM stated there should have been a staff member in the room with Resident 1 at all times and Resident 1 should not have been left alone. During an interview with the DON on 10/24/22 3:46 p.m., the DON stated that when a psychiatrist recommends a one-to-one sitter, the facility regards it as an actual order. During an interview with CP 1 on 10/24/22 at 5:30 p.m., CP 1 stated her role as a care partner is to help where needed. CP 1 stated she had been assigned as a one-to-one sitter for Resident 1 before and knew that he needed constant monitoring because the resident verbalized that he wanted to kill himself. CP 1 stated on the evening shift (3:00 p.m. to 11:00 p.m.) of 10/18/22, she was instructed to keep an eye on both Resident 1 and Resident 2 by Licensed Vocational Nurse 2 (LVN 2). CP 1 stated Resident 2 was a high fall risk and was actively trying to get out of bed. CP 1 stated she was sitting in Resident 1 ' s room but placed her chair closer to the hallway so she could keep an eye on both Resident 1 and Resident 2. CP 1 stated at around 7:15 p.m. she could see Resident 2 attempting to get out of bed, so she left Resident 1 and went into Resident 2 ' s room. CP 1 stated she should not have left Resident 1 alone, especially knowing that he needed a one-to-one sitter. During an interview with the CNA 1 on 10/25/22 at 3:18 p.m., CNA 1 stated that on 10/18/22 at around 7:30 p.m., he was passing by Resident 1 ' s room when he noticed blood on Resident 1 ' s gown. CNA 1 stated that as he approached Resident 1, he noticed that Resident 1 had a knife in his right hand and that his right thigh was heavily bleeding. According to CNA 1, there was no other staff in the room. CNA 1 stated he immediately called for help and LVN 1 and RN 1 came right away. During an interview with the RN 1 on 10/25/22 at 3:35 p.m., RN 1 stated that at the start of the evening shift (3:00 p.m. to 11 p.m.) for 10/18/22, she checked on all her residents and did see CP 1 sitting with Resident 1. RN 1 stated around 7:30 p.m., she was alerted by LVN 1 that Resident 1 was bleeding. RN 1 stated when she arrived at Resident 1 ' s room, she observed Resident 1 stabbing himself repeatedly in the abdomen (belly) with a sharp knife. RN 1 stated that with the help of LVN 1, they were able to confiscate the knife and put pressure on the wounds until the paramedics arrived. RN 1 stated CP 1was not in the room during the incident and was shocked that CP 1 had left Resident 1 alone. RN 1stated that as the assigned one-to-one sitter, CP 1 should not have left Resident 1 and if she needed to leave for any reason, she should have called for another staff to relieve her. RN 1 stated that by leaving Resident 1 alone, he was not receiving the supervision he needed. During an interview with the ADM on 10/26/22 at 2:15 p.m., the ADM stated Resident 1 should not have been left alone and should have had a one-to-one sitter with him at all times. The ADM stated that by leaving Resident 1 alone, he did not receive the care he was supposed to receive. A review of the Facility ' s Policy and Procedure titled, Neglect Policy, dated 3/2018, indicated the facility will ensure residents receive the necessary staff, supplies, services, policies, training, or staff supervision and oversight to meet their needs.

Based on observation, interview, and record reviews, the facility failed ensure effective pain management for one of 34 sampled resident (Resident 382), by failing to: 1. Ensure the licensed nursing staff would assess and re-evaluate Resident 382's pain when the pain worsened and was not relieved by current pain management regimen. 2. Promptly address Resident 382's pain, when the resident verbalized he was in pain. 3. Revise Resident 382's care plan to include the location of the pain (right lower extremity). 4. Revise Resident 382's care plan to address the pain the resident was experiencing during physical therapy (a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities) and provision of activities of daily living. 5. Notify the physician when Resident 382's pain management regimen was ineffective. 6. Provide Resident 382 with pain medication before physical therapy to promote comfort and ensure maximum participation. These deficient practices resulted in Resident 382's limited mobility, decreased participation during therapy due to pain, and experiencing constant pain unrelieved by pain medication for 6 days. Findings: A review of the consultation report from the General Acute Care Hospital (GACH) completed on (MONTH) 20, (YEAR), indicated Resident 382 experienced severe right lower extremity pain secondary to severe [MEDICAL CONDITION] ([MEDICAL CONDITION]-a circulatory problem in which narrowed arteries reduce blood flow to your limbs). The consultation report also indicated Resident 382 has discoloration of the right ankle, and the arterial flow study of the right leg indicated no flow in the right common, superficial, popliteal and tibial arteries- (leg arteries) in the right leg. A review of the admission record indicated Resident 382 was admitted to the skilled nursing facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the care plan initiated on (MONTH) 3, (YEAR), indicated Resident 382 had altered comfort due to pain related to [MEDICAL CONDITION] and amputation of right great toe. The care plan goal indicated Resident 382 will be relieved of pain within one hour of medication/interventions every shift daily for three months. The care plan interventions indicated to administer pain medication as ordered, report if ineffective and find out the location and intensity of the pain and document. The care plan did not identify any situation where an increase in the resident's pain may be anticipated, such as during physical therapy or movement. A review of the History and Physical (H&P) report completed on (MONTH) 6, (YEAR), indicated Resident 382 chief complaint was pain to the right lower extremity secondary to gangrene (death of body tissue due to either a lack of blood flow or a serious bacterial infection). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated (MONTH) 10, (YEAR), indicated Resident 382 was able to understand others and made himself understood. Resident 382 required extensive, two or more physical assistance with bed mobility, transfer, and personal hygiene. The MDS also indicated Resident 382 occasionally experienced pain of five out of 10, on a zero to 10 pain rating scale, with zero being no pain and 10 the worst possible pain he could feel. A review of Resident 382's physician orders [REDACTED]. 1. [MEDICATION NAME] 5 milligrams (mg)/325 mg one tablet oral for moderate pain (four to six out of 10 pain rating scale, dated (MONTH) 3, (YEAR). 2. [MEDICATION NAME] 5 mg/325 mg two tablets oral for severe pain (seven to ten out of 10 pain rating scale), dated (MONTH) 3, (YEAR). 3. [MEDICATION NAME] 100 mg oral two capsules three times a day for [MEDICAL CONDITION] (a result of damage to your peripheral nerves (the portion of the nervous system lying outside the brain and spinal cord), often causes weakness, numbness and pain, usually in your hands and feet), dated (MONTH) 3, (YEAR). 4. [MEDICATION NAME] (MS)[MEDICATION NAME](a controlled medication used to relieve moderate to severe pain) 15 mg oral twice a day (routinely), dated (MONTH) 6, (YEAR), for pain management. 5. Tylenol 325 mg 2 tablets by mouth every four hours prn for mild pain do not exceed 3 grams per day dated (MONTH) 21, (YEAR). 6. [MEDICATION NAME] mg subcutaneously every six hours prn if [MEDICATION NAME] is ineffective, (MONTH) 22, (YEAR) at 8 a.m. A review of the physician's progress note dated (MONTH) 8, (YEAR), indicated Resident 382 complained of pain to the right lower extremity with ischemia (inadequate blood supply to a local area). The progress note indicated the plan was to increase [MEDICATION NAME] week (on an unspecified date, (implied to be no later than (MONTH) 16th, (YEAR)). A review of Resident 382's Medication Administration Record and the PRN (as needed) Pain Medication Pre-Administration Intervention Records indicated the resident did not have a dose or interval (time between doses) increase in the [MEDICATION NAME] (MONTH) 8, (YEAR) through (MONTH) 21, (YEAR), to address the resident's pain as the physician progress notes [REDACTED]. On (MONTH) 20, (YEAR) at 9:17 a.m., during an observation, Resident 382 was sitting up in bed and rubbing his right leg. Resident 382 was awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 382 stated he had right leg pain (all the time) and was currently in pain with a rating of five out of 10, on a zero to 10 pain rating scale. Resident 382 stated his acceptable pain level was two to three out of 10. Resident 382 stated he was not happy with his current pain management regimen. A review of the (MONTH) (YEAR) Medication Administration Record (MAR) indicated Resident 382 received routine [MEDICATION NAME] (MS)[MEDICATION NAME] mg daily at 9 a.m., and at 5 p.m., as the physician ordered. There was no indication of a pain assessment on the (MONTH) (YEAR) MAR. A review of the PRN Pain Medication Pre-Administration Intervention Records indicated Resident 382 received [MEDICATION NAME] one tablet on (MONTH) 20, (YEAR), at 9:30 a.m. for general body pain of rating 5 of 10 pain scale, and at 10 a.m. and (one hour after) the resident had no pain. A review of the PRN Pain Medication Record indicated the resident's pain level was zero, for the Post Medication Pain Rating after each [MEDICATION NAME] administration from (MONTH) 6, to (MONTH) 23, (YEAR). A review of the PRN Pain Medication Pre-Administration Intervention Records, indicated Resident 382 received [MEDICATION NAME] two tablets on (MONTH) 21, (YEAR), at 5 a.m. for body pain of rating 8 of 10 pain scale and at 6 a.m. (one hour after) the resident had no pain. A review of the (MONTH) 21, (YEAR), Medication Administration Record indicated Resident 382 was also administered Tylenol 325 mg 2 tablets by mouth (used for mild pain), at an unspecified time, instead of [MEDICATION NAME] two tablets (used for severe pain). On (MONTH) 21, (YEAR) at 11:16 a.m., during an observation, 2 hours and 16 minutes after Resident 382 had routine [MEDICATION NAME] (MS)[MEDICATION NAME] 6 hours and 16 minutes after the resident had PRN [MEDICATION NAME] two tablets, Resident 382 was sitting in his wheelchair, and stated he had pain with a rating of seven to eight out of 10, (severe) on his right leg. A review of Resident 382's Physical Therapy Treatment Encounter Notes indicated (at an unspecified time) the following: Attempted to do both lower extremities strengthening exercises while sitting at the edge of the bed, however the resident complained of right foot pain (intensity: eight out of 10) when the resident brought both lower extremities off the bed to sit at the edge of the bed. Severe right foot pain due to arterial wounds, dated (MONTH) 21, (YEAR). A review of the PRN Pain Medication Pre-Administration Intervention Records did not indicate Resident 382 received [MEDICATION NAME] on (MONTH) 21, (YEAR), during the 7 a.m. to 3 p.m. shift, the 3 p.m. to 11 p.m. shift, even though the Physical Therapy Treatment Encounter Notes indicated the resident had experienced severe right foot pain. On (MONTH) 22, (YEAR) at 7:35 a.m., during an observation, Resident 382 was sitting up in bed, appeared to be uncomfortable (sighs, gasps, grimacing at times). Resident 382 was touching/rubbing/massaging his right leg. When asked, if he was in pain, Resident 382 responded I am in so much pain you will not believe it. On (MONTH) 22, (YEAR) at 7:50 a.m., during an observation, Resident 382's right leg (mid-calf to ankle) was black, with a foul smell. Resident 382 told LVN 1 his pain level was six to eight out of 10. Licensed Vocational Nurse 1 (LVN 1) told the resident he would notify the physician. On (MONTH) 22, (YEAR) at 8 a.m., after the observation, LVN 1 obtained an order to give Resident 382 [MEDICATION NAME] 2 mg subcutaneous (SQ- inject under the skin) every 6 hours as needed for breakthrough pain if [MEDICATION NAME] is ineffective. The physician progress notes [REDACTED]. On (MONTH) 22, (YEAR) at 8:29 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated she was frequently assigned to care for Resident 382, and the resident complained of pain every day. CNA 2 stated when Resident 382 verbalized pain, she would notify LVN 2. The resident would state the medication does not work. CNA 2 did not specify the date and time when she notified LVN 2 of the resident's pain. On (MONTH) 22, (YEAR) at 11:52 a.m., during an interview, LVN 2 stated she would administer [MEDICATION NAME] to address Resident 382's complaint of generalized pain. LVN 2 reviewed Resident 382's initial pain assessment tool dated (MONTH) 3, (YEAR), and stated the resident did not complain of any pain at the time of the initial assessment. LVN 2 stated the licensed nursing staff should have re-evaluated Resident 382's pain because the resident was receiving [MEDICATION NAME] on a daily basis (worsening of existing pain). On (MONTH) 23, (YEAR) at 9:20 a.m., during an interview, Resident 382 stated he was in pain (four out of 10). When asked if he had requested pain medication, the resident stated it was not the time for his pain medication, but he could use a pain pill. Resident 382 stated he always had pain on the right leg and had never achieved complete relief (zero out of 10). Resident 382 stated he told the facility staff (on an unspecified date and time) the pain medication was not working. Resident 382 stated he felt like the facility staff did not listen to him, which made him angry, but there was nothing he could do about it. Resident 382 stated since his admission into the facility, his pain had always been in the right lower leg. Resident 382 stated he received physical therapy services, but was not doing much exercise during therapy because he was always in pain. Resident 382 stated he did not get a pain pill prior therapy. Resident 382 stated it was hard to do anything if someone was in pain. The PRN Pain Medication Pre-Administration Intervention Record indicated Resident 382 was administered PRN [MEDICATION NAME] on (MONTH) 23, (YEAR) at 6 a.m. On (MONTH) 23, (YEAR) at 9:20 a.m. (3 hours and 20 minutes after the administration of [MEDICATION NAME]), the resident stated he had pain at a level of 4 of 10. There was no evidence on the MAR or the PRN Pain Medication Record the resident was offered [MEDICATION NAME] mg subcutaneously when the PRN [MEDICATION NAME] was not yet due for administration and the resident had breakthrough pain (pain medication was not effective before the next dose was scheduled). A review of the MAR did not indicate Resident 382 received [MEDICATION NAME] on (MONTH) 23, (YEAR), during the 7 a.m. to 3 p.m. shift. On (MONTH) 23, (YEAR) at 3:31 p.m., during an interview, Physical Therapist 1 (PT 1) stated she provided therapy services to Resident 382 from (MONTH) 20, (YEAR) to (MONTH) 23, (YEAR). PT 1 stated the sessions were conducted while the resident's was in bed because the resident refused to stand up, was not very motivated, and refused to perform therapy exercises at times; when performing range of motion (ROM- extent of joint movement) exercises. PT 1 stated Resident 382 would grimace and state the exercise was painful, then she would stop. PT 1 stated at this time, Resident 382 did not want to transfer because of pain in the right leg. PT 1 stated Resident 382 complained of right foot pain with a rating of (five to six out of 10) during therapy. PT 1 stated when she provided therapy earlier during the day on (MONTH) 23, (YEAR), Resident 382 complained of pain (seven out of 10). PT 1 stated when the resident complained of pain on (MONTH) 23, (YEAR), during PT, she notified LVN 2. PT 1 stated LVN 2 told her the resident was on scheduled (routine) medication. PT 1 stated LVN 2 did not offer other interventions such as additional pain medication or to notify the physician the resident was in pain. PT 1 stated she would not ask if Resident 382 received pain medication prior to starting therapy exercises with the resident did not have a permanent scheduled time for therapy services. On (MONTH) 27, (YEAR) at 9:42 a.m., during an interview, Registered Nurse 1 (RN 1) stated the licensed nursing staff should have re-evaluated Resident 382's pain, because the initial pain assessment did not address right leg pain. RN 1 stated the licensed nursing staff should have notified the physician to evaluate if the resident's pain was being managed effectively. RN 1 reviewed Resident 382's MAR and physical therapy treatment record of (MONTH) (YEAR), and stated the licensed nursing staff did not administer any pain medication after PT 1 notified the licensed nursing staff of the resident's pain on (MONTH) 23, (YEAR). The licensed nursing staff should have notified the physician, if the next dose of pain medication was not due yet. RN 1 stated the resident's care plan should have been updated to reflect the right leg pain and pain experienced during physical therapy. On (MONTH) 27, (YEAR) at 1:41 p.m., during an interview, the Director of Nursing Services (DON) reviewed the nurses' notes of (MONTH) (YEAR), and MAR of (MONTH) (YEAR), and stated the licensed nursing staff assessment of the resident's pain did not reflect current status of resident; the assessment did not include the specific location of Resident 382's pain. The DON stated it was professional standard of nursing practice to notify the physician if the resident was experiencing pain prior to the next scheduled time of pain administration. On (MONTH) 28, (YEAR) at 9:35 a.m., during an interview, Resident 382's Nurse Practitioner (NP) stated Resident 382's medical condition (right lower extremity ischemia, [MEDICAL CONDITION]) was very painful. The NP stated the resident's pain would always be present, and the resident would not achieve complete relief (zero out of 10). The NP stated the pain goal was to control his pain, so he could participate in activities. The NP stated the physical therapists or the licensed nursing staff did not notify her the resident experienced severe pain during physical therapy exercises. The NP stated if she had been notified, she would have written a specific order to administer pain medication 30 minutes to one hour before therapy. The NP stated she would have adjusted the frequency of the current pain medication, if the licensed nursing staff had notified her the resident was verbalizing the pain management regimen was not working. The NP stated the [MEDICATION NAME] not increased as indicated in the physician progress notes [REDACTED]. A review of the facility's undated policy and procedure titled, Pain Management, indicated the purpose was to assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication and/or non-drug interventions as appropriate for the resident. It is the policy of this facility to assess residents for pain upon admission to the facility, at the quarterly review, when there is a significant change in condition, when there is onset of new pain and worsening of existing pain. Assessment and Recognition: The Licensed Nurse will identify any situation or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation or repositioning. Treatment/Management: With input from the resident and/or advocate, the physician and Licensed Nurse will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects or improved functioning. The staff will evaluate and report how much and how often the individual asks for PRN pain medication. Depending on the severity and location of pain, the physician may start with PRN doses or supplement standing doses with PRN dose for breakthrough pain. Monitoring The Licensed Nurse will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADLs), behavior, and participation in activities. The Licensed Nurse will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. A review the facility's policy and procedure dated (MONTH) (YEAR), titled Pain Assessment, indicated nursing and other personnel on each shift will assess residents during interactions with the residents. If the staff member noticing a resident in pain or distress is not a licensed nurse, he or she will report such finding(s) to a licensed nurse in a timely manner. Residents who need PRN medications for pain management will have a pain assessment documented on the PRN pain assessment flow sheet and therefore need not be charted in duplicate on the MAR. The effectiveness of [MEDICATION NAME] administration shall be documented. A plan of care shall be developed for residents on pain management or for residents who are at risk for pain secondary to an acute trauma or illness.