Every finding on record at Casitas Care Center

Based on observation, interview, and record review, the facility failed to provide a homelike environment when the bathroom floor tiles were dirty, buckled and had three missing pieces for one of three sampled residents (Resident 1). This failure had the potential to affect the resident`s self-esteem and self- worth while living in an environment that is not in good repair. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/7/2026 with diagnoses including anxiety (a feeling of worry, nervousness, or fear about what might happen next) and venous insufficiency (a long-term condition where leg veins fail to send blood back up to the heart). During a review of Resident 1's History and Physical (H&P), dated 7/8/2026, the H&P indicated Resident 1 demonstrated an understanding of his (Resident 1) medical conditions and had the capacity to make his (Resident 1) own medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/10/2026, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 1 used a walker for mobility and required partial assistance (helper does less than half the effort) from staff for toileting. During a concurrent observation and interview with Resident 1 on 8/18/2026 at 9:57 a.m., in Resident 1's room, Resident 1 was sitting up in his (Resident 1) bed. Resident stated he (Resident 1) wished to use the toilet in the bathroom more, but the facility suggested he (Resident 1) use a bedside commode. Resident 1 stated to look at the bathroom because over a week ago, the bathroom floor was dirty, uneven, buckled and had tile pieces missing. Observed Resident 1's bathroom and the floor appeared dirty with loose and missing pieces of tile. Resident 1 stated he (Resident 1) told a staff member over a week ago but did not remember who and stated he (Resident 1) did not like the way the bathroom looked and it should be clean. Resident 1 further stated there was now a shower chair over the toilet for several days now and it should not be there. During a concurrent observation and interview on 8/18/2026 at 11:16 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was her (CNA 1) assignment, but she (CNA 1) had not worked in his (Resident 1) room for several days. CNA 1 stated that she (CNA 1) has not personally assisted Resident 1 to the bathroom and was not aware of the condition of the bathroom. CNA 1 observed the bathroom and stated the floor appeared dirty and the tiles looked loose and had some pieces missing. CNA 1 stated this is Resident 1's home and should be kept up and clean. During an interview on 8/19/2026 at 11:50 a.m. with the Maintenance Supervisor (MS), the MS stated the tiles in Resident 1's room were uneven and lifted due to water damage from the toilet. The MS stated Resident 1's bathroom floor is not homelike and could be dangerous since the resident can trip on the lifted and uneven tiles. During an interview with the Director of Nursing (DON) on 8/19/2026 at 12:16 p.m., the DON stated residents' spaces should be kept up and in good repair to create a comfortable environment. During a review of the facility's policy and procedures (P&P) titled, Homelike Environment, last reviewed on 1/8/2026, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards when the bathroom floor tiles were uneven, buckled, and had three missing pieces for one of three sampled residents (Resident 2) who was continent (the ability to control your bladder and bowels) and used the bathroom regularly. This failure placed Resident 2 at an increased risk for injuries. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/15/2026 fracture (broken bone) of neck of right femur (large, long bone from hip to knee) and a history of falls. During a review of Resident 2's History and Physical (H&P), dated 8/17/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. The H&P further indicated the resident was admitted from a general acute care hospital (GACH) for right hip pain after he fell off of his pool diving board at home. During a review of Resident 2's Activities of Daily Living Care Plan (CP), initiated on 8/18/2026, the CP indicated the resident requires x1 (one) staff participation to use the toilet. During an interview on 8/18/2026 at 10:55 a.m. with Resident 2, Resident 2 stated he (Resident 2) had a history of falls and the floor in the bathroom was buckled, uneven, and had several tiles missing. Resident 2 stated he (Resident 2) told staff, but he (Resident 2) was too new to remember any names of who he (Resident 2) told. Resident 2 stated it was not fixed, and he (Resident 2) felt unsafe and unsteady when walking in the bathroom. During a concurrent observation and interview on 8/18/2026 at 11:16 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 2's bathroom, CNA 1 stated Resident 2 was new to her (CNA 1) that day and stated the floor was uneven and had tiles missing. CNA 1 stated the floor is not safe for the resident to walk on and he (Resident 2) could fall. During an interview on 8/19/2026 at 11:50 a.m. with the Maintenance Supervisor (MS), the MS stated the flooring issue in Resident 2's room was not reported to him until the day before (8/18/2026) in the afternoon by a CNA. The MS stated he (MS) was not aware of how long the floor was buckled, uneven, and had tiles missing but that the buckling must have been from water damage from the toilet over time. The MS stated he (MS) has maintenance request logs at the nursing station and staff should put in any request as soon as possible as he (MS) checks the log daily. The MS stated the floor being buckled and uneven could be very dangerous to a resident that walks. During an interview on 8/18/2026 at 12:16 p.m. with the Director of Nursing (DON), the DON stated safety of residents is very important and the floor repair should have been reported by staff right away to prevent falls. During a review of the facility provided policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed on 1/8/2026, the P&P indicated the facility strives to make the environment as free from accident hazards as possible.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by failing to ensure that a shower chair containing fabric was not used as a toilet riser for one of three sampled residents (Resident 2). This failure had the potential to result in contamination of the shower chair padding and fabric and risk of transmission of bacteria that could lead to infection. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/15/2026 fracture (broken bone) of neck of right femur (large, long bone from hip to knee) and a history of falls. During a review of Resident 2's History and Physical (H&P), dated 8/17/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. The H&P further indicated the resident was admitted from a general acute care hospital (GACH) for right hip pain after he fell off of his pool diving board at home. During a review of Resident 2's Activities of Daily Living Care Plan (CP), initiated on 8/18/2026, the CP indicated the resident requires x1 (one) staff participation to use the toilet. During a concurrent observation and interview on 8/18/2026 at 10:55 a.m. with Resident 2, in Resident 2's room, Resident 2 was up in bed watching television and stated a staff member brought in a shower chair to use as a riser but could not remember which staff member brought it. Resident 2 asked staff if the facility had a plastic one, but the staff stated they did not. Resident 2 stated the shower chair was never removed to be cleaned in between use since he (Resident 2) arrived. During a concurrent observation and interview on 8/18/2026 at 11:16 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 2's bathroom, CNA 1 stated Resident 2 was new to her (CNA 1) that day and stated she (CNA 1) was not aware that there was a shower chair over his (Resident 2) toilet. CNA 1 stated a plastic toilet riser should have been used instead to prevent infection. During an interview on 8/19/2026 at 9:50 a.m. with the Infection Preventionist (IP), the IP stated a shower chair should never be used as a toilet riser because it contains fabric which needs to be washed between each use and cannot be wiped down. The IP stated the shower chair was being used as a riser and was unaware. The IP stated using the shower chair as a riser could spread bacteria. During a review of the facility provided policy and procedure (P&P) titled, Policies and Practices - Infection Control, last reviewed on 1/8/2026, the P&P indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to implement the facility's policy on fingernails and toenails care by failing to provide documented evidence that fingernail care was being provided for the month of August 2026 by nursing staff for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to result in a negative impact on the residents' self-esteem and self-worth.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident on 3/16/2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arm). During a review of Resident 1's Minimum Data Set, dated [DATE], the MDS (MDS- resident assessment tool) indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was intact. The MDS also indicated Resident 1 requires setup or clean-up assistance (staff sets up or cleans up; resident completes activity. Staff assists only prior to or following the activity) with eating, requires partial/moderate assistance from staff with oral hygiene, and requires substantial/maximal assistance with toileting hygiene, showering, bathing self, dressing upper body and personal hygiene. b. During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident on 6/13/2026 with diagnoses that included ischemic cardiomyopathy (heart muscle is weak and cannot pump blood well) and spinal stenosis (a medical condition where the open space inside the backbone gets too small). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS also indicated Resident 2 requires setup or clean-up assistance with eating and oral hygiene, requires partial/moderate assistance from staff with toileting, upper body dressing, and personal hygiene. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 1/29/2026 with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS also indicated Resident 3 requires substantial/maximal assistance from staff with eating, oral hygiene, toileting, shower/bathe self, upper body dressing, and personal hygiene. During an interview on 8/13/2026 at 11:01 a.m., with the Director of Staff Development (DSD), the DSD stated that Certified Nursing Assistants (CNAs) are to cut residents' fingernails when they notice they are getting long. There is no specific schedule to cut residents' fingernails, however it is typically done during shower days. Staff are not allowed to cut toenails. The DSD reviewed the medical records of Resident 1, Resident 2, and Resident 3 for the month of August 2026. The DSD stated that he was unable to find documented evidence that fingernail care is being performed by nursing staff. The DSD stated that documentation of nail care is important to ensure that residents' nail care is being done. The DSD further stated that on the facility's electronic health system, CNAs are able to chart for personal hygiene, but not specific to fingernail care. The DSD stated that there should be specific documentation for fingernail care. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, reviewed on 1/5/2026, the P&P indicated under documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 3. The condition of the residents' nails and nail beds including: a. Redness or irritation of skin of hands and feet; b. Breaks or cracks in skin, especially between toes; d. Bluish or dark color of nail beds; g. Bleeding; and/or; h. Pain. 4. Any difficulties in cutting the resident's nails. 5. Any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure. 6. If the resident refused the treatment, the reason(s) why and the intervention was taken. 7. The signature and title of the person recording the data.

Based on interview and record review, the facility failed to ensure staff honored resident's rights when a resident requested to have a motorized wheelchair and the facility did not allow the resident to have a motorized wheelchair for one of three sampled residents (Resident 1). This deficient practice resulted in not honoring the resident's right to choose and had the potential to affect the self-esteem, self-worth, and sense of independence for Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident on 3/16/2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 6/16/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was intact. The MDS also indicated Resident 1 requires setup or clean-up assistance (staff sets up or cleans up; resident completes activity. Staff assists only prior to or following the activity) with eating, requires partial/moderate assistance from staff with oral hygiene, and requires substantial/maximal assistance with toileting hygiene, showering, bathing self, dressing upper body and personal hygiene. During an interview on 8/12/2026 at 1:12 p.m., with Resident 1, Resident 1 stated that Resident 1 is unable to independently go around the facility without assistance from staff on a regular facility-provided wheelchair. Resident 1 stated that the Social Services Director (SSD) was assisting Resident 1 in obtaining a motorized wheelchair however, the Administrator (ADM) did not allow Resident 1 to have a motorized wheelchair while in the facility. During an interview on 8/12/2026 at 1:40 p.m., with the Director of Rehabilitation (DOR), the DOR stated that the rehabilitation department can assess residents for the use of motorized wheelchair, however, residents are not allowed to use a motorized wheelchair while in the facility. The DOR stated that the facility does not have the capacity for the use of motorized wheelchairs and motorized wheelchairs cannot be used in the facility because it is the facility policy. The DOR continued to state that most nursing homes do not allow motorized wheelchairs due to resident safety. The DOR further stated that Resident 1 would benefit from a motorized wheelchair because of his diagnosis of quadriplegia. During an interview on 8/12/2026 at 2:00 p.m., with the MDS Nurse (MDSN), the MDSN stated that Resident 1 is unable to have a motorized wheelchair because of facility policy. During an interview on 8/12/2026 at 2:20 p.m., with the Social Services Director (SSD), the SSD stated that she was assisting Resident 1 in obtaining a motorized wheelchair, however, according to the ADM Resident 1 was unable to have a motorized wheelchair in the facility because it is facility policy. During an interview on 8/12/2026 at 2:58 p.m., with the Specialty Account Manager (SAM), the SAM stated that she had a lengthy conversation with the ADM on 7/27/2026, and the ADM stated that motorized wheelchairs are not allowed in their facility due to safety concerns. The SAM stated that Resident 1 has the right to know what his options are as far as mobility equipment to encourage his independence. During an interview on 8/12/2026 at 3:20 p.m., with the ADM, the ADM stated that Resident 1 is young and motorized wheelchairs are not allowed in the facility. During a follow up interview on 8/12/2026 at 3:20 p.m., with the SSD, the SSD stated that Resident 1 not being allowed to receive a motorized wheelchair goes against resident's rights. During a following up interview on 8/12/2026 at 4:40 p.m., with the SAM, theSAM stated that Resident 1's motorized wheelchair order was placed on hold on 7/27/2026 since the ADM stated that the facility will not allow Resident 1 to have a motorized wheelchair. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, reviewed on 1/5/2026, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; e. self-determination; g. exercise his or her rights as a resident of the facility and as a resident and as a resident or citizen of the United States; h.be supported by the facility in exercising his or her rights. During a review of the facility's P&P titled, Power Mobility Device Use, reviewed on 1/5/2026, the P&P indicated to provide a safe environment for residents, employes and visitors while ensuring that residents with disabilities and physical limitations have access to devices that improves their independence. Power mobility device/motorized wheelchair are allowed when deemed medically necessary. The P&P further indicated all residents who drive or request to use a power mobility device/motorize wheelchair will be assessed by licensed certified medical professional.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant (RNA- specialized Certified Nursing Assistant [CNA- an entry-level healthcare worker who provides daily hands-on care to patients] who helps residents in nursing homes or rehabilitation centers regain and keep their physical mobility and independence ) 2 did not willfully falsify (knowingly make a false entry into a resident's medical record) the application of right (R) knee brace (an external medical device worn around the knee joint to provide support, stability, and protection after an injury, during sports, or while recovering from surgery), R elbow splint (an external support device worn on the arm to stabilize, protect, or compress the elbow joint), R hand splint (a supportive device designed to support a weak or ineffective joint or muscle), and left (L) hand roll up (a cylindrical device-often made by rolling up a washcloth, towel, or specialized foam-placed in a resident's palm to keep the hand, thumb, and fingers in a natural, functional alignment) on 8/12/2026 for one of three sampled residents (Resident 1). This willful material falsification (when staff purposefully document false information in a medical record) resulted in the clinical record of Resident 1 fraudulently reflecting the care provided.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/16/2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms). 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 cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was intact. The MDS also indicated Resident 1 requires setup or clean-up assistance (staff sets up or cleans up; resident completes activity. Staff assists only prior to or following the activity) with eating, requires partial/moderate assistance from staff with oral hygiene, and requires substantial/maximal assistance with toileting hygiene, showering, bathing self, dressing upper body and personal hygiene. During a review of Resident 1's physician order dated 4/13/2026, the physician order indicated to don (to place)/doff (remove) bilateral (both) Pressure Relief Ankle Foot Orthosis (PRAFO - a specialized medical boot used in rehabilitation to hold the foot and ankle in a safe, correct position while keeping the heel completely floating off any surface to stop pressure sore) R knee brace, R elbow splint, R hand splint, and L hand roll for 4 hours/day as tolerated, everyday seven (7) times per week. During an observation on 8/12/2026 at 9:00 a.m., in Resident 1's room, observed Resident 1 lying in bed and did not have Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on. During an observation on 8/12/2026 at 10:50 a.m., in Resident 1's room, observed Resident 1 lying in bed and did not have Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on. During an observation on 8/12/2026 at 1:12 p.m. in the facility's patio, observed Resident 1 in his manual wheelchair under the shade. Observed Resident 1 did not have Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on. During a concurrent observation and interview on 8/12/2026 at 4:02 p.m., in the facility's patio, observed Resident 1 in his manual wheelchair under the shade. Observed Resident 1 did not have Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on. Resident 1 stated that staff did not place splints and hand roll today and that Resident 1 knows they are supposed to have it on and the staff did not put in on them today. During a review for Resident 1's document titled, Tasks: RNA to render bilateral (both) lower extremities (BLE)/ bilateral upper extremities (BUE) passive range of motion (PROM- refers to the movement of a joint by an outside force-such as a physical therapist, a machine, or another part of your body-while your muscles stay completely relaxed and do not actively work to create the motion) exercise followed by don /doff bilateral PRAFO, R knee brace, R elbow splint, and L hand roll for four (4) hours a day as tolerated, every day seven (7) times per week. Skin check every hour. The documentation indicated that on 8/12/2026, Resident 1's right knee brace, right elbow splint, right hand splint, and left-hand roll were placed, and Resident 1 tolerated for (4) hours. During a concurrent interview and record interview on 8/13/2026 at 12:50 p.m., with RNA 1, reviewed Resident 1's document titled, Tasks: RNA. RNA 1 stated that he documented that he applied Resident 1's R knee brace, R elbow splint, and L hand roll. RNA 1 stated that yesterday, 8/12/2026, Resident 1 was assigned to him. RNA 1 stated that Resident 1 has orders for splints and hand rolls to be placed four (4) hours a day as tolerated. When asked if Resident 1's splint and hand roll were applied yesterday (8/12/2026), RNA 1 stated that he was unable to apply Resident 1's splints and hand roll yesterday (8/12/2026) because he was the only RNA for the facility yesterday (8/12/2026). RNA 1 stated that he was aware he documented that Resident 1's splints and hand roll were applied, and he also was aware that he did not apply them. RNA 1 continued to state that he just wanted to finish charting for all his residents yesterday (8/12/2026). RNA 1 further stated that he knew what he was documenting when he was documenting on Resident 1's medical record. RNA 1 stated that he should not have documented that he applied Resident 1's splints and hand roll because he did not do it. RNA 1 stated that he should have left Resident 1's medical record blank and should have reported to the charge nurse. RNA 1 was asked if RNA 1 documented willfully and falsely in the RNA tasks for Resident 1's donning of R knee brace, R elbow splint, R hand splint, and left hand roll, for 8/12/2026, and RNA 1 stated Yes, I did. I'm sorry. During an interview on 8/13/2026 at 1:26 p.m., with the Director of Staff Development (DSD), the DSD stated that if RNA 1 knew that he did not place Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on and RNA 1 still documented that he placed Resident 1's right knee brace, right elbow splint, right hand splint, and left hand roll on, then RNA 1 willfully falsified Resident 1's medical record. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, reviewed on 1/5/2026, the P&P Indicated all services provided to their residents, progress toward the care plan goals, or any changes in the residence medical, physical, functional or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. Documentation in the medical record will be objective, complete, and accurate.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- resident assessment tool) section GG (measures a resident's functional abilities and support needs in self-care and mobility) was accurately coded for one of three sampled residents (Resident 1). This deficient practice placed the resident at risk for unsafe resident care and may lead to a delay in the ability to evaluate the appropriateness of the care to be delivered. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident on 3/16/2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was intact. The MDS also indicated Resident 1 requires setup or clean-up assistance (staff sets up or cleans up; resident completes activity. Staff assists only prior to or following the activity) with eating, requires partial/moderate assistance from staff with oral hygiene, and requires substantial/maximal assistance with toileting hygiene, showering, bathing self, dressing upper body and personal hygiene. During a concurrent interview and record review on 8/13/2026 at 12:12 p.m. with the MDS Nurse (MDSN), reviewed Resident 1's MDS dated [DATE]. The MDSN stated that when assessing residents for MDS, the MDSN speaks to the resident and/or residents' families, observed residents, speaks to staff, and reviews residents' medical records to ensure an accurate assessment and to determine the appropriate code for MDS sections. The MDSN continued to state that he is responsible for assessing residents for MDS and coding the MDS. The MDSN reviewed Resident 1's MDS section GG. The MDSN stated that Resident 1's MDS section GG was inaccurately coded. The MDSN stated that all sections of the MDS section GG should be coded 01, indicating Resident 1 is dependent (staff does all effort, resident does none of the effort to complete the activity, or the assistance of 2 or more staff is required for the resident to complete the activity) on staff because of his diagnosis of quadriplegia. The MDSN stated that he based Resident 1's assessments on the charting of the certified nursing assistants. When asked if the MDSN personally went to assess Resident 1, the MDSN did not answer. The MDSN stated that he should have spoken to Resident 1 and should have done a better assessment. The MDSN stated that it is important of the MDS to be accurate because the facility uses the MDS to formulate resident centered care plans (a written step-by-step guide that lists a resident's health problems, sets recovery goals, and explains what treatments or daily actions the medical team and resident will use to reach those goals) and for reimbursement. During a review of the facility's policy and procedure titled, Resident Assessments, reviewed on 1/5/2026, the P&P indicated a comprehensive assessment of each resident is completed. The Resident Assessment Instrument (RAI - is an official guide created by the Centers for Medicare & Medicaid Services [CMS]. It gives nursing homes step-by-step instructions to assess, code, and plan care for residents using the MDS) User's Manual provides detailed information on timing and submission of assessments. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The interdisciplinary team uses the MD's form currently mandated by federal and state regulations to conduct the resident assessment. Residents and/or their representatives are encouraged to participate in the assessment process. The resident assessment coordinator or designee is responsible for notifying the residents and/or representatives in advance of the scheduled assessment or review. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had accurate and complete documentation on the Fall Risk Assessment (a form used by the facility to assess a resident's risk for a fall) dated 6/30/2026. This deficient practice had the potential to place Resident 1 at greater risk for a fall and decreased supervision by facility staff.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/11/2026, with the most recent admission on [DATE] with diagnoses that included fracture (a break in the bone) of the right femur (the long bone in the upper part of the leg), hemiplegia (total paralysis [partial or complete loss of voluntary muscle function in a part of the body] of the arm, leg and trunk on the same side of the body) following cerebral infarction (CVA- stroke, loss of blood flow to a part of the brain) affecting right dominant side, type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and atrial fibrillation (abnormal heart rhythm). During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a resident's medical condition) dated 6/30/2026, the H&P indicated Resident 1 had mental capacity. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/30/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated Resident 1 was dependent on staff for activities of daily living (ADLs- routine tasks or activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated that Resident 1 had not had a fall in the last six months. During a concurrent interview and record review on 7/10/2026 at 11:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), the Fall Risk Assessment form dated 6/30/2026 was reviewed. LVN 1 confirmed completing the Fall Risk Assessment on 6/30/2026 and stated that Resident 1 had not had a fall within the last six months. However, LVN 1 confirmed that Resident 1 sustained a fall in the facility on 6/24/2026. LVN 1 stated that the Fall Risk Assessment should have indicated that Resident 1 had one fall within the last six months. During a concurrent interview and record review on 7/10/2026 at 12:00 p.m. with the Director of Nursing (DON), the Fall Risk assessment dated [DATE] was reviewed. The DON confirmed that Resident 1's Fall Risk assessment dated [DATE] incorrectly indicated that Resident 1 had no falls within the last six months despite Resident 1 having sustained a fall in the facility on 6/24/2026. The DON stated that the Fall Risk Assessment for Resident 1 dated 6/30/2026 should have indicated that Resident 1 had one fall within the last six months. The DON further confirmed that the Fall Risk Assessment is used by the facility to evaluate a resident's risk for falls and that accurate documentation is necessary to ensure an appropriate assessment of fall risk. During a review of the facility's policy and procedure (P&P) titled Falls - Clinical Protocol last reviewed on 1/5/2026, the P&P indicated . The staff and physician will document in the medical records a history of one or more recent falls.The staff will evaluate and document falls that occur while the individual is in the facility. During a review of the facility's P&P titled Charting and Documentation last reviewed on 1/5/2026, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The following information is to be documented in the resident medical records, objective observations.changes in the resident's condition.Documentation in the medical records will be objective, complete and accurate.

Based on observation, interview and record review, the facility failed to: 1. Maintain a comfortable sound levels to promote a restful environment for two of three residents (Resident 3 and 89) investigated under the care area Safe/Clean/Homelike Environment. This deficient practice resulted in the residents feeling disrespected, annoyed and awaken unnecessarily. 2. Provide a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 91) when there was dust buildup on the base of the resident's facility provided fan and wall. This deficient practice denied Resident 91 the right to a clean, comfortable, and homelike environment and had the potential to negatively impact Resident 91's quality of life. Findings: 1.a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 2/28/2025 with diagnosis including heart failure (heart muscle is weakened or stiffened, failing to keep up with the body's blood demand) and obstructive sleep apnea (a common disorder where breathing repeatedly stops and starts during sleep due to throat muscles relaxing and blocking the airway). During a review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 11/27/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 3 required partial/moderate assistance (helper does more than half the effort) upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene and substantial/maximal assistance (helper does more than half the effort) with toileting shower hygiene. During an interview on 03/23/2026 at 11:38 a.m. in Resident 3`s room, Resident 3 stated that there is this one Certified Nurse Assistant that is very loud when she talks and he would get startled when she goes in the room because of her loud voice and staff should tone down their voices because it disturbs us when we are resting. 1.b.During a review of Resident 89's admission Record (AR), the AR indicated the facility admitted the resident on 1/21/2026 with diagnosis including, alcohol dependence (alcohol addiction) and depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy). During a review of Resident 89's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 89 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene and substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, upper body dressing, lower body dressing and personal hygiene. During a Resident Council group interview on 03/24/2026 at 1:30 p.m., Resident 89 (one of the participants) stated that sometimes early in the morning around 6 a.m. to 7 a.m. the noise in the hallway near the nurses` station is very loud. Resident 89 stated that they sometimes play loud music and we can hear their conversation which sometimes awaken us and its difficult for him to go back to sleep. During an interview and record review on 03/26/2026 at 1:58 p.m., with the Director of Staff Development (DSD), the DSD stated that he is aware of the complaint of some residents about a specific staff that is very loud. The DSD stated that this facility is their home (residents) and should be restful and homelike. The DSD stated that the noise level should be comfortable for the residents and must not interrupt their sleeping time especially in the early morning. The DSD stated that he had provided in-service to the staff regarding maintaining a comfortable noise level. Upon review of the In-Service Training Minutes for Noise Level dated 1/8/2026 with the DSD, the In-Service training did not include the specific staff that was mentioned by the residents. During an interview on 3/26/2026 at 2:04 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA1 stated that she is aware that she is loud and needs to tone down her voice so as not to disturb the residents especially if they are sleeping. CNA 1 stated it is disrespectful if we are loud in the facility and makes the environment not homelike. During a review of the facility`s policy and procedures (PP) titled, Homelike Environment, last reviewed on 1/5/2026, the PP indicated that Residents are provided with a safe, clean, comfortable and homelike environment.the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment, comfortable sound levels. 2. During a review of Resident 91's admission Record, the admission Record indicated the facility admitted the resident on 10/17/2025 with diagnoses including, but not limited to, fracture of the left humerus (broken left arm) and idiopathic peripheral autonomic neuropathy (a condition where the nerves outside of the brain and spinal cord are damaged for an unknown reason). During a review of Resident 91's MDS, dated [DATE], the MDS indicated the resident was cognitively intact (able to think, learn, and remember clearly). The MDS indicated Resident 91 required substantial assistance (helper does more than half of the effort) for showering, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 91 required moderate assistance (helper does less than half of the effort) with toileting, upper body dressing, and personal hygiene. The MDS indicated Resident 91 required set up or cleaning assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene. During an observation on 3/23/2026 at 12:44 p.m. at Resident 91's bedside, the resident's fan on the floor in front of her bed had a thick layer of dust build up on the base. The wall behind the fan had dust on top of the cover mounted to the wall which contained cords connected to the resident's television. During a concurrent observation and interview on 3/25/2026 at 10:56 a.m. with the Maintenance Supervisor (MS) at Resident 91's bedside, the MS observed and validated the dust build up on the resident's fan and cord covering along the wall. The MS stated the facility provided this fan for the resident and it came from the facility's storage. The MS stated there should not be dust in the observed areas and they should have been cleaned. The MS stated he was the supervisor for both the maintenance and housekeeping departments. The MS stated housekeeping should be cleaning these areas as a part of their regular duties. The MS stated they should be dusted so they provide a clean area for the resident. The MS stated the dust could affect the air quality in the resident's room. During a review of the facility's P&P titled, Homelike Environment, last reviewed 1/5/2026, 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 facility that reflect a personalized, homelike setting including a clean, sanitary, and orderly environment.

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 2) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 2 did not have duplicate (more than one [1]) medication treatments with the use of quetiapine (antipsychotic [medication used to treat mental illness]) and clonazepam (a psychotropic drug used for agitation and as anxiolytic [reduce anxiety]) between 12/23/2025 and 3/24/2026. This deficient practice had the potential to place Resident 2 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) such as drowsiness, dizziness and respiratory depression (stoppage of breathing) from the use of unnecessary psychotropic and antipsychotic drugs, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 2's admission Record (a document containing demographic and diagnostic information,) dated 3/24/2026, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including psychotic disorder (a mental health condition that causes a person to lose touch with reality, making it hard for them to distinguish what is real from what is imagined,) depression and anxiety. During a review of Resident 2's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 3/16/2026, the MDS indicated Resident 2 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS was marked for diagnoses including depression, anxiety and psychotic disorder and indicated Resident 2 received antipsychotics on a routine basis. During a review of Resident 2's Medication Administration Record (MAR - a record of medications administered to residents), for March 2026, the MAR indicated Resident 2 was prescribed the following: -clonazepam 0.5 milligram (mg - a unit of measure of mass) to give 0.5 tablet (0.25 mg) by mouth at bedtime for manifested by combative behavior and kicking staff, starting 3/8/2025 -monitor for anxiety manifested by combative behavior, kicking staff every shift -quetiapine 25 mg to give half tablet (12.5 mg) by mouth every 12 hours for manifested by agitation, starting 12/23/2025. -monitor behaviors(s) of agitation manifested by kicking every shift for use of quetiapine use, every shift for continues kicking. During a concurrent document review and interview on 3/24/2026 at 2:12 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Resident 2's MAR for March 2026. LVN 3 stated Resident 2's MAR indicated clonazepam was prescribed for combative behavior and kicking staff and quetiapine was also prescribed for kicking staff, and to monitor combative behavior and kicking staff for clonazepam use and to monitor kicking staff for quetiapine use. LVN 3 stated the addition of quetiapine order on 12/23/2025 did not have a specific indication or behavior that was different than the use for the clonazepam order. LVN 3 stated, as a result, the physician will not be able to make an accurate assessment of the effectiveness of clonazepam or quetiapine, as both were used and monitored for the same indication. LVN 3 stated that duplicate indications and monitoring for clonazepam and quetiapine lead to unnecessary psychotropic medication use and increased Resident 2's risk of experiencing additive adverse effects, such as drowsiness, dizziness, confusion, impaired coordination and respiratory depression. During an interview on 3/24/2026 at 2:54 p.m., with LVN 1, LVN 1 stated psychotropic and antipsychotic medications require a specific indication for behaviors unique for each medication prescribed, to allow for accurate assessment of the medication's effectiveness. LVN 1 stated the clonazepam and quetiapine orders for Resident 2 were both prescribed and monitored for the same indication resulting in duplication. During a concurrent record review and interview on 3/24/2026 at 3:07 p.m., with the Director of Nursing (DON), the DON reviewed March 2026 MAR for Resident 2. The DON acknowledged the MAR indicated clonazepam was prescribed for combative behavior and kicking staff and quetiapine was prescribed for kicking staff. The DON also acknowledged clonazepam was monitored for combative behavior and kicking staff and there was no documentation for behaviors noted in March 2026, and quetiapine was monitored for kicking staff and the MAR indicated behaviors documented on 3/9/2026 and 3/10/2026. The DON added due to lack of having clear and specific indications and target behaviors identified and monitored for clonazepam and quetiapine, created a confusion amongst licensed nurses for appropriately documenting the behaviors. The DON added that this failure caused duplicate therapy for Resident 2, creating the potential for the resident to experience additive adverse medication effects and causing the physician to make inaccurate assessments of the specific medication's effectiveness, which could result in unnecessary dose increases. During a review of the facility's Policies & Procedures (P&P) titled, Psychotropic Medication Use, last reviewed 1/5/2026, the P&P indicated: A psychotropic drug is any medication that affects brain activity associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics and antidepressants. The Facility should comply with the State Operations Manual, and all other Applicable Laws relating to the use of psychoactive medications. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying mediation or psychiatric causes of behavioral symptoms. During a review of the facility's P&P titled Antipsychotic Medication Use, last reviewed 1/5/2026, the P&P indicated: An antipsychotic medication should be used only for conditions/diagnoses as documented in the record and as meets the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV TR) or subsequent editions. In addition, before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and monitored objectively and qualitatively.

Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKIT - kit containing medications needed to be used during emergencies) containing Controlled Substance-[CS, medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication, CM]) for March 2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 2.Reconcile two (2) medication eKITs containing CS for March 2026, in two (2) of three (3) inspected Medication Carts (Medication Cart 1 Station 1, Medication Cart AM Station.) 3. Replace one (1) open used medication eKIT within 72 hours of opening the kit on 3/19/2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 4. Account for one (1) dose of CS for Resident 85 in one (1) of three (3) inspected medication carts (Medication Cart AM Station 2.) As a result, control and accountability of CSs and replacement of eKITs did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and increased 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, hospitalization and death. In addition, Resident 85 could have accidental overdose (administration of more than the prescribed dose) to CS leading to their health and well-being to be negatively impacted. Findings: During an observation on 3/23/2026 at 12:40 p.m., with Registered Nurse (RN) 1 and the Director of Nursing (DON), in Medication room [ROOM NUMBER], there was: 1.One (1) open medication eKIT containing antibiotics (medications that are used to treat infections) and intravenous (medications given through the vein) medications with a document indicating the eKIT was opened on 3/19/2026 at 1:30 p.m. 2. Two (2) medication eKITs containing CSs stored in the refrigerator and labeled REF455 and REF587, without an accountability log for the reconciliation of CS inventory at every shift change for March 2026. 3. Two (2) medication eKITs containing CSs stored at room temperature in the cabinet and labeled PO656 and PO738, without an accountability log for the reconciliation of CS inventory at every shift change for March 2026. During a concurrent interview with RN 1 and the DON, RN 1 and the DON acknowledged the antibiotic and intravenous medication eKIT was open, used, contained documents indicating the kit was opened on 3/19/2026 and was awaiting replacement for a new one from pharmacy. The DON stated the eKIT should have been replaced with a new one from pharmacy within 72 hours of opening the eKIT. RN 1 and the DON acknowledged the eKIT was not replaced within 72 hours of opening. The DON stated the facility was not compliant. The DON stated the facility failed to replace the medication eKIT with a new one within 72 hours of opening the eKIT and this failure could increase the risk of not having critical medications available for residents during emergencies leading to negative consequences causing resident harm, potential hospitalization and delay in medication treatment. During the interview, RN 1 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. RN 1 stated the eKITs labeled above in the refrigerator and cabinet containing CSs in Medication room [ROOM NUMBER] was not reconciled at every shift in March 2026, and it was important to account for all CSs to ensure accountability and prevent Cs diversion. During an observation on 3/23/2026 at 1:08 p.m., with Licensed Vocational Nurse (LVN) 3, in Medication Cart 1 Station 1, there was one (1) medication eKIT containing CSs stored at room temperature and labeled 552, without an accountability log for the reconciliation of CS inventory at every shift change for March 2026. During a concurrent interview, LVN 3 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 3 stated the eKIT labeled 552 in Medication Cart 1 Station 1 was not reconciled at every shift in March 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an observation on 3/23/2026 at 1:42 p.m., with Licensed Vocational Nurse (LVN) 2, in Medication Cart AM Station 1, there was: 1.One (1) medication eKIT containing CSs stored at room temperature and labeled 355, without an accountability log for the reconciliation of CS inventory at every shift change for March 2026. 2. a discrepancy in the count between the Antibiotic or Controlled Drug Record accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for Resident 85. One (1) dose of diazepam (a CS used for feelings of panic) tablet was missing from the bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 85. The Antibiotic or Controlled Drug Record accountability log for diazepam indicated the bubble pack should have contained a total of 9 diazepam 5 milligram)[mg]- a unit of measure of mass) tablets, after the last administration of diazepam 5 mg tablet documented/signed-off on 3/22/2026 at 5 p.m., however the medication bubble pack contained 8 diazepam 5 mg tablets and contained no other documentation of subsequent administrations. During a review of Resident 85's Medication Administration Record ([MAR - record of medications administered to a resident) for March 2026, the MAR indicated Resident 85 was prescribed diazepam five (5) mg orally twice a day for panicky feelings, to be given at 9 a.m. and 5 p.m. During a concurrent interview, LVN 2 stated LVN 2 administered one (1) diazepam 5 mg tablet to Resident 85 at 9 a.m., that morning (3/23/2026), and forgot to sign the Antibiotic or Controlled Drug Record accountability log. LVN 2 stated LVN 2 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the dose for the resident. LVN 2 stated LVN 2 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 2 stated if documentation was not accurate then it can lead to medication error if overdosed leading to stoppage of breathing, hospitalization and possibly death for Resident 85. During the same interview, LVN 2 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 2 stated the eKIT labeled 355 containing CSs in Medication Cart AM Station 2 was not reconciled at every shift in March 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an interview, on 3/24/2026 at 3:15 p.m., with the DON, the DON stated medication eKITs containing CSs need to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON acknowledged the eKITs labeled 355, 552, REF455, REF587, PO656M and PO738, did not have accountability logs and were not reconciled at every shift in March 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During the same interview, the DON stated that LVN 2 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 85. The DON stated not documenting the Antibiotic or Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. During a review of the facility's Policy and Procedures (P&P) titled Controlled Medications, last reviewed 1/5/2026, the P&P indicated: C. When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) date and time of administration 2) amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. During a review of the facility's P&P, titled Controlled Medication Storage, last reviewed 1/5/2026, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. a.The DON and the consultant pharmacist maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. d. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. During a review of the facility's P&P titled Emergency Pharmacy Services/Emergency Kits, last reviewed 1/5/2026, the P&P indicated: An emergency supply of medications including emergency drugs, antibiotics, CSs,.is supplied by the provider pharmacy in limited quantities in portable, sealed containers that are in compliance with applicable state regulations. N. If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting two (2) of four (4) residents observed for medication administration (Resident 18 and 57.) The medication errors were as follows:1. Resident 18 did not receive a form of aspirin (a medication used for cerebrovascular accident [CVA - an interruption in the flow of blood to cells in the brain, mainly caused by hypertension (high blood pressure)] prophylaxis [PPX - prevention]) as ordered by Resident 18's physician. 2. Resident 57 did not receive a form of aspirin as ordered by Resident 57's physician. These failures had the potential to result in Resident 18 and 57 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 18's and 57's health and well-being to be negatively impacted. Findings: During an observation on 3/23/2026 at 9:10 a.m., in Medication Cart 1, Licensed Vocational Nurse (LVN) 3 was observed administering aspirin 81 milligram ([mg]-a unit of measure of mass) chewable tablet to Resident 57. Resident 57 was observed swallowing the aspirin tablet with glass of water. During an interview on 3/23/2026 at 2:04 p.m., with LVN 3, LVN 3 stated that LVN 3 administered aspirin 81 mg chewable tablet during the morning medication administration at 9:10 a.m. to Resident 57. LVN 3 stated that LVN 3 failed to follow the physician orders to administer aspirin 81 mg enteric coated ([EC] - a form of aspirin that is designed to slowly release medication) tablet. LVN 3 stated EC tablets release slowly in the stomach and chewable tablets release immediately into the stomach. LVN 3 stated administering chewable tablet was considered a medication error because it was the wrong form of the medications. LVN 3 stated administration of aspirin 81 mg chewable tablet increased the risk of stomach irritation to Resident 57. During an observation on 3/23/2026 at 9:25 a.m., in Medication Cart 1, LVN 6 observed administering aspirin 81 mg chewable tablet to Resident 18. Resident 18 was observed swallowing the aspirin tablet with glass of water. During an interview on 3/23/2026 at 2:08 p.m., with LVN 6, LVN 6 stated that LVN 6 administered aspirin 81 mg chewable tablet during the morning medication administration at 9:25 a.m. to Resident 18. LVN 6 stated that LVN 6 failed to follow the physician orders to administer aspirin 81 mg EC tablet. LVN 6 stated EC tablets release slowly in the stomach and chewable tablets release immediately into the stomach. LVN 6 stated administering chewable tablet was considered a medication error because it was the wrong form of the medications. LVN 6 stated administration of aspirin 81 mg chewable tablet increased the risk of stomach irritation to Resident 18. During an interview on 3/24/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that LVN 3 and 6 failed to administer aspirin 81 mg EC tablet to Resident 18 and 57, according to the physician orders. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered to residents. The DON stated Resident 18 and 57 may be at risk for developing stomach irritation from receiving aspirin 81 mg chewable tablet, and that the administration of chewable tablet was considered a medication error. During a review of Resident 18's admission Record (a document containing demographic and diagnostic information,) dated 3/23/2026, indicated the resident was originally admitted to the facility on [DATE] with diagnoses including hypertension. During a review of Resident 18's Order Summary Report, dated 3/23/2026, the Order Summary Report indicated Resident 18 was prescribed aspirin EC 81 mg once a day for CVA PPX, starting 2/18/2026. During a review of Resident 18's Medication Administration Record ([MAR] - a record of mediations administered to residents), for March 2026, the MAR indicated Resident 18 was prescribed aspirin EC 81 mg one (1) tablet once a day orally for CVA PPX, to be given at 9 a.m. During a review of Resident 57's admission Record dated 3/23/2026, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertension. During a review of Resident 57's Order Summary Report, dated 3/23/2026, indicated Resident 57 was prescribed aspirin 81 mg EC tablet once a day for CVA PPX, starting 9/29/2025. During a review of Resident 57's MAR for March 2026, the MAR indicated Resident 57 was prescribed aspirin EC 81 mg one (1) tablet once a day orally for CVA PPX, to be given at 9 a.m. During a review of the facility's policy and procedures (P&P), titled Administering Medications, last reviewed 1/5/2026, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the facility's P&P titled Medication Administration - General Guidelines, last reviewed 1/5/2026, the P&P indicated Medications are administered as prescribed. 2. Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled Procedures for All Medications, last reviewed 1/5/2026, the P&P indicated: To administer medications in a safe and effective manner. F. Read medication label before administering. During a review of the facility's P&P titled Adverse consequences and Medication Errors, last reviewed 1/5/2026, the P&P indicated: 2. An 'adverse consequence' is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction; b. Side effect; 4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 3. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 4. Examples of medications errors include: e. wrong dosage form.

Based on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to ensure eye drops were stored separately from orally administered medications, in one (1) of three (3) inspected Medication Carts (Medication Cart 1 Station 1.) This deficient practice increased the risk of contamination of medications and receiving medications via the wrong route (internal versus external routes,) for residents in the facility, possibly leading to adverse health consequences resulting in the negative impact to their health and well-being. Findings: During a concurrent observation and interview on 3/23/2026 at 1:08 p.m., in Medication Cart 1 Station 1, with Licensed Vocational Nurse 3 (LVN 3), the following medications were stored in a manner contrary to the facility's P&P: -One (1) artificial tears (a medication used for dry eyes) eye drop bottle and one (1) atropine (a medication used to dilate the pupils of the eye) eye drop bottle was stored with several oral medication bottles (including docusate [stool softener], acetaminophen [pain medication], vitamin b complex [supplement], lactobacillus [probiotic], oyster shell calcium [supplement], glucosamine [joint support] in the same bin/container of the medication cart. LVN 3 stated that eye drops should be stored separately from oral medications, to prevent errors in wrong route administration and possible infections/contaminations. LVN 3 acknowledged one (1) medication bin/container contained one (1) artificial tear eye drop bottle and one (1) atropine eye drop bottle with several orally administered medication bottles. LVN 3 stated the facility failed to store eye drops separate from oral medications. During an interview, on 3/24/2026 at 3:15 p.m., with the Director of Nursing (DON,) the DON stated internally (such as oral) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store the artificial tears and atropine eye drop bottles in Medication Cart 1 Station 1 separate from several orally administered medication bottles. During a review of facility's P&P titled, Storage of Medications, last reviewed on 1/5/2026, the P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. C. Orally administered medications are kept separate from externally used medications.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure a staff member knocked prior to entering a resident`s room for one of two residents (Resident 26) observed during dining observation. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 26`s sense of self-worth and self-esteem. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted the resident on 3/31/2020 with diagnosis including, major depressive disorder (a serious mental health condition characterized by persistent, severe sadness, loss of interest, and low energy lasting at least two weeks) and hypertension (high blood pressure). During a review of Resident 26's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/02/2026, the MDS indicated Resident 26 had the ability to understand others and be understood and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, showers, lower body dressing and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, upper body dressing, putting on and taking off footwear and personal hygiene. During a concurrent observation and interview on 3/28/2026 at 12:15 p.m. with Certified Nurse Assistant 1 (CNA 1) outside of the main dining room, CNA1 was observed receiving a finished meal tray, from a staff member, containing a cup of ice cream and a crumpled plastic shrink wrap. CNA1 disposed of these items in the trash bin without wearing gloves and did not sanitize her hands after completing the task. CNA 1 then proceeded to wheel an open meal cart with three new meal trays and a container of food containing an unidentified soup. As CNA 1 was wheeling the meal cart, staff were observed taking out the trays from the meal cart. When CNA 1 reached the room of Resident 26, she then took out the container of food with an unidentified soup with her bare hands and entered the resident`s room without knocking and delivered the food container and placed them in the overbed table and removed the lid. When interviewed, CNA 1 stated that she should have performed hand hygiene by washing her hands or use a hand sanitizer after discarding items from a dirty tray and before delivering the food to Resident 26. CNA 1 stated that hand hygiene (washing, sanitizing) is important before touching meal trays to prevent infection and cross contamination among residents and staff. CNA 1 stated that she should have knocked on the resident`s door and asked permission to go in as a sign of respect for their right to privacy. During a review of the facility`s policy and procedure titled Dignity, last reviewed on 1/05/2026, the policy indicated that Each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being, level of satisfaction with life, and feeling of self-worth and self-esteem.staff are expected to knock and request permission before entering residents` rooms.

Based on interview and record review, the facility failed to develop a comprehensive care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) by failing to: a. Develop a care plan for a skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers) sustained during a fall incident for one of five sampled residents (Resident 30) investigated under the Accidents care area. This deficient practice had the potential to result in failure to deliver the necessary care and services to Resident 30. b. Develop a care plan regarding the refusal of the 2025/2026 COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) and influenza (also known as the flu, a contagious respiratory illness caused by influenza viruses that infects the nose, throat, and lungs) vaccinations (medications used to prevent diseases usually given by injection or by mouth) for one of five sampled residents (Resident 44) investigated for immunizations (the action of making a person or animal resistant to a particular infectious disease or pathogen, typically by vaccination). This deficient practice had the potential for Resident 44 to be at a higher risk of developing a respiratory infection, obtaining further health complications from the infection, and spreading the infection to other residents. Findings: a. During review of Resident 30's admission Record, the admission Record indicated that the facility admitted the resident on 1/27/2026 with diagnoses that included depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical symptoms that disrupt daily life) and hypertension (high blood pressure). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2026, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear and partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene. During a concurrent interview and record review on 03/25/2026 at 9:08 with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 30`s Change of Condition (COC- any sudden or significant deviation from a patient's baseline physical, cognitive, functional, or behavioral status) dated 3/17/2026 and care plan (CP) for Actual Fall with skin tear. The COC indicated Resident 30 had a fall incident and sustained a skin tear to the right antecubital measuring 3-centimeter (cm-unit of measurement) length by 1 cm width. The CP's objective indicated the resident's injured areas would be resolved without complication. LVN 5 stated that the care plan was not resident-centered, as it did not include specific interventions to address the resident's skin tear and a target date to evaluate the effectiveness of the treatment. LVN 5 stated that without specific interventions identified in the CP, licensed nurses may not be able to provide the necessary care and services to promote the healing of the skin tear sustained after the fall and had the potential to delay treatment and place the resident at risk for infection. During a review of the facility`s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 1/5/2026, the P&P indicated that The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident`s highest practicable physical, mental, and psychosocial well-being. b. During a review of Resident 44's admission Record, the admission Record indicated the facility originally admitted the resident on 10/17/2022 and most recently readmitted the resident on 4/5/2025 with diagnoses including, but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and acute 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). During a review of Resident 44's MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) skills for daily decision making and never or rarely made decisions. The MDS indicated Resident 44 was dependent (helper does all of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 3/26/2026 at 10:15 a.m. with the Infection Preventionist, Resident 44's Immunization Report and care plan were reviewed. Resident 44's Immunization Report indicated the resident had not received the updated 2025/2026 COVID-19 or influenza vaccinations. The IP stated Resident 44 was not capable of making her own decisions, and her representative had refused the vaccines. Resident 44's care plan did not indicate the resident had not received these vaccinations or any interventions regarding the representative's refusal. The IP stated a care plan should be made regarding these refusals, so nursing staff knows to monitor the resident for in case they develop any symptoms of the flu or COVID, to reeducate the resident's representative, and to prevent illness. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/5/2026, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated assessments of the resident are ongoing and care plans are revised as information about the resident and resident's condition changes.

Based on observation, interview and record review, the facility failed to properly use the air redistribution mattress (a specialized mattress that continuously circulates air) when it was turned off for one of four sampled residents (Resident 54). This failure had the potential to result in development of pressure ulcers (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), increased skin breakdown and slower healing. Findings: During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction that causes confusion, memory loss or loss of consciousness), cerebral infarction (a type of stroke, loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 54's physician's order, dated 1/25/2025, the physician's order indicated a PRM set at level three should be used for skin integrity management. During a review of Resident 54's Braden Scale (an assessment tool used to predict a resident's risk of developing pressure related damage to the skin and/or underlying tissue usually over a bony prominence) dated 2/4/2026, the Braden Scale indicated Resident 54 is at high risk of having pressure related skin damage. During a review of Resident 54's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 2/5/2026, the MDS indicated Resident 54 has severely impaired cognitive skills for daily decision making. Resident 54 requires a helper to do all the effort for activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview on 3/26/2026 at 10:15 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the facility started using a new pressure redistribution mattress (PRM). These mattresses are used for those with pressure ulcers as well as those that are bed bound (unable to leave one's bed). During a concurrent observation and interview on 3/26/2026 at 11:15 am with the Director of Nursing (DON), the PRM was turned off. The DON stated the power was off on the PRM. When the power is off on the PRM, it cannot control the air flow at level 3 as ordered. The DON further stated the PRM being turned off places Resident 54 at risk of developing pressure related skin damage and skin that will not be maintained. During a review of the facility's PRM user-service manual dated 2022, the service manual indicated loss of power requires pump hoses to be disconnected from the mattress to continue air redistribution in the mattress. During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines, revised 2013, the P&P indicated any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.

Based on interview and record review, the facility failed to accurately document orthostatic blood pressure (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) measurements for one of five sampled residents (Resident 4). This failure had the potential to result in residents receiving the wrong treatments, physician miscommunication and inconsistent care. Findings: During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted on [DATE] with diagnoses that included sepsis (a life threatening blood infection), psychotic disorder (a serious mental illness causing a loss of touch with reality), and acute respiratory failure with hypoxia (a critical condition defined by severely low blood oxygen). During a review of Resident 4's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 1/12/2026, the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making and required a helper to do more than half of the effort for toileting hygiene, showers and baths, dressing, sit to lying, and lying to sitting on the side of bed. During a review of Resident 4's Order Summary Report (OSR) dated March 2026, the OSR indicated to monitor Resident 4's orthostatic blood pressure while lying and sitting daily and report a drop in blood pressure to the physician. During a review of Resident 4's Medication Administration Record (MAR) dated March 2026, the MAR indicated the same blood pressure while Resident 4 was lying and sitting on eight different days. During a concurrent interview and record review on 3/25/2026 at 2:45 pm with Licensed Vocational Nurse (LVN) 1, Resident 4's MAR dated March 2026 was reviewed. The MAR indicated LVN 1 had the same blood pressure reading while Resident 4 was lying and sitting that morning. LVN 1 stated the lying and sitting blood pressure reading were different and the documented blood pressure was taken while Resident 4 was lying down. LVN 1 further stated the orthostatic blood pressure readings are always different between lying and sitting. During a concurrent interview and record review on 3/26/2026 at 11:00 am with the Director of Nursing (DON), Resident 4's Weights and Vitals Summary for March 2026 were reviewed. The Weights and Vitals Summary indicated, only a lying blood pressure was taken on the morning of 3/25/2026. The DON stated orthostatic blood pressure for Resident 4 cannot be determined due to inaccurate documentation. The DON further stated inaccurate documentation will not show if the orthostatic blood pressure was taken which can cause miscommunication with the interdisciplinary team. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one of four residents (Resident 26) reviewed during the Infection Control task by failing to ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the process of cleaning hands with soap and water or alcohol-based sanitizer to remove germs and prevent the spread of infections) after handling a soiled meal tray and prior to delivering a meal to Resident 26. The deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted the resident on 3/31/2020 with diagnosis including, major depressive disorder (a serious mental health condition characterized by persistent, severe sadness, loss of interest, and low energy lasting at least two weeks) and hypertension (high blood pressure). During a review of Resident 26's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/02/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 26 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, shower, lower body dressing and setup or clean-up assistance ( helper sets up or cleans up; resident completes activity) with eating, oral hygiene, upper body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 3/28/2026 at 12:15 p.m. with Certified Nurse Assistant 1 (CNA 1) outside of the main dining room, observed CNA 1 receive a finished meal tray from another staff which contained a cup of ice cream and crumpled plastic shrink wrap. CNA 1 disposed these items into a trash bin. CNA 1 did not perform hand hygiene (washing hands or using hand sanitizer) after discarding the trash. CNA 1 then proceeded to an open meal cart with three new meal trays and a container of soup. Upon reaching Resident 26's room, CNA 1 removed the soup container from the meal cart using bare hands, entered the room, placed the food on the overbed table, and removed the lid. CNA 1 was not observed performing hand hygiene before delivering the meal to Resident 26. CNA 1 stated that she should have performed hand hygiene, either by washing her hands or using a hand sanitizer after discarding items from a soiled tray and prior to delivering the food to Resident 26, to prevent infection and cross contamination among residents and staff. During a review of the facility`s policy and procedure (PP) titled Handwashing/Hand Hygiene, last reviewed on 1/05/2026, the PP indicated that This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infection.all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.hand hygiene is indicated immediately after touching the resident`s environment.

Based on observation, interview, and record review, the facility failed to ensure the double door exit in the middle station (MSDDE) was fully sealed when closed and did not have gaps, which created an opening from top to bottom measuring 72 inches in length and 1/3 of an inch in width for one of three doors in the facility. This deficient practice created an entry point and access for insects to get inside the building which could potentially transmit insect borne illnesses to the 94 out of 94 residents in the facility. Findings: During a concurrent observation and interview on 3/25/2026 at 12:54 p.m., with the Maintenance Director (M-Dir.) while inspecting the MSDDE, the M-Dir stated that the exit doors must always be closed and sealed to prevent insect infestation in the facility. The M-Dir confirmed that the MSDDE had a wide opening, allowing visibility of cars passing through from the gaps in the double door. The M-Dir measured the opening which measured 72 inches in length and 1/3 of an inch in width. The Medical Director (M-Dir) stated that he would immediately go to Home Depot to obtain materials to seal the door. The M-Dir further stated that the gap could serve as an entry point for insects, such as flies and mosquitoes, which could potentially increase the risk of infection for residents in the facility During a review of the facility`s policy and procedure (P&P) titled Homelike Environment, last reviewed on 1/05/2026, the P&P indicated that The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include clean, sanitary and orderly environment. During a review of the facility`s policy and procedure (P&P) titled Pest Control, last reviewed on 1/5/2026, the P&P indicated that Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to accurately measure the pressure ulcer/injuries (PU/ls - injury to skin and underlying tissue resulting from prolonged pressure on the skin) wound measurements for two of three sampled residents' (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of further skin breakdown.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/27/2025 with diagnoses including unstageable pressure ulcer unspecified site, osteomyelitis (infection of the bone that causes inflammation and pain), spina bifida (a birth defect where the spine doesn't close completely during early pregnancy, leaving the spinal cord and nerves exposed), and abnormal posture. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2025, the MDS indicated Resident 1'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 1 required maximal assistance from staff for toileting and personal hygiene, shower, upper and lower body dressing, and bed mobility (movement). The MDS further indicated that Resident 1 was at risk of developing PUs/ls and had one or more unhealed PUs/ls. During a review of Resident 1's Progress Notes dated 11/28/2025 timed at 11:22 a.m., the Progress Notes indicated that Resident 1 had an unstageable by depth (UTD - a serious, deep pressure ulcer covered by dead tissue that hides how deep the damage goes) pressure ulcer on the sacrococcyx (pertaining to both the sacrum [triangular bone located in the lower back] and coccyx [tailbone]) that was present on admission [DATE]). The Progress Notes indicated a wound size of 7.66 centimeter (cm - a unit of measurement) in length, 10.87 cm in width, 0 cm in depth, and 67.66 centimeter squared (sq. cm - unit of measurement) in area. During a review of Resident 1's Surgical Consult dated 12/4/2025, the Surgical Consult indicated wounds located at the sacrococcyx extending to bilateral (affecting both the left and right sides of the body) buttocks stage four (IV- full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) PU/I. The Surgical Consult indicated a wound size of 11.5 cm in length, 15.0 cm in width, 2.5 cm in depth, and 172.50 sq. cm in area before performing bone tissue debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for sacrococcyx extending to bilateral buttocks stage IV PU/I: Cleanse with wound cleanser, pat, dry apply Medi-honey (a specialized, sterilized, medical-grade honey) and calcium alginate (used to heavily draining wounds to promote wound healing) then cover with super absorbent dressing, ordered 12/8/2025. During a concurrent interview and record review on 1/15/2026 at 1:57 p.m., with Treatment Nurse 1 (TN 1), reviewed Resident 1's wound photo that indicated the wound measurements of 7.66 cm in length, 10.87 cm in width, 0 cm in depth, and 67.66 sq. cm, that was taken by TN 1 on 11/28/2025 and the wound measurements indicated on the Progress Notes dated 11/28/2025. TN 1 stated that the photo taken by TN 1 indicated the wound depth was zero (0) cm, which was read automatically by the device when taking the photos. TN 1 further stated that she did not measure Resident 1's wound sizes manually on 11/28/2025, and the actual wound measurements were not done until 12/4/2025. When TN 1 was asked how TN 1 could tell the progress of the wound without the actual wound measurements, TN 1 stated they would know the wound progress by the photos taken for all wounds upon admission or at least on the following day then on a weekly basis. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/29/2025 with diagnoses including acute kidney failure (when the kidneys suddenly stop effectively filtering waste and balancing fluids) and disorder of the skin and subcutaneous (under the layers of the skin) tissue. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated that Resident 2 required maximal assistance from staff for toileting hygiene, lower body dressing, sit to stand, and transfer. The MDS further indicated that Resident 2 was at risk of developing PUs/ls and had one or more unhealed PUs/ls. During a review of Resident 2's Progress Notes dated 12/30/2025 timed at 12:38 p.m., the Progress Notes indicated that Resident 2 had a sacral PU/I that was present on admission [DATE]) and had a wound size 1.14 cm in length, 0.57 cm in width, 0 cm in depth, and 0.43 sq. cm in area. During a review of Resident 2's Surgical Consult dated 1/15/2026, the Surgical Consult indicated a wound on the coccyx extending to right and left buttock stage two (II) PU/I (partial-thickness loss of skin, presenting as a shallow open sore or wound). The Surgical Consult indicated a wound size of 7.0 cm in length, 3.0 cm in width, 0.1 cm in depth, and 21 sq. cm in area, and the wound progress was undetermined because it was the first visit. During a concurrent interview and record review on 1/15/2026 at 1:45 p.m., with TN 1, reviewed Resident 2's wound photo that indicated the measurements of 1.14 cm in length, 0.57 cm in width, 0 cm in depth, and 0.43 sq. cm in area taken by TN 1 on 12/30/2025 and the wound measurements indicated on the Surgical Consult Progress Notes dated 1/15/2026. TN 1 reviewed Resident 2's skin assessment done upon arrival, 12/29/2025, and stated that the admitting nurse marked the skin sites without measurements upon arrival on 12/29/2025. TN 1 stated TN 1 took photos and measured Resident 2's wounds on the following day, 12/30/2025, indicating a stage II PU/I. When TN 1 was asked how TN 1 measured Resident 2's PU/I on the sacral area on 12/30/2025 because the depth was zero (0) cm, TN 1 stated that she did not measure the wound size manually, and the wound measurements documented on the photo were measured automatically by the device when taking the photos. TN 1 stated TN 1 was aware that sometimes the measurements that were read automatically when taking wound pictures were not correct but stated she did not take the actual measurements because the treatment nurse and the wound consultant would measure the wound together when the wound consultant visits weekly. During a concurrent interview and record review on 1/16/2026 at 3:40 p.m., with the Director of nursing (DON), reviewed Resident 1 and 2's skin assessments and the photos taken by TN 1 of Resident 1 and Resident 2's wounds since their admissions. The DON stated that TN 1 took the photos but documented Resident 1 and 2's wound measurements incorrectly and did not measure the PU/I sizes manually to correct the wound sizes and depths that were read automatically by the devices when taking the photos. The DON stated that it was important to measure and document the wound sizes correctly, otherwise, there would be confusion with wound healing progress, and could not tell if the wounds were improving or worsening without the wound measurements measured correctly. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer/Injury Risk Assessment, last reviewed on 1/5/2026, the P&P indicated, Steps in the Procedure: Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. Documentation:. The condition of the resident's skin (i.e., the size and location of any red or tender areas). During a review of the facility's P&P titled, Charting and Documentation, last reviewed on 1/5/2026, the P&P indicated, Documentation in the medical record will be objective (not optional or speculative), complete, and accurate.