Every finding on record at Cedarwood Post Acute

Based on observation, interview and record review, the facility failed to store, handle, and prepare food in the facility kitchen in accordance with food standards when:Foods were not properly labeled with the use by or open dates;Proper hand hygiene was not followed by kitchen staff;Cold foods were not maintained at safe temperatures during food service and,Wet stainless steel pans were stacked before allowing to dry.These failures had the potential for residents to receive food outside the safe use by dates and for the spread of food borne illness in the kitchen to 42 residents receiving food from the kitchen service.1.During an observation on 6/14/26, at 8:08 a.m., in the kitchen freezer, frozen dessert puffs were in an open plastic bag with no open date or use by date.During an interview on 6/14/26, at 8:10 a.m, with Dietary Aid (DA 1), DA 1 stated he did not see a date on the frozen puff dessert, and it should have the date it was opened and a use by date on it.During an observation on 6/14/26, at 8:15 a.m., in the kitchen freezer, an opened bag of frozen peas was noted with no dates on the bag.During an interview on 6/14/26, at 8:15 a.m, with DA 1, DA 1 stated he did not see any dates on the bag of peas and they should be dated with the open and use by dates.During an interview on 6/14/26, at 8:26 a.m., with Certified Dietary Manager (CDM), CDM stated the staff label and date foods when they are received, and when the item is opened, they will put the open date and use by date.A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage dated 2022 indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.1. All foods stored in the refrigerator and freezer are covered, labeled and dated ( use by date).2. During an observation on 6/15/26, at 10:18 a.m., in the kitchen. DA 2 was observed entering the kitchen and did not perform hand hygiene prior to beginning to work in the kitchen.During an observation on 6/15/26, at 10:35 a.m., in the kitchen, [NAME] 2 finished portioning the lunch item of coleslaw into serving containers while wearing gloves. [NAME] 2 removed the gloves and threw them into the trash can while touching the handle of the trash with bare hands, and was observed to return working with food without washing their hands.During an interview on 6/15/26, at 10:36 a.m., with [NAME] 2, [NAME] 2 stated, he should have washed his hands after removing the gloves and throwing them away.During an observation on 6/15/26, at 12:10 p.m., in the kitchen, DA 2 was observed returning to the kitchen after delivering a food cart to the nursing staff. DA 2 did not wash his hands upon entering the kitchen and was seen placing gloves on with dirty hands and returning to work with food.During an interview on 6/15/26, at 12:10 p.m., with CDM, CDM stated, DA 2 needed to wash his hands.A review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated 2022 indicated, Food and nutrition service employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.1. Employees must wash their hands.c. whenever entering or re-entering the kitchen.g. during food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.Gloves and Direct food contact .2 gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced.3. During an observation on 6/15/26, at 11:59 a.m, the kitchen food service for lunch was observed. [NAME] 1 checked the temperature of the lunch item corn coleslaw' which read 41 degrees Fahrenheit (F) at the start of food service. The corn coleslaw were divided into singe serving plastic containers placed on a sheet tray on the kitchen counter, with no ice bath or cooling methods noted.During a concurrent observation and interview on 6/15/26, at 12:29 p.m., with CDM and Registered Dietician (RD) in the kitchen, the last tray plated was observed for a temperature check. The corn coleslaw was checked with a thermometer which was calibrated by [NAME] 1 prior to food service and noted to be 47F. The CDM and RD both stated they believe the high temperature is okay, because it was the proper temperature while it was in the refrigerator. A review of the facility's recipe titled, Corn Coleslaw indicated, Directions: .4>. Cover and refrigerate for 1 hour. Hold at less than 41 F until service. 5. Serve on trayline at the recommended temperature of 41F or less.4. During an observation on 6/15/26, at 10:34 a.m., in the kitchen, [NAME] 1 removed a stainless steel square pan from the shelf in the center of the kitchen and liquid was noted to drip consistently from the removed pan. On observation 3-4 other pans stacked underneath the first pan noted multiple wet pans stacked on the shelf.During an interview on 6/15/26, at 10:35 a.m., with [NAME] 1, [NAME] 1 stated the pans were still wet and they should be completely dry before stacking them.

Based on interview and record review, the facility failed to ensure two of 17 sampled residents (Resident 41 and Resident 42) received treatment and services to prevent or minimize a decline in functional abilities when:1. The facility did not clarify Resident 41's physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program and did not communicate the physician order to RNA; and2. Resident 42's order for left hand splint did not include how many hours per day to be applied and it was not documented how long it was worn per day. These failures resulted in Resident 41 not receiving needed services for 8 months and had the potential to place the resident at risk for further functional decline and resulted in Resident 42's hand splint application to not be monitored for effectiveness or for any changes in application. 1. A review of the admission record indicated the facility admitted Resident 41 in 2025 with multiple diagnoses which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. A review of Resident 41's clinical record contained a physician's order dated 10/3/25 for occupational therapy (OT, type of therapy that helps people do everyday activities independently) evaluation and to transition Resident 41 to RNA services. The order indicated that it was completed on 10/3/25. In addition, the order did not contain clarification regarding specific interventions of which extremities and the frequency of the services Resident 41 was to receive. A review of Resident 41's annual Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/19/26 indicated that the resident scored 15 out of 15 on a Brief Interview for Mental Status, which indicated that he was cognitively intact. Section O of the MDS indicated that Resident 41 did not receive any therapy services and was not on Restorative Nursing Programs (RNA services). A review of the quarterly MDS assessment, Section O dated 4/21/26 indicated that Resident 41 did not receive any therapy services and was not on Restorative Nursing Programs (RNA services). A review of the undated care plan with the focus on activities of daily living (ADLs, activities done every day such as eating, personal hygiene, bathing, dressing, and toileting) indicated that Resident 41 required assistance with ADLs related to his clinical condition. The care plan goal indicated that the resident will not experience a decline in self care. One of the interventions indicated, Restorative Nursing as ordered. A review of Resident 41's 'At risk for falls and injuries' undated care plan indicated the following interventions, Refer resident to physical therapy and occupational therapy if indicated.Encourage resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. A review of Resident 41's clinical records indicated no documented evidence the resident had received RNA services since 10/3/25. During a concurrent observation and interview on 6/14/26 at 10:28 a.m., Resident 41 was observed in bed. Resident 41 answered appropriately to all questions and was able to carry out a meaningful conversation. Resident 41 stated that he was too weak to get out of bed and did not receive therapy services for several months. Resident 41 stated it was upsetting to him that he was getting weaker and weaker. A review of Resident 41's clinical record contained a document titled, Occupational Therapy [OT] Evaluation and Plan of Treatment, dated 10/3/25. The OT documented that Resident 41 expressed wanting to maintain functional abilities. The OT documented that Resident 41 had good potential for achieving rehabilitation (therapy given to restore an individual back to their highest possible level of physical well-being). The OT evaluation indicated, Focus of Plan of Treatment=Skilled therapy.Patient able to increase/improve functional status with increased participation. RNA program re-established. During an interview with Certified Nursing Assistant (CNA 3) on 6/16/26 at 4:25 p.m., CNA 3 described Resident 41 as alert, oriented and able to verbalize his needs. CNA 3 was not able to recall if Resident 41 was on RNA services recently. During an interview and record review on 6/17/26 at 12:25 p.m., the Director of Rehab (DOR) stated that it has been a while since Resident 41 had therapy. The DOR stated that Resident 41 had an OT evaluation on 10/3/25 and was transitioned to RNA services. The DOR stated that the referral for RNA services was placed on 10/3/25 and Resident 41 should have been receiving RNA services since 10/6/25 until present. During an interview on 6/17/26 at12:30 p.m., with Restorative Nursing Assistant (RNA 1), RNA 1 was asked how the RNA referrals and orders were communicated to RNAs when the residents were transitioned from OT to RNA services. RNA 1 explained that therapist would communicate the physician order and referral to Director of Staff Development (DSD) who would place an order into resident's clinical record and notify RNA of resident's referral. RNA 1 stated that Resident 41 had not been receiving RNA services for several months. RNA 1 stated that she was not aware if Resident 41's clinical record contained any order for RNA services. During an interview and record review on 6/17/26 at 1:37 p.m., the DSD stated stated RNA program was guided by therapy department and the DSD was overseeing it. The DSD explained the process, I get referral from therapy from Director of Rehab.I put RNA orders in [resident's clinical chart] and put [RNA referral] into task in resident's clinical records. The DSD stated, I don't remember if he [Resident 41] is receiving RNA services. Upon reviewing Resident 41's clinical record, the DSD stated that he was unable to find any orders for RNA services. The DSD reviewed 10/3/25 order to transition Resident 41 to RNA services and stated, It shows that it was completed the same day, 10/3/25. It did not populate. The DSD stated that the order for RNA was not clear and added that it did not contain specific resident's needs what to do and how often [RNA services] were to be offered, whatever the goal was for the resident. The DSD stated the order should have been clarified with physician, but it was not done and Resident 41 did not receive needed services since 10/3/25. A review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, revised 7/2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The P&P indicated that residents would receive restorative nursing program at any time during their stay and the resident should be included in determining restorative goals. During an interview with Director of Nursing (DON) on 6/17/26 at 1:35 p.m., the DON was informed that Resident 41 had not received the ordered RNA services for approximately 8 months. The DON acknowledged the concern and stated that the resident should have been receiving the restorative program in accordance with the physician orders and care plan. The DON acknowledged that failure to provide the RNA services could have placed the resident at risk for functional decline. 2. A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility in May 2013 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain cell death), contracture (tightening of muscles, tendons, and tissues that causes the joints to shorten and become stiff) of left hand, osteoarthritis (arthritis caused by cartilage on the ends of the bones that wears down), and diabetes (too much sugar in the blood). A review of Resident 42's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/26/26, indicated Resident 42 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 42 was cognitively intact. A review of Resident 42's physician order, dated 4/11/25, indicated .Restorative Nursing Program-Splint to SPECIFY (Left wrist/hand) every day as tolerated. every day shift . A review of Resident 42's Task: NURSING REHAB RNA PROGRAM: Assistance with Splint left wrist/hand as tolerated, for 5/18/26 to 6/16/26, indicated Amount of minutes spent providing splint or brace assistance was 2 minutes per day for 25 days and was not applied on 2 days. The Task did not indicate how long the splint was worn each day. A review of Resident 42's RNA Weekly Summary, dated 6/14/26, indicated .How many times this week was the resident seen by RNA for Splint or Brace application? 7 days . A review of Resident 42's Care Plan, dated 9/12/22 .Restorative Nursing Program: SPECIFY PROM [Passive Range of Motion], Splint /Brace Assistance To Address: . Potential for decline in range of motion, self-feeding skills .Interventions .Restorative Nursing Program- Splint/Brace Assistance: Palm Protector .Apply Left hand protector to be worn by the resident 7 days/week for minimum of 4 hrs [hours] or as tolerated for contracture management and to prevent nails from digging into the palm . During an observation and interview on 6/15/26 at 1:35 p.m. with Resident 42, observed that Resident 42 was not wearing left hand splint. When asked if staff applied the left hand splint today, Resident 42 did not state splint had been applied. During an observation on 6/16/26 at 9:01 a.m. of Resident 42, Resident 42 was asleep. Observed Resident 42 was not wearing left hand splint. During a concurrent interview and record review on 6/16/26 at 9:03 a.m. with Licensed Nurse (LN 3), LN 3 stated Resident 42 has left hand splint ordered and is usually on every day. Reviewed Resident 42's order for the left hand splint and LN 3 acknowledged the order did not indicate how long the splint is to be worn daily. During a concurrent interview and record review on 6/16/26 at 9:09 a.m. with the Director of Rehab (DOR), the DOR stated the referral for Resident 42's left hand splint was put in by the Occupational Therapist (OT), but the Director of Staff Development (DSD) puts in the actual order. The DOR stated the splint is put on by the RNAs and is to be worn throughout the day and removed at bedtime. The DOR stated there is no timeframe for the length of time splint is to be worn. Reviewed with the DOR Resident 42's order for left hand splint. The DOR acknowledged the order does not indicate when the splint should be applied, should be removed, or how long it should be worn daily. The DOR stated the order should be adjusted. During a concurrent interview and record on 6/16/26 at 9:24 a.m. with RNA 1 and RNA 2, RNA 1 stated Resident 42's left hand splint is applied by the RNAs and is supposed to be worn 6 to 8 hours per day but has not been applied today. Reviewed with RNA 1 and RNA 2 Resident 42's order for left hand splint and they acknowledged the order did not reflect when it was to be applied or how long it was to be worn. RNA 1 stated the order should indicate how long the splint should be worn [NAME]. RNA 2 stated they do not document in the Task section of the electronic chart when the splint was applied, when it was removed, or how long it was worn. During a concurrent interview and record review on 6/16/26 at 9:31 a.m. with the Director of Staff Development (DSD), the DSD stated he puts RNA orders in the system after he receives the referral from the therapy department. Reviewed Resident 42's order for left hand splint. The DSD acknowledged the order did not indicate how long the splint is to be worn daily. The DSD stated the order is not specific enough. Reviewed the Task section of the electronic chart that did not indicate when splint was applied or removed. The DSD stated it needs to indicate the time of application and the time of removal of the splint. The DSD stated that if there is no documentation as to length of time worn unable to determine if splint is effective or not. A review of the facility's Policy and Procedure (P&P) titled Resident Mobility and Range of Motion, revised 7/17, indicated .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in mobility .the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility including . contractures .The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .The care plan will include the type, frequency and duration of interventions, as well as measurable goals and objectives .Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs . A review of the facility's P&P titled Restorative Nursing Services, revised 7/17, indicated .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative care .Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care .Restorative goals may include .Adjusting or adapting to changing abilities .

Based on observation, interview, and record review, the facility failed to ensure medication error rates are not 5 percent of greater when the medication error rate was 15.38 % for four medication errors out of 26 opportunities observed during a medication pass for four of seven residents (Resident 73, Resident 13, Resident 17, and Resident 8):1. Resident 73 was not given Omeprazole (medication to treat acid in the stomach) 30 minutes prior to meal, and2. Resident 8 was not given Omeprazole 30 minutes prior to meal, and3. Resident 17 was given Metoprolol (medication to treat high blood pressure) without checking blood pressure prior to administration, and4. Resident 13's Clopidogrel (medication that prevents clots) was not given on time.This failure resulted in medications not given in accordance with the prescriber's orders and had potential to adversely affect the residents' clinical conditions.1.During an observation of medication pass on 6/15/26 at 7:34 a.m., Licensed Nurse (LN 3) was observed to prepare Resident 73's morning medications for administration. LN 3 was observed administering Omeprazole Oral Tablet Delayed Release 20MG (milligrams) -2 tablets to Resident 73 at 7:54 a.m. A review of Resident 73's order, dated 6/15/26, indicated Omeprazole Oral Tablet Delayed Release 20MG . Give 2 tablet by mouth one time a day for gastric acid reduction Give at least 30 min (minutes) prior to meal on an empty stomach. During an interview on 6/15/26 at 7:54 a.m. with LN 3, LN 3 stated the medication was due to be given at 7 a.m. LN 3 stated breakfast is delivered at 6:45 a.m. LN 3 stated Resident 73 had already eaten breakfast when he administered the omeprazole, and it was not given on an empty stomach per the prescriber's orders. LN 3 stated the omeprazole should have been given earlier. LN 3 stated his choices were to not give it or give it on a full stomach. LN 3 stated he chose to give it on a full stomach. During an interview on 6/15/26 at 4:20 p.m. with the Director of Nursing (DON), reviewed medication pass observation for Resident 73 omeprazole not being administered 30 minutes before a meal on an empty stomach per prescriber's order. The DON acknowledged that the medication was not given per the prescriber's order and the expectation is that medications will be given according to the prescriber's order. The DON stated may need to clarify the order with the physician and change the order. 2. During an observation of medication pass on 6/15/26 at 8:02 a.m., LN 3 was observed to prepare Resident 8's morning medications for administration. LN 3 administered Omeprazole DR (delayed release) 20 MG -1 capsule to Resident 8 at 8;07 a.m. A review of Resident 8's order, dated 5/30/26, indicated Omeprazole DR 20 MG Cap [capsules] Give 1 capsule by mouth two times a day for Gastro-esophageal reflux disease [GERD-stomach acid flows back up into the esophagus] . (Give 30 mins prior to morning and evening meal on an empty stomach). During an interview on 6/15/26 at 8:07 a.m. with LN 3, LN 3 stated the medication was due at 7 a.m. LN 3 stated he was late administering the omeprazole. LN 3 stated Resident 8 had already eaten breakfast. LN 3 stated Resident 8 did not receive the omeprazole 30 minutes prior to the morning meal on an empty stomach per the prescriber's orders. During an interview on 6/15/26 at 4:20 p.m. with the DON, reviewed observation of omeprazole for Resident 8 not being administered 30 minutes before a meal on an empty stomach per prescriber's order during medication pass observation. The DON acknowledged that the medication was not given per the prescriber's order and the expectation is that medications will be given according to the prescriber's order. The DON stated may need to clarify the order with the physician and change the order. 3. During an observation of medication pass on 6/15/26 at 8:29 a.m., LN 3 was observed to prepare Resident 17's morning medications for administration. LN 3 checked Resident 8's apical heart rate and administered Metoprolol Succinate ER (extended release) 24 hour 25 MG oral tablets- 0.5 tablet to Resident 17 at 8:32 a.m. LN 3 did not check Resident 8's blood pressure prior to administering the medication. A review of Resident 17's order, dated 3/10/26, indicated Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG . Give 0.5 tablet by mouth one time a day for Hypertension Hold if systolic [upper number in a blood pressure reading] is less than 100 HR [Heart Rate] less than 60. Do not crush or chew. A review on Resident 17's Blood Pressure Summary, for 6/15/26, indicated Resident 8's blood pressure was 156/74 at 6:36 a.m. During an interview on 6/15/26 at 8:36 a.m. with LN 3, LN 3 stated Resident 8's heart rate was 62. LN 3 stated Resident 8's blood pressure was taken at 6:40 a.m. and was 156/74. Reviewed Resident 8's medication order that indicated medication to be held if systolic was less than 100. LN 3 stated he did not check Resident 8's blood pressure prior to administering the medication. LN 3 stated he should have taken the blood pressure again to obtain a current blood pressure reading prior to administering the medication. LN 3 stated the blood pressure should be taken at the time the medication is given. During an interview on 6/15/26 at 4:20 p.m. with the DON, the DON stated if a medication has hold parameters for blood pressure, the blood pressure should be taken at the time the medication is given. 4. During an observation of medication pass on 6/15/26 at 8:51 a.m., LN 3 was observed to prepare Resident 13's morning medications for administration which did not include Clopidogrel Bisulfate Oral Tablet 75 MG- 1 tablet. LN 3 administered rest of morning medications to Resident 13 at 8:51 a.m. except clopidogrel. A review of Resident 13's order, dated 3/19/26, indicated Clopidogrel Bisulfate Oral Tablet 75 MG . Give 1 tablet by mouth one time a day for Thromboembolus Prophylaxis [prevention of clots]. During an interview on 6/15/26 at 8:51 a.m. with LN 3, LN 3 stated Resident 13's clopidogrel was due to be given at 8 a.m. but was not available in the medication cart to be given. LN 3 stated it was ordered three days ago and may have been delivered but was not placed in the medication cart. LN 3 stated he will need to find out if the medication had been delivered. LN 3 stated if available it will be given late. A review of Resident 13's Medication Administration Record (MAR), for 6/1/26 to 6/30/26, indicated Resident 13's clopidogrel was given at 9:36 a.m. on 6/15/26. During an interview on 6/15/26 at 4:20 p.m. with the DON, the DON stated that Resident 13's clopidogrel was placed in the wrong medication cart when it was delivered. Reviewed that Resident 13's medication was due at 8 a.m. but was not given until after 9 a.m. The DON acknowledged that the medication was administered late. A review of the facility's Policy and Procedure (P&P) titled Administering Medications, revised 4/19, indicated .Medications are to be prescribed in a safe and timely manner, and as prescribed .Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Ensure that the six rights of medication administration are followed .Right time . Right documentation .Review MAR to identify medications to be administered .Compare medication sources .with MAR to verify resident name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time .Administer medications as ordered in accordance with manufacturer specifications .Provide appropriate amount of food and fluid .Sign MAR after administered. For those medications requiring vital signs, record vital signs .Correct any discrepancies and report to nurse manager .

Based on observation, interview, and record review the facility failed to ensure infection control precautions were followed for two of seventeen sampled residents (Resident 30 and Resident 46) when: 1.Enhanced Barrier Precautions (EBP-an infection control intervention to reduce transmission of [NAME]-drug resistant organisms, MDROs) were not followed for Resident 30 when enteral tube feeding formula (nutrition delivered directly into stomach) was administered without proper PPE (personal protective equipment- supplies such as gowns and gloves used to minimize exposure to infectious organisms), and 2. Contact Precautions (infection control measures used in healthcare settings to prevent the spread of diseases transmitted through direct or indirect contact, requiring gown and glove use before entering the room regardless of care or contact provided to resident) were not implemented timely for Resident 46 after his positive results for a wound infection were received by the facility. These failures increased the risk of spread of infection to other residents. 1.A review of Resident 30's admission Record indicated Resident 30 was initially admitted to the facility in August 2022 with multiple diagnoses including Parkinsons (movement disorder of the nervous system), neurocognitive disorder with Lewy bodies (a progressive dementia that leads to decline in thinking, reasoning, and independent function), carrier of carbapenem-resistant enterobacterales (bacteria resistant to antibiotic carbapenem making infections difficult to treat), and gastrostomy (G tube-surgical opening through the skin of the abdomen to the stomach to insert a tube in order to deliver nutrition directly into the stomach). A review of Resident 30's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/13/26, indicated Resident 30 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 that indicated Resident 30 had severe cognitive impairment. A review of Resident 30's physician order dated 2/6/26, indicated . (EBP) Enhanced Barrier Precautions to reduce MDRO transmission due to increased risk of MDRO . A review of Resident 30's Care Plan, dated 8/26/25, .The resident is on (ESP) Enhanced Standard Precautions to reduce MDRO transmission due to increased risk of MDRO transmission r/t [related to] CARRIER OF CARBAPENEM-RESISTANT ENTEROBACTERALES .Interventions .Enhanced Barrier Precautions require the use of gown and gloves only for high contact resident care activities .Follow Enhanced Barrier Precautions (gloves/gown) during high-contact care activities .Place a sign for (EBP) near the entrance of the room . During an observation on 6/14/16 at 8:49 a.m. of Resident 30's room, observed EBP sign at door and PPE, including gowns and gloves, hanging on the door. During a concurrent observation and interview on 6/15/26 at 7 a.m. with Licensed Nurse (LN 3), observed LN 3 administering tube feeding formula through Resident 30's G tube. Observed LN 3 wearing gloves but was not wearing a gown. LN 3 stated Resident 30 is on Enhanced Barrier Precautions because he has a G tube. LN 3 acknowledged he was wearing gloves but was not wearing a gown when he administered the tube feeding. LN 3 stated he should have been wearing a gown when he administered Resident 30's tube feeding. During an interview on 6/16/26 at 9:44 a.m. with LN 5, LN 5 stated residents are placed EBP based on their diagnosis. LN 5 stated an orange EBP sign is placed outside the room to indicate EBP. LN 5 stated the sign tells the staff what precautions needed to be taken to care for resident and if providing direct patient care needed to wear gloves and gown. LN 5 stated if EBP not followed there could be possible contamination to other residents and staff. During an interview on 6/16/26 at 11:23 a.m. with the Infection Preventionist (IP), the IP stated if resident is on EBP should be sign at the door and PPE should be put on prior to providing direct care. A review of the facility's Policy and Procedure (P&P) titled Enhanced Barrier Precautions, revised 12/24, indicated .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug resistant organisms (MDROs) during high contact resident activities .Indwelling medical devices include .feeding tubes .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .feeding tube .) .Enhanced barrier precautions are in place for the duration of the resident's stay or until .discontinuation of the indwelling medical device .Staff are trained prior to caring for residents on EBPs . 2. During an observation on 6/14/26, at 10:32 a.m., outside Resident 46's room, an isolation precaution sign read Enhanced Barrier Precautions. A review of Resident 46's Wound Culture results, dated 6/9/26 indicated, Resident 46's wound was positive for Methicillin Resistant Staphylococcus Aureus (MRSA: type of staph bacteria that is highly resistant to many common antibiotics, making it significantly harder to treat than ordinary staph infections). The results indicated Resident 46's Provider signed the document on 6/9/26 indicating they were aware of the results on 6/9/26. During an interview on interview on 6/16/26, at 9:58 a.m., with Director of Nursing (DON), DON stated the facility was aware of Resident 46's wound being infected with MRSA on 6/9/26. DON stated, a resident who has MRSA needs to be on contact precautions, not enhanced barrier precautions, and the contact precaution was not ordered until 6/14/26 at 2300 (11p.m.). A review of Resident 46's Order summary report dated 6/14/26, indicated contact precautions were not started until 6/14/26.

Based on observation, interview, and record review, the facility failed to promote a dignified environment that maintained resident's dignity and privacy for one of 17 sampled residents (Resident 79), when Resident 79's urinary catheter tubing and bag (tubing which allows urine to drain from the bladder into a collection bag) was not placed in a privacy bag and its contents exposed while the resident was ambulated through the hallway.This failure violated Resident 79's rights to privacy and had the potential to compromise the resident's dignity and self worth.A review of the admission record indicated the facility admitted Resident 79 in the summer of 2026 following hospitalization for left knee joint infection.A review of Resident 79's physician's orders indicated an order dated 6/12/26 for foley catheter (a soft flexible tube inserted into a bladder to continuously drain urine) for wound management.During a concurrent observation and interview on 6/14/26 at 1:14 p.m., a urinary catheter bag was observed attached to Resident 79's bed frame. Resident 79 explained that she has been having lots of pain in her knee and it was difficult for her to turn self in bed, so the doctor ordered a catheter.During an observation on 6/15/26 at 11:48 a.m., two therapy staff were ambulating Resident 79 in the hallway. Another staff was walking behind Resident 79 pushing a wheelchair with catheter bag attached to the right side of wheelchair. The uncovered bag was half-filled with urine and was not placed in a privacy bag and not covered from public view. At the time of the observation, a visitor had entered the facility and was standing in the hallway for several minutes with an unobstructed view of Resident 79 and the exposed urinary drainage bag.During an observation and concurrent interview on 6/15/26 at 11:57 a.m., Licensed Nurse (LN 1) validated that catheter bag was uncovered and visible to residents, staff and a visitor who was standing in the hallway. LN 1 stated, Catheter should be in privacy bag. It's a dignity issue.During an interview with the Director of Nursing (DON) on 6/17/26 at 1:35 p.m., when DON was asked about the exposed catheter bag, the DON stated, Exposed catheter is a dignity issue whether it's in her room or in the public. The DON stated that staff should cover the urinary bag for privacy and dignity.A review of the undated facility's policy and procedure (P&P) titled, Dignity, indicated, Residents are treated with dignity and respect at all times .Each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated that staff is expected to promote dignity and protect resident's privacy during assistance with care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to accurately code the skin condition section of the Minimum Data Set (MDS, a standardized assessment and care screening tool) for one of 17 sampled residents (Resident 41), when the MDS did not accurately reflect Resident 41's documented chronic neck wound and right lower extremity venous stasis ulcer (an open sore that develops because blood does not flow properly through the vein). This failure resulted in MDS assessment not accurately representing Resident 41's clinical condition and had the potential to affect care planning for the appropriate care needs. A review of the admission record indicated the facility admitted Resident 41 in 2025 with multiple diagnoses which included chronic peripheral venous insufficiency (when the leg veins (blood vessels) did not work properly, making it difficult for blood to return to the heart from legs, causing increased vein pressure and venous ulcers).A review of Resident 41's annual MDS assessment dated [DATE], indicated the resident was cognitively intact. The skin condition section of the MDS assessment indicated Resident 41 had no venous or arterial ulcers present and did not have any other skin issues, including open wounds.A review of Resident 41's physician's orders dated 1/3/26 indicated the following:Treatment to right leg venous stasis every day. The order indicated, Cleanse.Pat dry, apply calcium alginate [a natural seaweed derived fiber used in wound care], cover with bordered dressing. The order directed nursing staff to notify physician if Resident 41's wound gets worse or if the resident develops signs and symptoms of wound infection. Treatment to right neck, unknown etiology (cause of condition). The order indicated, Clean.Pat dry.Cover with Duoderm [a special type of dressing] every.2 days. The physician directed nursing to notify if Resident 41's wound gets worse or if the resident develops signs and symptoms of wound infection.A review of Resident 41's Treatment Administration Records (TARs) for January 2026 indicated that he received wound treatments to his right neck every other day and to left leg every day as directed by physician.During am observation and interview on 6/14/26 at 10;28 a.m., Resident 41 was observed lying in his bed with both lower legs elevated on pillows. Resident 41's left leg below knee was wrapped in kerlix. Resident 41 stated that he had issues with chronic wound to his left leg and another wound on his posterior neck upon admission and the wounds were not healing well.During a concurrent interview and record review on 6/17/26 at 11:56 a.m., the Regional MDS Consultant (RMDSC) explained that any open skin areas or wounds should be coded in Section M of the MDS assessment. The RMDSC stated that the MDS should accurately capture the resident's clinical condition during the 14 days look-back period and that existing wounds should be reflected in the MDS assessment if any were present during that timeframe.During continued interview and record review on 6/17/26 at 11:56 a.m., Resident 41's MDS assessment dated [DATE] was discussed with the RMDSC. The RMDSC reviewed section M of the MDS dated [DATE] addressing skin conditions for Resident 41 and validated that it was coded as zero, which indicated that the resident did not have skin issues, including open wounds or venous ulcers at that time. During a further review the RMDSC reviewed Resident 41's clinical records, including physician treatment orders dated 1/3/26 for neck and left leg venous ulcers and physician progress notes for 1/13 and 1/16/26 and stated the MDS was not accurate and was coded incorrectly. The RMDSC added that Resident 41's skin issues should have been captured when the MDS was completed and should not have been coded as '0.'A review of the facility's policy and procedure (P & P) titled MDS Assessment Coordinator, revised 11/2019 indicated, A Registered Nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's assessment (MDS). Each individual who completes a portion of the assessment MDS must certify the accuracy of that portion of the assessment. Any individual who willfully and knowingly certifies in material and false statement in the resident assessment is subject to disciplinary action and such incident must be promptly reported to the Administrator.

Based on observation, interview, and record review the facility failed to ensure the residents received adequate supervision to prevent fall accidents and residents' environment remained free of accident hazards for two of 17 sampled residents (Resident 53 and Resident 76) when:The facility did not implement resident specific interventions to provide adequate supervision and safety for Resident 53 after the resident experienced fall with head contusion, and The facility failed to ensure Resident 76's (a non-verbal resident, dependent with care and unable to reposition self in bed or use call light) room was free from hazards when her call light string was observed on the back of her neck and pinned to her pillowcase.These failures resulted in Resident 53 experiencing another fall where she sustained cephalohematoma (blood-filled bump on the right side of her head), large skin tear on her right hand/wrist area, broken bone near the knuckle of the index finger to her right hand and had the potential for Resident 76 to sustain injuries from a string wrapped around the back of her neck and unable to reposition herself or call for help. 1. A review of the admission record indicated the facility admitted Resident 53 early 2026 with multiple diagnoses which included encephalopathy (a condition characterized by brain malfunction resulting in mental changes and confusion) and muscle weakness. A review of Resident 53's admission fall risk assessment dated [DATE] indicated the resident was at risk for falls. A review of Resident 53's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/19/26, indicated Resident 53 had moderate cognitive impairment. The MDS assessment indicated Resident 53 required assistance with activities of daily living (ADLs, activities done every day such as eating, personal hygiene, bathing, dressing, and toileting). A review of the comprehensive care plan (a guide that provides the direction on the type of needs the individual required) initiated 3/15/26 indicated Resident 53 was identified at risk for falls and injuries related to her underlying diagnoses, including encephalopathy. The interventions included anticipating and meeting resident's needs, encouraging resident to request assistance with transfers and ambulation, and monitoring for medications' side effects that may increase Resident 53's risk for falls. The care plan did not include interventions for Resident 53's oversight, necessary supervision, and monitoring to mitigate the resident's fall risks. A review of Resident 53's nursing progress note (NPN) dated 4/19/26 at 1:47 p.m., indicated that Resident 53's roommate informed nursing staff that the resident had a fall. LN 6 documented, .Noted that Pt [Resident 53] was on the floor. Roommate notified, Pt slipped from the w/c [wheelchair] .and since w/c was unlocked it was moved back and Pt hit the floor.Bump noted on the back of head. LN 6 documented that Resident 53 complained little discomfort on bump side and was transferred to hospital for further evaluation. A review of Resident 53's fall risk assessment completed post-fall on 4/19/265 indicated that the resident was identified at high risk for falls. Resident 53's at risk care plan was revised and a new intervention for 'lock the wheels of wheelchair' was added. There was no documented evidence that new interventions addressing Resident 53's supervision and monitoring was added to 'at risk for falls care plan.' A review of the post fall evaluation by Interdisciplinary team (IDT, a group of professional disciplines that discuss resident plan of care and care needs) dated 4/20/26 indicated that Resident 53's risk factors for falls were reviewed by the IDT. The IDT document indicated, New Fall Intervention Implemented: TRANSFER TO ACUTE. Always lock the W/C [wheelchair]. The IDT evaluation did not list any new recommendations intended to prevent future falls for Resident 53. There was no documented evidence that IDT evaluated Resident 53's medications associated with increasing Resident 53's risk for falls as documented in the resident's 'At risk for falls' care plan. A review of Resident 53's NPN dated 5/7/26 at 1:30 a.m., indicated, At aprox [approximately] 0130, a loud bang was noted by staff. LN arrived to the room and noted patient [Resident 53] lying prone [face down] wedged in between bed and dresser. Upon assessment, significant bleeding was noted from dorsal [ back] R [right] hand with a significant skin tear.Upon further assessment, patient was noted with a bump to R aspect of forehead in addition to small skin tear to R elbow. The NPN indicated that Resident 53 had uncontrolled bleeding from the injury to her right hand and the resident was sent to the hospital. A review of the post fall evaluation by IDT dated 5/8/26 did not indicate that the IDT identified a root cause for Resident 53's fall and New Fall Prevention Intervention Implemented documented on IDT evaluation indicated Send to ER. Resident 53's at risk for falls care plan was not revised and no new interventions to ensure the resident's safety were identified and documented. There was no documented evidence that IDT evaluated Resident 53's medications associated with increasing Resident 53's risk for falls as documented in the resident's 'At risk for falls' care plan. A review of Resident 53's clinical record contained a hospital record titled, TRAUMA DISCHARGE SUMMARY [TDS] dated 5/7/26. The document indicated that Resident 53 was admitted on [DATE] status post ground level fall where she suffered an open right hand metacarpal [palm bones] neck fracture with associated skin defect on the right dorsal [back] hand, and sustained cephalohematoma [collection of blood within the skull] to right side of the head. According to hospital record, Resident 53's wound to the back of her hand was cleaned and approximated [edges of the wound were brought together]. A review of physician progress note dated 5/9/26 indicated that Resident 53 sustained a contusion (a bruise/injury caused from impact that damages blood vessels under the skin) to her right forehead and laceration of her hand. The physician further documented, Patient underwent suturing of.portion of right hand. A review of Resident 53's clinical record contained an 'After visit summary' dated 5/19/26 which indicated that the resident was seen by orthopedic (doctor specializing in treating fractures) and a cast (hard protective shell placed around a broken bone to keep it from moving until it heals) was placed on his right-hand bone fracture. A review of Resident 53's clinical records did not contain any documented evidence that the resident's risk for falls assessment was completed after her fall on 5/7/26. During a concurrent observation and interview on 6/14/26 at 12:58 p.m., a fall floor mat (a soft cushioned mat to help reduce the injuries if the residents falls) was observed on the floor next to Resident 53's bed. Resident 53 was observed sitting in wheelchair in her room eating lunch. Resident 53's had a cast on her right hand/wrist wrapped in green ACE wrap. Resident 53 responded to all questions appropriately and explained, I fell at night.my head got wedged between bed and nightstand. Took all the skin off, it was like flapped. At ED [emergency department] they put something to glue it together.I also fractured fingers bone.Now I have this, pointed to her right wrist [cast]. Resident 53 stated that she needed to use a bathroom, and nobody was there to assist her and when she attempted to get up by herself, she slipped on the mat on the floor and fell. During an interview on 6/15/26 at 4:45 p.m., a Certified Nursing Assistant 1 (CNA 1) stated Resident 53 was alert with periods of forgetfulness. CNA 1 stated that Resident 53 required to have assistance with getting out of bed and ambulation when she needed to use the bathroom. CNA 1 stated, Occasionally she [Resident 53[ would use the call light to call for help, other times her roommate calls when she sees that resident attempt to get up from wheelchair and walk to the bathroom. During an interview on 6/16/26 at 8:35 a.m., CNA 2 stated that Resident 53's balance was not stable when ambulating, and the resident required staff's assistance. CNA 2 added, She is forgetful.She attempts to stand up and walk by herself.needs frequent checking on her. During an interview on 6/16/26 at 8:43 a.m., LN 2 stated that Resident 53 was at high risk for falls due to her unstable balance, confusion and forgetfulness. LN 2 stated that staff should be rounding on Resident 53 every one to two hours to check for any needs and reminding the resident to call for assistance. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 3/2018 indicated, Based on Previous evaluations and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The stuff. will implement a resident- centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. If falls recurs. staff will implement additional or different interventions. The staff will monitor and document each resident's response to interventions intended to reduce falling or their risks of falling. During an interview on 6/16/26 at 8:51 a.m., with Director of Nursing (DON), the DON explained that each resident was assessed for fall risks upon admission to see the resident's baseline and the level of assistance resident required. The DON further stated that after the assessment, the comprehensive care plan addressing resident's needs with interventions was developed. The DON was asked how IDT addressed residents' safety and he stated, We discuss falls during IDT meetings to address root cause of falls and recommend interventions to ensure resident's safety. During a continued interview and record review with DON on 6/16/26 at 8:51 a.m., the DON stated that Resident 53 had two falls since her admission. The DON stated that post fall IDT evaluation dated 4/20/26 included a recommendation to educate Resident [53] to make sure the wheelchair is locked before attempting to get up. The DON stated the IDT did not identify any other interventions to prevent or minimize Resident 53's falls. The DON confirmed that the post fall IDT dated 5/8/26 did not include any recommendations to ensure Resident 53's safety. The DON stated that post fall risk assessment for Resident 53 was not completed and there was no care plan addressing 5/8/26 fall and fracture. A review of the facility's P&P titled, Interdisciplinary Team Meeting, indicated, It is the policy of this facility to develop and maintain comprehensive, person-centered care plans through an interdisciplinary team (IDT) process. to ensure resident care is coordinated, individualized, and responsive to changes in condition, needs. Comprehensive, person- centered care plans are based on resident assessments and developed by an interdisciplinary team. A review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017 indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 2. A review of Resident 76's Facesheet indicated, Resident 76 had the following diagnoses: Nontraumatic intracerebral hemorrhage (bleeding directly into the brain tissue without any preceding physical trauma), Hypertension (high blood pressure), Hemiplegia affecting right side (severe or complete paralysis of one entire side of the body (left or right), caused by injury to the brain or spinal cord), hemiplegia of the left side, quadriplegia (paralysis affecting all four limbs, both arms and both legs, as well as the torso), and altered mental status. During an observation on 6/16/26, at 9 a.m., in Resident 76's room, Resident 76 was observed lying in bed, not able to respond or speak out loud. Resident 76 was observed to be visibly upset moving her head to the left and right repeatedly and was noted to be unable to move the rest of her body. Resident 76's hands were placed in supportive braces to keep her palms open to prevent deformities. Resident 76's call light device was noted to be a string attached to the wall and pinned with a metal clip onto Resident 76's pillow on her left side. The call light string was noted to be laying around the back of Resident 76's neck under her. During a concurrent observation and interview on 6/16/26, at 9:08 a.m., in Resident 76's room with Treatment Nurse (TN), Resident 76's call light was noted laying around the back of her neck and clipped onto the left side of her pillow. The TN stated the call light string location was a hazard for Resident 76 and removed the clip from her pillow and removed the string from the back of Resident 76's neck. TN stated she did not know if Resident 76 could even use the call light or if another device would be more appropriate. A review of the facility's policy and procedure titled, Safety and Supervision of Residents dated 2017 indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

Based on observation, interview, and record review, the facility failed to provide appropriate care for one of 17 sampled residents (Resident 30) receiving enteral feeding (nutrition delivered directly into the stomach through a feeding tube) when Resident 30's head of bed was not elevated to 45 degrees at all times. This failure resulted in an increased risk of aspiration (when fluid, food, or gastric acid gets into the airways causing airway blockage or infection) for Resident 30. A review of Resident 30's admission Record indicated Resident 30 was initially admitted to the facility in August 2022 with multiple diagnoses including Parkinsons (movement disorder of the nervous system), dementia (loss of memory, language, and thinking abilities), gastrostomy (G tube-surgical opening through the skin of the abdomen to the stomach to insert a tube in order to deliver nutrition directly into the stomach), pneumonia, respiratory failure, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD-stomach acid flows back up into the esophagus). A review of Resident 30's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/13/26, indicated Resident 30 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 indicated Resident 30 had severe cognitive impairment. A review of Resident 30's physician's order, dated 2/6/26, indicated .Aspiration Precautions: Elevate HOB [Head of Bed] 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every shift . A review of Resident 30's physician's order, dated 5/25/26, indicated .Tube Feeding orders: Glucerna 1.2 [tube feeding formula] - 355 mL [milliliters] (1,5 carton) bolus 4 times a day + 30 mL water flush before and after each bolus every 6 hours .A review of Resident 30's Care Plan, dated 1/13/26, .The resident requires tube feeding r/t [related to dysphagia] . Interventions .The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed .A review of Resident 30's Care Plan, dated 1/19/26, .The resident has GERD .Interventions .Avoid Lying down at least 1 hour after eating. Keep HOB elevated A review of Resident 30's Care Plan, dated 1/31/26, .Ineffective airway clearance r/t excessive respiratory secretions and decreased level of consciousness .Interventions .Position pt [patient] with head of bed elevated as tolerated to promote airway patency and facilitated drainage of secretions . During an observation on 6/14/26 at 8:49 a.m., Resident 30 was observed in bed asleep. Observed head of bed elevated to less than 30 degrees. Observed sign posted on wall over the bed that indicated KEEP HEAD OF BED ELEVATED TO 45 DEGREES PLEASE.During a concurrent observation and interview on 6/14/26 at 9:27 a.m. with Licensed Nurse (LN) 6, LN 6 acknowledged that Resident 30's head of bed was elevated to 30 degrees or less. LN 6 stated Resident 30's head of bed should be elevated to 45 degrees at all times especially with bolus feedings to prevent aspiration. During an interview on 6/15/26 at 7 a.m. with LN 3, LN 3 stated Resident 30's head of bed should be elevated at all times not just during feeding due to high risk of aspiration for this resident. A review of the facility's Policy and Procedure (P&P) titled Enteral Tube Feeding via Syringe (Bolus), not dated, indicated .The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally .Review the resident's care plan and provide for any special needs of the resident .

Based on observation, interview, and record review the facility failed to provide necessary respiratory care consistent with professional standards of practice, goals and preferences for one of 17 sampled residents (Resident 77), when Resident 77's oxygen tubing was not labeled.This failure had the potential for Resident 77 to be exposed to respiratory infectious agents from old or dirty tubing.During an observation on 6/14/26, at 9:15 a.m., in Resident 77's room, Resident 77 was receiving oxygen through a nasal cannula (thin plastic tubing that provides oxygen to the nose) with no label or date on the tubing.During an interview on 6/14/26, at 9:20 a.m., with Respiratory Therapist (RT), RT stated she did not see a date or label on Resident 77's tubing, and there should be one, so we know how old the tubing is (period it has been in use).During an interview on 6/17/26, at 10:58 a.m., with Director of Nursing (DON), DON stated the oxygen tubing should be replaced every 7 days and labeled with the date. DON stated, they should chart in the residents medical record that they changed the tubing, and he does not see it charted for Resident 77, that the tubing was changed. A review of Resident 77's Order Summary Report dated 6/14/26 indicated, no order to change oxygen tubing.A review of the facility's policy and procedure titled, Oxygen Administration Policy undated, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.

Based on interview and record review the facility failed to provide pain management that met professional standards of practice and residents plan of care for two of 17 sampled residents (Resident 77 and Resident 80) when:1. Nursing staff did not reassess Resident 77 timely after administering a PRN (as needed) pain medication to check for effectiveness, and 2. The facility did not follow physician's order to assess Resident 80's pain using a pain scale. This failure resulted in the facility being unaware of the effectiveness of the PRN pain medication administered to Resident 77 and had the potential for Resident 77's and Resident 80's pain to not be adequately managed. 1. During a review of Resident 77's Diagnosis information dated 6/16/26 indicated, Resident 77 had the following diagnoses: prostate cancer, major depressive disorder, osteoarthritis (painful joint disease where the protective cartilage on the ends of your bones gradually wears away) anxiety, fractured humerus (upper arm) with implant, artificial right hip, and an older spinal fracture. During an interview on 6/14/26, at 9:12 a.m., with Resident 77 in his room, Resident 77 stated his pain is almost constant and primarily in his hip, back and groin area since he had prostate cancer. A review of Resident 77's Medication Administration Record (MAR) dated 6/16/26 at 11 a.m., indicated, Resident 77 was given his PRN pain medication Oxycodone (controlled narcotic medication prescribed to treat moderate to severe pain) by Licensed Nurse (LN 5) at 0752 (7:52 a.m.). During an interview on 6/16/26, at 11:15 a.m., with Resident 77, Resident 77 stated the nurse did not come back in the room since she had given him his pain medication earlier this morning and stated he was still in some pain. During an interview on 6/16/26, at 11:35 a.m., with LN 5, LN 5 stated she gave Resident 77 his PRN pain medication at 0752. LN 5 further stated when they give PRN pain medications they are supposed to check after 30 minutes to an hour if the pain medication was effective and chart on the MAR. LN 5 stated she did not chart the pain reassessment (3 hours after administration) on the MAR and was not sure of Resident 77's pain level. A review of Resident 77's Care plan titled, Pain: At risk for alteration in comfort/pain. Interventions .Observe the effectiveness of pain medications for the control of pain. A review of the facility's undated policy and procedure titled, Pain Management Policy indicated, It is the policy of this facility to provide appropriate pain management for residents who require such services, consistent with professional standards of practice, the comprehensive assessment, the resident's goals and preferences.Pain monitoring and follow-up may be documented through the medication administration record and/or routine clinical documentation.Documentation reflects assessment findings and pain management approaches in the normal course of care. 2. A review of the admission record indicated the facility admitted Resident 80 in June of 2026 with multiple diagnoses including dorsalgia (a constant aching or burning back pain that radiates to other areas), spinal stenosis (narrowing of the spaces inside the backbone causing pain), and recurrent falls. A review of Resident 80's history and physical dated 6/8/26, indicated the resident was admitted to the facility for chronic back pain and pain management resulting after recent fall. A review of Resident 80's physician's order dated 6/5/26 indicated, Pain- monitor for presence of Pain Every Shift and as needed Using Pain Scale 0-10: 0=no pain, 1-2=Least Pain, 3-4= Mild Pain, 5-6=Moderate Pain, 7-8= Severe Pain, 9-10=Very Severe/Horrible/Worst pain. A review of the Nursing admission assessment dated [DATE] indicated Resident 80 was alert and oriented. During an observation and interview on 6/14/26 at 10:20 a.m., Resident 80 was lying in her bed. Resident 80 responded appropriately and was able to carry a meaningful conversation. Resident 80 was noted to be grimacing when she attempted to turn to her side. Resident 80 explained that she had chronic pain in her lower back and described that her pain on a scale from 1 to 10 was about 4-5. Resident 80 was asked about how her pain was managed by the facility and the resident stated she thought she had some pain medication ordered by her physician. Resident 80 did not reply when asked if nursing assessed her pain on a regular basis and offered pain medications. A review of Resident 80's undated care plan indicated that the resident had an alteration in musculoskeletal function related to spinal stenosis and dorsalgia. The interventions included administering pain medications as ordered by physician, monitoring and documentation pain medications effectiveness and side effects. The care plan did not contain any interventions for nursing staff to monitor Resident 80's pain every shift as ordered by physician. A review of Resident 80's Medication Administration Record (MAR) for the month of June, the MAR indicated that nurses did not assess Resident 80 for presence of pain using a scale from 1 to 10 as directed by resident's physician. According to Resident 80's MAR, it indicated that starting 6/5/26 nurses placed checkmarks ( ) instead of documenting Resident 80's pain level every shift. During an interview on 6/16/26 at 8:40 a.m., Licensed Nurse (LN 2) explained that each resident was assessed for pain using the scale from 1 to 10. LN 2 stated that if pain medication was administered, the resident was to be reassessed for effectiveness one hour after the administration. During a concurrent interview and record review on 6/16/26 at 1 p.m., the Director of Nursing (DON) stated that nurses were expected to assess resident's pain throughout the shift and document the highest level that resident reported on that shift using the numeric pain scale from 1 to 10. Upon reviewing Resident 80's medical history, the DON acknowledged that the resident was at risk for experiencing pain due to her diagnosed medical conditions. The DON further reviewed the physician's order requiring nursing staff to monitor and document Resident 80's pain using a numeric pain scale from 1 to 10. The DON validated that nursing staff did not follow physician's order and placed checkmarks instead of documenting resident's pain level using numeric pain scale from 1 to 10 as ordered by physician. The DON did not provide an answer when asked if the lack of physician ordered pain monitoring could delay the identification and management of Resident 80's pain. A review of the undated facility's policy and procedure (P&P) titled, Pain Management Policy, indicated, It is the policy of this facility to provide appropriate pain management for residents who require such services, consistent with professional standards of practice.Pain recognition, monitoring and interventions are. incorporated into the comprehensive person centered care plan.The facility uses a pain rating method appropriate to the residents cognitive and communication status, including verbal or non-verbal indicators.

Based on observation, interview, and record review the facility failed to ensure residents received their prescribed therapeutic diet (a meal plan prescribed by a physician and tailored by a registered dietitian) for one of 17 sampled residents (Resident 39). When Resident 39 was served lunch with a salt packet, while on a no added salt diet during lunch mealtime. This failure had the potential for Resident 39's chronic medical conditions of high blood pressure and chronic kidney disease to worsen, causing negative health outcomes. During an observation on 6/14/26, at 12:30 p.m., in Resident 39's room, Resident 39 was eating her lunch while in bed, with her family member at bedside. A salt packet was noted on Resident 39's meal tray. Resident 39's meal tray ticket read NAS (No Added Salt).During an interview on 6/14/26, at 12:31 p.m., with Resident 39's family member, family stated, [Resident 39] is probably not supposed to have salt because she has high blood pressure.During an interview on 6/14/26, at 12:34 p.m., with Certified Dietary Manager (CDM), outside of Resident 39's room, CDM stated he checked the tray and [Resident 39] did receive the salt packet, she is on NAS and should not have gotten one.A review of Resident 39's Diet order, dated 6/2/26 indicated, NAS* diet SOFT & BITE SIZED.A review of the facility's policy & procedure (P&P) titled, Therapeutic Diets dated 2017 indicated, Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan od care and in accordance with his or her goals and preferences.

Based on interview and record review, the facility failed to maintain a system to monitor COVID-19 vaccination status of staff and education to staff related to benefits and potential side effects of the COVID-19 vaccine. This failure resulted in the facility not having accurate monitoring of the staff's COVID-19 vaccination status with the potential for infection to staff and residents. During an interview on 6/16/26 at 9:44 a.m. with Licensed Nurse (LN 5), LN 5 stated she has received information regarding the COVID-19 vaccine and that it was offered yearly. During an interview on 6/16/26 at 11:23 a.m. with the Infection Preventionist (IP), the IP stated he started as the IP at the facility in January 2026. The IP stated that COVID-19 vaccines are offered to the staff. Requested tracking or monitoring log for staff COVID-19 vaccination status and education. The IP stated the only tracking of staff vaccinations is currently in the personnel files. The IP stated the vaccination consents and declinations are in the personnel files. The IP stated if an employee reports to him that they have received a vaccination he will place that in the personnel file. The IP stated that currently he has to rely on the reporting of the staff to him to monitor and track vaccination status. The IP stated he relied on staff to report to him if received the vaccine from outside the facility. The IP stated there is no electronic or handwritten tracker to monitor staff vaccination status. The IP stated there is no record of education or screening of staff for the COVID-!9 vaccine. A review of the facility's Policy and Procedure (P&P) titled Employee Infection and Vaccination Status, revised 1/24, indicated .Prior to or upon and employee's duty assignment, the facility will assess the status of an employee's vaccination against infectious conditions . Vaccinations are documented on the Employee Record of Vaccination .Employees are offered or provided with vaccinations per state or local agency's policies/regulations .Employees are provided with educational materials to make informed decisions or non-mandated vaccinations . A review of the facility's Job Description for Infection Preventionist, revised 2/26, indicated .Duties and Responsibilities .Coordinate, implement, monitor, and update the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities .Establish, implement and monitor data collection tools for process and outcome surveillance outcome .Assist and oversee the tracking, administering and recordkeeping of required employee immunizations .Establish immunization programs for staff and residents .Provide personnel with information concerning the facility's policies governing vaccinations .

Based on observation, interview, and record review, the facility failed to maintain safe equipment for one of 17 sampled residents (Resident 40), when Resident 40's bed control power cord was frayed with exposed wires. This failure placed Resident 40 at risk for injury. A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility in August 2025 with multiple diagnoses including metabolic encephalopathy (change in how the brain works due to an underlying condition causing confusion or memory loss), dementia (loss of memory, language, and thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (lung condition that limits airflow into and out of the lungs), and dysphagia (difficulty swallowing). A review of Resident 40's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 4/14/26, indicated Resident 40 had a long-term and short-term memory problem and his cognitive skills for daily decision making were severely impaired. During an observation on 6/14/26 at 8:49 a.m., Resident 40 was asleep with head of bed elevated. Observed bed control power cord wrapped around bed rail and the power cord was frayed with exposed wires. During an observation on 6/15/26 at 11:05 a.m., Resident 40 was awake and listening to music. Observed bed control power cord wrapped around the bed rail and the power cord was frayed with exposed wires. During a concurrent observation and interview on 6/15/26 at 11:16 a.m. with Licensed Nurse (LN 5), LN 5 confirmed that Resident 40's bed control power cord was frayed with exposed wires. LN 5 stated the bed control was working but acknowledged that the frayed cord and exposed wires was a safety hazard to the resident. During an interview on 6/15/26 at 4:20 p.m. with the Director of Nursing (DON), the DON stated if a bed control power cord is frayed and wires are exposed his expectation was staff will contact maintenance to replace it. During an interview on 6/17/26 at 7:50 a.m. with the Maintenance Director (MD), the MD stated if there is an issue with equipment or the bed the staff will put it in the maintenance log kept at the nursing station. The MD stated Resident 40's frayed bed control power cord was not in the maintenance log. The MD stated it must have been missed by the Certified Nursing Assistant (CNA) because the bed control was still working. The MD stated it needed to be replaced. A review of the facility's Policy and Procedure (P&P) titled Maintenance Service, revised 12/2009, indicated .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . A review of the facility's P&P titled Safety and Supervision of Residents, revised 7/17, indicated .Our facility strives to make the environment as free from accident hazards as possible .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents .Our individualized, resident-centered approach to safety, addresses safety and accident hazards for individual residents . A review of the facility's P&P titled Homelike Environment, not dated, indicated .Residents are provided with a safe, clean, comfortable, and homelike environment .

Based on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) Significant Change in Status Assessment (SCSA, an MDS assessment done within 14 days after a resident has a significant change in their health status) was completed for one of six sampled residents (Resident 3) when Resident 3 developed a stage 3 pressure ulcer (tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible) and was not assessed.This failure had the potential to delay wound treatment, placing Resident 3 at risk for increased pain, infection, and a decline in functional status for the resident. Findings:Resident 3 was admitted to the facility in March of 2026 with diagnoses that included a femur fracture.A review of Resident 3's document titled admission Assessment: Nursing - V2, dated 3/14/26, indicated that Resident 3 did not have a pressure ulcer at the time of the assessment.A review of Resident 3's document titled Wound Assessment Report, dated 5/14/26, the document indicated, Location: Midline Sacrum Etiology: Pressure Injury Stage/Severity: Stage 3 pressure injury (fat-layer, granulation, slough [a layer of dead tissue and protein buildup that forms in a wound], eschar [a layer of dead, non-viable tissue that develops over a wound]) Acquired in House: Yes Date Wound Acquired: 04/30/2026.During Resident 3's record review, no MDS SCSA was found in the medical record.During a concurrent interview and record review on 6/8/26 at 3:16 p.m. with the MDS Licensed Nurse (MDS LN), Resident 3's medical record was reviewed. The MDS LN verbally confirmed that Resident 3 had developed a stage 3 pressure ulcer in the facility and did not have an MDS SCSA performed.During an interview on 6/8/26 at 3:31 p.m. with the Director of Nursing (DON), the DON indicated that, if a resident experienced significant changes to their health status, an MDS SCSA should have been done. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 12/25, the P&P indicated, If a sifnificant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [Omnibus Budget Reconciliation Act] regulations governing resident assessments and as outlined in the MDS RAI [Resident Assessment Instrument, a comprehensive system used to evaluate and manage a resident's care] User's instruction Manual.

Based on interviews and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) assessments accurately reflected residents' current clinical status for two of six sampled residents (Resident 1 and Resident 2), when Resident 1's chest incisions were not coded on the MDS admission assessment and Resident 2's ongoing dialysis (a treatment that filters waste and excess fluid from your blood when the kidneys are no longer functioning) treatment was not coded on a quarterly MDS assessment.These failures could have resulted in Resident 1 not receiving necessary wound care and Resident 2 missing or receiving poorly coordinated dialysis treatments.Findings:Resident 1 was admitted to the facility in May of 2025 with diagnoses that included atherosclerotic (buildup of fatty plaques made of cholesterol, fat, and other material inside the arteries) heart disease.During a review of Resident 1's admission MDS assessment section M (MDS section that assesses residents for skin conditions), dated 6/5/26, the MDS indicated that Resident 1 did not have a surgical wound on admission.During a review of Resident 1's document titled, SKIN & BODY ASSESSMENT, dated 5/23/26, indicated that Resident 1 had three surgical wounds on his chest area on admission.During a review of Resident 1's Care Plan [CP], the CP did not mention any interventions for incision care and monitoring.Resident 2 was admitted to the facility in February of 2026 with diagnoses that included end stage renal (kidney) disease (the stage of renal disease that necessitates dialysis).During a review of Resident 2's quarterly MDS assessment section O (MDS section that assesses residents for special treatments, procedures, and programs received during specific time periods), dated 5/27/26, the MDS indicated that Resident 2 had not received dialysis during her stay at the facility from 5/1/26 to 5/14/26. During a review of Resident 2's documents titled Dialysis Communication Form, indicated Resident 2 had received dialysis on dates 5/2/26, 5/8/26, 5/9/26, and 5/12/26.During a concurrent observation and interview on 6/8/26 at 11:11 a.m. with Resident 1, Resident 1 had a large incision in the middle of his chest and two smaller incisions, one on his right chest and one on his upper abdomen area. Resident 1 indicated that staff had not closely monitored his incisions and that the only time he ever saw a nurse specifically for his incisions had been on 6/5/26.During a concurrent interview and record review on 6/8/26 at 3:16 p.m. with the MDS Licensed Nurse (MDS LN), Resident 1's admission MDS section M was reviewed. The MDS LN confirmed that Resident 1's incisions were not captured on the MDS. The MDS LN further indicated that it was important for MDS assessments to be accurate to give staff an accurate representation of the resident.During an interview on 6/8/26 at 3:31 p.m. with the Director of Nursing (DON), the DON indicated that MDS assessments should be accurate, and he expected his staff to have filled them out to accurately reflect the resident's health status.During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 11/19, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.The information captured on the assessment reflects the status of the resident during the observation ( look-back) period for that assessment.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food properly in accordance with professional standards for food service safety for a census of 49 when: 1) Two metal bowls and 9 plate cover lids stored wet and stacked, 2) Two plastic cups had white film build up inside the cups, 3) Two thermometers missing inside freezers, 4) Open food items were not labeled with use by date, and, 5) Food items were not covered during resident food distribution of meal trays These failures increased the potential for food borne illness. Findings: 1.During a concurrent initial tour observation and interview on 6/10/25 at 8:20 a.m. with the Dietary Manager (DM), nine plate cover lids and two small bowls were stored upright with water collected at the bottom of the bowl. The DM stated that the plate cover lids and bowls should be on a drying rack to air dry completely before storing. During an interview on 6/12/25 at 1:10 p.m. with the Registered Dietician (RD), RD stated lids and bowls should always be air dried and confirmed that if not dried it could grow bacteria. During a review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-901.11 Equipment and Utensils, Air Drying Required, After cleaning and sanitizing, equipment and utensils; shall be air dried . During a review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-903 Storing, indicated Clean EQUIPMENT and UTENSILS shall be stored .In a self-draining position . 2. During a concurrent initial tour observation and interview in the kitchen tour on 6/10/25 at 8:32 a.m. with the DM, there were two plastic cups observed stored on the shelf that had white film build up inside the cups. DM confirmed that the cups had residual inside the cups. During an interview on 6/12/25 at 1:15 p.m. with the RD, the RD confirmed that the cups did not look clean, and the resident's perceptions is that the kitchen has served dirty cups. During a review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-601.11 Cleaning of Equipment and Utensils, indicated EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 3. During a concurrent observation and interview on 6/10/25 at 8:40 a.m. in the kitchen, DM verified there were no thermometers inside both freezers. Food items were observed in both freezers. DM stated there should be a thermometer in every fridge and freezer and confirmed that kitchen staff would not know what the appropriate safe temperature for food to be stored. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage revised November 2022, the P&P indicated .must have working thermometers and are monitored for temperature according to state guidelines. 4. During a concurrent observation and interview on 6/10/25 at 8:58 a.m.in the kitchen, DM verified there were frozen opened waffle, opened corn, opened spices, a box of cream of wheat that had no used by dates. During an interview on 6/12/25 at 1:20 p.m. with the RD, the RD confirmed that no use by dates had a risk of kitchen staff not knowing if food items were sitting and stored for a long period of time. During a review of the facility P&P titled Food Receiving and Storage revised November 2022, indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 5. During an observation on 6/10/25 at 12:04 p.m. in Wing C, the meal trays with dessert were not covered while being transported from the kitchen to residents' rooms. The delivery cart had plastic bags covering only three sides of the cart, but the staff rolled the plastic coverings up to the top exposing the desserts that were not covered. During an interview on 6/12/25 at 1:25 p.m. with the RD, the RD was shown a picture of the uncovered dessert and confirmed that they should be covered. The RD confirmed and agreed that items should be covered to prevent contamination and maintain cleanliness and sanitation and prevent foodborne illness. During a review of the FDA Food Code 2022, Section 8-203.10 Preoperational Inspections, indicated Food is managed so that the safety and integrity of the food from the time of delivery to the establishment throughout its storage, preparation, and transportation.

Based on observation, interview and record review the facility failed to ensure resident needs were accommodated for seven out of 19 sampled Residents (Resident 13, Resident 47, Resident 152, Resident 19, Resident 4, Resident 5, and Resident 10), when 1. The call light was not within reach for Resident 13, Resident 47, Resident 152 and Resident 19; 2. Resident 4 and Resident 5 did not have interventions regarding inability to use call lights in their care plans; and, 3. Resident 10 did not have a call light that accommodated his special needs These failures had the potential to result in the residents not attaining their highest practicable physical, psychosocial and emotional well-being. Findings: 1. Review of Resident 13's admission Record indicated Resident 13 was admitted [DATE] with diagnoses including rhabdomyolysis (a condition which damaged skeletal muscle breaks down rapidly), muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, and need for assistance with personal care. Review of Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 4/17/25, indicated Resident 13 had moderately impaired cognition. The MDS also indicated that Resident 13 was dependent to required partial/moderate assistance (helper does less than half of the effort) for activities of daily living (ADL's-routine tasks such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 6/10/25 at 9:38 a.m. in Resident 13's room, Resident 13 was lying in bed and stated he could not reach his call light. Certified Nurse's Assistant (CNA) 2 confirmed the call light was out of reach of Resident 13 and stated the call light should be within reach. Review of Resident 13's Care plan dated 4/12/25, indicated Resident 13 was at risk for skin breakdown related to Actual skin breakdown .related to Rhabdomyolysis .interventions . keep the call light within reach and encourage resident to call for assistance. Review of Resident 47's admission Record indicated Resident 47 was admitted [DATE] with diagnoses including muscle weakness, difficulty in walking, and need for assistance with personal care. Review of Resident's 47's MDS dated [DATE], indicated Resident 47 had intact cognition. The MDS also indicated Resident 47 was dependent to needed setup or clean up assistance for ADL's. During a concurrent observation and interview on 6/10/25 at 9:18 a.m., in Resident 47's room, Resident 47 was lying in bed, and the call light was hanging against the wall out of reach of Resident 47. Resident 47 stated he did not know where his call light was. CNA 3 confirmed Resident 47's call light was out of reach and stated the call light should be within reach. Review of Resident 47's care plan dated 5/15/25, indicated Resident 47 was at risk for skin breakdown related to impaired mobility .interventions . Keep call light within reach and encourage resident to call for assistance. Review of Resident 152's admission Record, indicated Resident 152 was admitted [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by muscle rigidity, tremors and slow imprecise movements), multiple fractures of ribs unspecified side, dementia (a progressive state of decline in mental abilities), other reduced mobility, and need for assistance with personal care. Review of Resident 152's MDS dated [DATE], indicated Resident 152 had severely impaired cognition. The MDS also indicated that Resident 152 was dependent to required partial/moderate assistance for ADLs. During a concurrent observation and interview on 6/10/25 at 8:49 a.m., Resident 152 was sitting in her wheelchair in the middle of her room and her call light was hanging from the wall out of reach of Resident 152. Licensed Nurse (LN) 1 confirmed the call light was out of reach of Resident 152 and stated the call light should be attached to where it is within reach. During a review of Resident 152's Care plan dated 5/28/25, indicated Resident 152 was .at risk for skin breakdown related to Parkinson's disease . intervention . keep call light within reach and encourage resident to call for assistance . During an interview on 6/12/25 at 1:05 p.m. with the Director of Nursing (DON), the DON stated it was unacceptable to have the call light out of a resident's reach. The DON further stated it could be a problem meeting a resident's needs, they could not call for help and the staff would not be able to help the resident. Review of the facility's Policy and Procedures (P&P) titled, Call Lights: Accessibility and Timely Response, undated, indicated, .staff will ensure the call light is in reach of resident and secured as needed . During a review of Resident 19's admission Record, indicated, Resident 19 was admitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) affecting left non-dominant side, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) left hand and need for assistance with personal care. During a review of Resident 19's MDS, dated [DATE], the MDS indicated, Resident 19 had severe memory problems. During a concurrent observation and interview on 6/10/25 at 10:37 a.m. in Resident 19's room, Resident 19's call light was clipped to the gown at the top backside of the left shoulder. Resident 19's left arm was contracted. When asked to activate the call light, Resident 19 used the right hand to reach over to the left side. Upon pulling the call light the call light was not activated. Resident 19 attempted to pull the string again, his arms were shaking, and Resident 19 was unable to pull the call light. Resident 19 stated, .It's hard for me to pull this (call light string); I use my right hand, and it is placed on my left side . During a concurrent observation and interview on 6/10/25 at 10:42 a.m. with LN 5 in Resident 19's room, Resident 19's call light string was observed still clipped on the gown on the left side. LN 5 stated call lights should be accessible, and operable by the resident. LN 5 further stated that Resident 19's call light should have been positioned on his right side and that he should have been using a touchpad call light. During an interview on 6/12/25 at 9:19 a.m. with DON, the DON stated, the call light served as a form of communication for residents when they needed assistance. The DON stated that a resident's ability to use the call light was an essential component of the call system. During a review of the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response, undated, the P&P indicated, .special accommodations will be identified and provided accordingly .examples include touch pads .staff will ensure the call light was within reach of resident . 2. During a review of Resident 4's admission Record, dated 12/23, indicated Resident 4 was admitted to the facility with diagnoses including schizophrenia (a long-term mental health condition that causes a range of psychological symptoms) and epilepsy (a disorder causing seizures). During a review of Resident 4's MDS, dated [DATE], indicated Resident 4 had severe memory problems. During concurrent observation and interview on 6/10/25 at 9:10 a.m. in Resident 4's room, Resident 4 was sitting in bed and was unable to retrieve food on the back corner of her meal tray with her utensil. Resident 4 stated that she could not locate where her call light was. During an interview on 6/11/25 at 12:14 p.m. with LN 1, stated Resident 4's inability to use call lights can result in resident being in constant pain and neglect of care. During a review of Resident 5's admission Record, dated 7/22, indicated Resident 5 was admitted to the facility with diagnoses of Type II Diabetes Mellitus (a condition that impairs the body's ability to use sugar for energy) and schizophrenia. During a review of Resident 5's MDS, dated [DATE], indicated Resident 5 had severe memory problems. During a concurrent observation and interview on 6/11/25 at 11:46 a.m. in Resident 5's room, Resident 5 was in bed calling out for assistance with pain. Resident 5 stated she did not know where her call light was or how to call the nurse. During a concurrent interview and record review on 6/12/25 at 11:35 a.m. with DON, Resident 4's and Resident 5's Care Plans, undated, were reviewed. The Care Plan for Resident 4 indicated, .keep the call light within reach and encourage resident to use it for assistance, as needed .Provide use of call light . The Care Plan for Resident 5 indicated, .place call light within reach and encourage to use it .Resident needs prompt response to all requests for assistance There was no documented evidence of Resident 4's and Resident 5's care plans were updated to address both residents' inability to use the call light. The DON acknowledged interventions should be specific to the resident and should include an intervention stating staff to perform frequent checks on the safety and needs of Resident 4 and Resident 5. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/22, indicated, .care plans are revised as information about the resident and resident's conditions change . 3. During a review of Resident 10's admission Record, the face sheet indicated, Resident 10 was admitted to the facility July 2021 with multiple diagnoses which included Sequelae of Cerebral Infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 255 needed supervision with ADLs including self-care. During an observation on 6/11/25 at 12:00 p.m. in Resident 10's room, Resident 10 was lying down comfortably. Resident 10's hands were completely wrapped with a self-adhering elastic bandage. During a concurrent observation and interview on 6/11/25 at 12:13 p.m. in Resident 10's room, with CAN 1 confirmed Resident 10's hands were wrapped with a self-adhering elastic bandage. Resident 10 attempted to activate the call light. Resident 10 had difficulty pulling on the call light string. Resident 10 wrapped the string around his arm several times before the call light could be activated. CAN 1 acknowledged the delay in Resident 10 activating the call light due to Resident 10 having difficulty in pulling the call light string. During an interview on 6/13/25 at 9:05 a.m. with DON, DON acknowledged not providing Resident 10 with a call light that accommodated Resident 10's needs could cause a delay in care and injury. During a review of the facility's P&P titled Call Lights: Accessibility and Timely Response, undated, the P&P indicated, .Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system .Special accommodations will be identified and provided accordingly. (Examples include touch pads, larger buttons .) .

Based on observation, interview, and record review, the facility failed to ensure medication error rate was below 5% or greater when the error rate was 25.81% based on eight medication errors out of 31 opportunities observed during a medication administration observation for four out of six residents (Resident 20, Resident 36, Resident 101, and Resident 25). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the residents' clinical conditions. Findings: 1.During a medication administration observation on 6/11/25 at 7:55 a.m. with Licensed Nurse (LN) 1, outside of Resident 20's room, LN 1 was observed preparing 6 medications for Resident 20, including chewable aspirin (ASA-medication for pain that can be used as prevention for heart disease) and omeprazole delayed-release tablet (medication used to treat excess stomach acid and help control heartburn). At 8:01 a.m., LN 1 went inside the room with a 5 oz (ounces-unit of measurement) cup of water to give the medications to Resident 20. No food or other drinks were observed on the bedside table. When LN 1 told Resident 20 ASA was one of the medications he was administering, Resident 20 stated, Oh, I need to chew it. LN 1 responded, You can swallow it. No further instructions were provided. Resident 20 swallowed the ASA, and the other medications LN 1 brought with the 5 oz cup of water. During an observation on 6/11/25 at 8:08 a.m., outside Resident 20's room, observed label on bottle for Resident 20's chewable aspirin, bottle indicated, Adult Low Dose Chewable Aspirin. During an interview on 6/11/25 at 8:26 a.m. with Resident 20, Resident 20 stated she had breakfast a little after 7 a.m. that morning. During a review of Resident 20's Order Summary Report (OSR), dated 6/11/25, the OSR indicated Resident 20 had an order for ASA 81mg (milligram-unit of measurement) oral tablet (tab) chewable to be given, indicated, 1 tablet by mouth one time a day for blood clot prophylaxis (action taken to prevent disease) Chew and swallow the tablet. Give with food or a full glass (240ml [8oz]) of water or milk to minimize gastric irritation. During a review of omeprazole delayed-release manufacturer's packaging, the directions indicated, swallow 1 tablet with a glass of water before eating in the morning. During a telephone interview on 6/12/25 at 11:04 a.m. with Facility Pharmacy Consultant (PC), stated, A full glass of water is 8 oz . It's good to have that amount of water to coat the stomach. PC further stated it was important to take aspirin with food or full glass of water to prevent gastrointestinal (related to the stomach and intestines) discomfort and chew aspirin first before swallowing for better absorption. During a telephone interview on 6/13/25 at 9:48 a.m. with PC, stated, Omeprazole should be taken 3 minutes to an hour before breakfast because it is important for better absorption .more readily absorbed on empty stomach. 2.During a medication administration observation on 6/11/25 at 8:07 a.m., LN 1 was observed preparing 10 medications for Resident 36, including chewable aspirin, metoprolol (medication affecting the heart used to treat chest pain and high blood pressure), and potassium chloride (medication used to prevent or treat low blood levels of potassium-mineral needed for body functions). During a concurrent observation and interview on 6/11/25 at 8:17 a.m., LN 1 entered Resident 36's room with the prepared medications and a 5 oz cup of water. LN 1 informed Resident 36 of the medications he was administering. No food or other drinks were observed on the bedside table. No further instructions were given to resident. Resident 36 drank twice from the 5 oz cup of water when taking the pills. Observed 1/3 of the water remained in the 5 oz cup. LN 1 stated Resident 36 ate breakfast at 7am. LN 1 was observed throwing the cup with the remaining water into the trash. LN 1 confirmed he threw the 5 oz cup with water remaining into the trash. During a review of Resident 36's OSR, dated 6/11/25, the OSR indicated, Aspirin Tablet Chewable 81 MG. Give 1 tablet by mouth one time a day for CVA (Cerebrovascular accident-stroke, loss of blood flow to a part of the brain) Give with food or a full glass (240ml[8 oz]) of water or milk to minimize gastric (of or relating to the stomach) irritation .Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension (high blood pressure) .Administer with food .Potassium Chloride ER Oral Tablet Extended Release 8 MEQ (milliequivalent-unit of measurement) .Give with full glass of water [8 oz] and food. During a telephone interview on 6/12/25 at 11:04 am with PC, PC stated it was important to take metoprolol with a snack or a meal because metoprolol is better absorbed with food, and it was important to take potassium chloride tablet with a full glass of water and food to prevent irritation of the stomach. PC further stated a full glass of water is 8 oz. 3.During an observation on 6/11/25 at 8:35 a.m. with LN 2 in Resident 101's room, LN 2 asked Resident 101 his pain level and Resident 101 responded his pain level was 9 out of 10 (severe pain). During a medication administration observation on 6/11/25 at 8:36 a.m., in the hallway outside of Resident 101's room, LN 2 was observed preparing tramadol hcl (hydrochloride; medication used to treat pain) 50mg for Resident 101. At 8:39 a.m., LN 2 administered the tramadol to Resident 101. During a concurrent medication observation and interview on 6/11/25 at 8:52 a.m. with LN 2, LN 2 was observed preparing 5 medications, including carvedilol 3.125mg (medication used to treat heart failure and high blood pressure). During an observation on 6/11/25 at 8:53 a.m. outside of Resident 101's room, the pharmacy label on the bubble pack (packaging oral medication is dispensed from) for Resident 101's carvedilol medication indicated, carvedilol 3.125 MG TAB Take 1 tablet by mouth 2 times a day with breakfast and dinner. During a concurrent medication administration observation and interview on 6/11/25 at 8:59 a.m., LN 2 entered the room and administered Resident 101's medications without food. Resident 101 stated he had breakfast at 7:15 a.m. During a review of Resident 101's OSR, dated 6/11/25, the OSR indicated, TraMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for Moderate back pain (4-7). During a telephone interview on 6/11/25 at 11:04 a.m. with PC, PC stated if tramadol is ordered just for moderate, it is not appropriate to be administered for severe pain. If a medication is indicated for moderate pain, it should only be given for moderate pain. PC further stated if there was no pain scale indicated in the medication order to cover severe pain, a doctor's order was needed to administer the medication for severe pain. PC stated carvedilol should be given with breakfast or dinner for better absorption. PC further stated the meal is needed to reduce the rate of absorption of the medication and carvedilol gets absorbed too rapidly when the stomach is empty. During a review of the facility's document titled, Integrated Patient Education-Medication Leaflets (IPE-MedLeaf) for carvedilol printed from the facility's electronic health record (EHR) by Treatment Nurse (TN) on 6/12/25 at 8:54 a.m., the IPE-MedLeaf indicated, Take this drug with food. During a review of the carvedilol manufacturer's label from the FDA (package insert that includes approved uses and dosage administration information: Food and Drug Administration), indicated, under Dosage and Administration, [brand name for the medication carvedilol] should be taken with food to slow the rate of absorption and reduce the incidence of orthostatic (low blood pressure when standing up) effects. 4.During a medication administration observation on 6/11/25 at 9:19 a.m. in the hallway outside of Resident 25's room, LN 2 was observed preparing five medications for Resident 25, including allopurinol 100mg (medication used to treat gout, a type of arthritis). During a concurrent observation and interview on 6/11/25 at 9:25 a.m., LN 2 was observed administering Resident 25's medications. No food or snacks were observed on Resident 25's bedside table or given. Resident 25 stated he ate breakfast at 7 a.m. During a review of Resident 25's OSR, dated 6/11/25, OSR indicated, Allopurinol Oral Tablet 100 MG (Allopurinol) Give 1 tablet by mouth two times a day for gout. Administer with food and water. During a telephone interview on 6/11/25 at 11:04 a.m. with PC, PC stated it is important to take allopurinol with food and water because the medication can be associated with gastrointestinal (related to the stomach and intestines) issues and can cause dehydration (condition caused by the loss of too much fluid from the body). PC further stated allopurinol should be taken with 8 oz of water. During an interview on 6/12/25 at 9:31 a.m. with Director of Nursing (DON), DON stated, There is an expectation that nurses follow doctor's orders when administering medications. During a concurrent observation and interview on 6/12/25 at 9:38 a.m., DON took a cup from a medication cart and confirmed cups were 5 oz when filled to the rim. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .Administer medication as ordered in accordance with manufacturer's specifications. Provide appropriate amount of food and fluid.

Based on observation, interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for a census of 49 residents when a shared blood pressure (BP) cuff was not cleaned and sanitized properly in between resident use. This failure resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause infections among residents. Findings: During an observation on 6/11/25 at 7:48 a.m., Licensed Nurse (LN) 1 took the blood pressure (BP) of Resident 20 using a BP cuff from the medication cart without sanitizing it. LN 1 placed the BP cuff on Resident 20's right arm. After completing the task, LN 1 exited the room and placed the BP cuff in the medication cart without sanitizing it. At 8:04 a.m., LN 1 used the same BP cuff on Resident 36 without sanitizing it prior to use. LN 1 did not sanitize the BP cuff in between resident use before placing it back into the medication cart. During an observation on 6/11/25 at 8:51 a.m., LN 2 was observed taking the blood pressure of Resident 101 using a BP cuff from the medication cart. LN 2 placed the BP cuff on Resident 101's right arm. After exiting the room, LN 2 cleaned the BP cuff using a single alcohol prep wipe (tiny size) and then placed it back into the medication cart. During an interview on 6/11/25 at 9:37 a.m. with LN 1, LN 1 confirmed that he did not clean the BP cuff between residents and stated that he was not aware if the facility had a policy for cleaning BP cuffs between resident uses. During an interview on 6/12/25 at 8:08 a.m. with Infection Preventionist (IP), IP stated the expectation was to disinfect BP cuffs between resident use with disinfectant wipes from the canister with a purple top [brand name; germicidal disposable wipe) to prevent cross-contamination. The IP stated, This tiny little thing (alcohol prep pad)-how can it clean the whole blood pressure cuff? The IP further stated that it was not acceptable and not effective to use an alcohol prep wipe to clean a bp cuff. During a review of the facility policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/22, the P&P indicated, .reusable items are cleaned and disinfected or sterilized between residents .

Based on observation, interview and record review, the facility failed to ensure five residents out of a census of 49 (Resident 201, Resident 29, Resident 31, Resident 12, and Resident 44) were treated with dignity and respect when: 1) Resident 201's urinary catheter bag was not covered by a dignity bag; and, 2) RNA 1 and RNA 2 were standing up when assisting to feed Resident 29 and Resident 31; and, 3) Resident 12 and Resident 44 were not asked if they had a preference on using clothing protectors during their meals. These failures placed Resident 201, Resident 29, Resident 31, Resident 12 and Resident 44 at potential risk of diminished self-esteem and feelings of self-worth. Findings: 1.During a review of Resident 201's admission Record, indicated Resident 201 was admitted [DATE] with a diagnosis of metabolic encephalopathy (a condition characterized by altered brain function) and bacteremia (bloodstream infection). During a review of Resident 201's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/27/25, the MDS indicated Resident 201 was rarely/never understood. The MDS further indicated Resident 201 had a foley catheter (a hollow tube inserted into the bladder to drain or collect urine). During a concurrent observation and interview on 6/10/25 at 10:36 a.m., in Resident 201's doorway, Resident 201 was in bed and a urinary catheter bag half-filled with urine, hung beside the bed without a dignity bag cover. A blue dignity bag was hanging on Resident 201's wheelchair. Registered Nurse (RN) 1 came into the room and confirmed that the catheter bag was not covered. RN 1 stated, Resident 201's catheter bag should have been covered with the dignity bag. The RN 1 acknowledged that it was a dignity issue. During an interview on 6/13/25 at 10 a.m., the Director of Nursing (DON) stated, licensed nurses and certified nursing assistants were responsible for checking that urinary catheter bags were covered with dignity bags. The DON acknowledged that Resident 201's catheter bag should have been covered because it was a dignity issue. During a review of the facility's policy and procedure (P&P), titled, Quality of life-Dignity, revised February 2020, indicated, Staff are expected to promote dignity and assist residents. For example: Helping the resident to keep urinary catheter bags covered . 2. During a review of Resident 31's admission Record, indicated Resident 31 was admitted to the facility in April 2025 with multiple diagnoses which included cerebral infarction (loss of blood flow to a part of the brain), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 31's MDS, dated [DATE], indicated Resident 31 was rarely/never understood. The MDS further indicated Resident 31 was independent in eating. During a review of Resident 29's admission Record, indicated Resident 29 was admitted to the facility in August 2024 with multiple diagnoses which included cerebral infarction and hemiplegia. During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had intact cognition. The MDS further indicated Resident 29 needed set up or clean up assistance for eating. During a concurrent observation and interview on 6/10/25, at 11:59 a.m., Resident 29 and Resident 31 were sitting in their respective wheelchairs in the dining room with other residents. Restorative Nurse Assistant (RNA) 1 and RNA 2 stood over Resident 29 while she was eating. RNA 2 standing went behind Resident 31's wheelchair and reached over to take a cup from his tray to prompt him to drink. RNA 2 still standing went to Resident 29 and took her spoon and assisted Resident 29 while reaching around from behind the wheelchair. RNA 1 and RNA 2 acknowledged that they remained standing during lunch. RNA 1 and RNA 2 could not explain why it was important sitting down while assisting residents with feeding. During a review of facility's In service attendance record-Nutrition & Hydration/Feeding, the training indicated that RNA 1 and RNA 2 received training on dignity and feeding on Monday 6/9/25. During an interview on 6/13/25, at 10:10 a.m., the DON stated it was expected for RNAs to be seated at eye level and not standing over the residents when assisting to feed. The DON acknowledged it was a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, revised November 2020, indicated, .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, feeling of self worth and self esteem . 3. During a review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility in March 2025 with a diagnosis of compression fracture of .vertebra (broken bone in the spine). Resident 12's MDS indicated that he had intact cognition. During a review of Resident 44's admission Record, indicated Resident 44 was admitted to the facility in March 2025 with a diagnosis of cerebral infarction. Resident 44's MDS indicated that he had intact cognition. During an observation on 6/10/25, at 11:59 a.m. in the dining room, six of the eight residents had clothes protectors on. Resident 12 and Resident 44 were observed with clothes protectors on and fastened to their neck. During an observation on 6/11/25 at 11:54 a.m., in the dining room, Resident 12 and Resident 44 were observed with clothes protector on and fastened to their neck. Staff did not ask residents if they prefer to wear clothes protectors during their lunch. During an interview on 6/11/25 at 3 p.m. with Resident 12, Resident 12 stated, The staff do not ask me if I want to wear a bib . During an interview on 6/12/25 at 11 a.m. with Resident 44, Resident 44 stated, he is depressed, and he does not like using the clothes protector. Resident 44 further stated .It makes me feel like a baby . Resident 44 confirmed that he was not asked at mealtime. During a review of Resident 12's and Resident 44's care plans, no documented evidence that Resident 12 and Resident 44 had a choice or preference to wear the clothes protector during mealtimes. During a review of the facility's P&P, titled Quality of Life-Dignity, revised November 2020, indicated, The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences .

Based on observation, staff interview, and clinical record review, the facility failed to provide quality of care to promote the highest practible well-being for 1 of 15 sampled residents (Resident 5) when: A psychiatric consultation was not provided as ordered by a physician, and Interventions to prevent significant weight loss were ineffective and/or were not implemented timely. The delay of possible medical intervention(s) caused Resident 5 to experience severe significant weight loss, and a loss of ability to maintain function at prior level. Findings: Resident 5 was admitted to the facility in December 2015 with a primary medical [DIAGNOSES REDACTED]. Upon admission to the facility, Resident 5 was taking an antipsychotic medication to manage the symptoms of [MEDICAL CONDITION]. The goal for care was short-term rehabilitation to get stronger and discharge to a lower level of care. Resident 5's initial admission summary documentation dated 12/10/15, at 8:52 p.m., indicated .Resident is alert and receptive to care .no c/o (complaints of) pain and skin intact .able to ambulate with 1 person assist .resident complain of generalized weakness in all 4 limbs . The initial admission weight for Resident 5 on 12/10/15, at 2:20 p.m., was 162 pounds. The Registered Dietician Nutrition Assessment dated 12/21/15 indicated the Registered Dietitian (RD) evaluation as .Res (resident) with good appetite. No acute nutrition problem identified .goal: maintain current wt (weight) of 164 +/- 5 lbs. During a review of the clinical record for Resident 5, the physician's orders [REDACTED]. Review of Resident 5's, weight record for 1/25/16, at 1:12 p.m., was 147 pounds, a weight loss of 15 pounds since admission 45 days prior. During a review of the clinical record for Resident 5, the physician progress notes [REDACTED]. failure and weight loss . Under history of present illness the physician stated .patient continues to lose weight and has poor appetite and has functional decline. In the assessment and plan area of the progress note, the physician wrote .abnormal weight loss .continue to monitor .Monitor weights weekly. Consider starting appetite stimulant in future if it remains low and he continues to lose weight . During a review of the clinical record for Resident 5, the Registered Dietician Note dated 2/2/16 at 10:54 a.m., indicated the Registered Dietician (RD) assessed the nutritional needs and reviewed the intake history for the resident. The RD notes reflected, .Current po (intake by mouth) meets estimated nutrition needs but Res (resident) continues to lose wt (weight) .will recommend to increase Health shake to 8 oz TID (three times a day) and plan to maintain current wt. RN reports res needs encouragement to eat and sometimes he plays with meals. Eats in the dining room for lunch and dinner . On 3/23/16, at 8:28 a.m., Resident 5's weight was recorded as 134.4 pounds, a weight loss of 27.6 pounds since admission three months prior. A review of the 3/25/16 quarterly Minimum Data Set (MDS (an assessment tool)) in Resident 5's clinical record, revealed the resident had an acute change in mental status, an increase in depressive symptoms, an increase in level of assistance required for activities of daily living, and a significant weight loss. During a review of the clinical record for Resident 5, the physician progress notes [REDACTED].Out-pt psych referral still pending appointment . Adult failure to thrive- .Nutritional supplementation. Monitor .-Abnormal Weight loss .Consider starting appetite stimulant in future if it remains low and he continues to lose weight .Able to make decisions- Yes. Review of Resident 5's Registered dietician note dated 4/1/16 at 11:54 a.m., indicated the second assessment by the RD regarding the resident's continued weight loss. The RD stated .current po does not meet estimated nutrition needs .will recommend to fortify current diet to provide more kcal (calories) . The Registered dietician note dated 5/17/16 at 10:19 a.m., indicated the RD assessed the resident for a seven pound weight loss in one month. The RD recommended for the second time, to .fortify current diet . A review of the clinical record for Resident 5 indicated an order for [REDACTED]. Review of Resident 5's physicians orders dated 4/15/16, indicated an order to start [MEDICATION NAME] Capsule 2.5 MG (Dronabinol) Give 1 capsule by mouth two times a day for weight loss R/T (related to) cachexia (weakness and wasting of the body). This medication is prescribed to stimulate the appetite and is the first prescription of its kind ordered for this resident since the significant weight loss was noted by the physician in January 2016, four months earlier. The weight documented in the clinical record for Resident 5 on 5/6/16, at 10:19 a.m., indicated a weight of 126 pounds, a total weight loss of 36 pounds since admission. During a review of the clinical record for Resident 5, the physicians orders dated 5/10/16, indicated an order to start [MEDICATION NAME] Tablet ([MEDICATION NAME]) Give 7.5 mg by mouth at bedtime for Anorexia related to MAJOR [MEDICAL CONDITION], RECURRENT, UNSPECIFIED . [MEDICATION NAME], an anti-depressant, is prescribed to treat depression and may encourage weight gain due to the common side effect of increased appetite and weight gain with its use. A review of Resident 5's physician progress notes [REDACTED].still looks very debilitated .IF patient continues to lose weight and does;t eat, consider G tube (gastrostomy tube, a flexible tube surgically inserted through the abdomen wall into the stomach that delivers nutrition directly to the stomach) placement if family is interested .-Adult failure to thrive, Abnormal weight loss .Consider appetite stimulant .Cont [MEDICATION NAME] (a medication to stimulate the appetite) bid (twice a day) for anorexia (a lack or loss of appetite for food). Also started [MEDICATION NAME] (an anti-depressant, prescribed to treat depression and may encourage weight gain) for anorexia and depression .Patient is also pending visit from psychiatrist regarding management of [MEDICAL CONDITION] .Out-pt psych referral still pending appointment . Overall poor prognosis due to continued deterioration .Able to make decisions- No. A physician progress notes [REDACTED]. per nurse- Continues to lose weight. 4 Lbs in one month. 30 Lbs in 3 months .No benefit with [MEDICATION NAME]. Continue [MEDICATION NAME] for anorexia and depression. Started [MEDICATION NAME] (a medication) for appetite stimulation Patient is also pending visit from psychiatrist regarding management of [MEDICAL CONDITION] .Out-pt psych referral still pending appointment .Overall poor prognosis due to continued deterioration .Able to make decisions- No. Resident 5's, physicians orders dated 6/8/16, indicated an order to start [MEDICATION NAME] Acetate Tablet Give 200 mg by mouth one time a day related to ANOREXIA (a lack or loss of appetite for food). [MEDICATION NAME] is prescribed to treat loss of appetite and weight loss. During an observation on 6/20/16, at 11:12 a.m., Resident 5 was in bed on his right side with his eyes open, pale skin, bony facial features, and a thin body frame. The resident was observed with a nasal cannula (a device used to deliver supplemental oxygen via small tubes inserted 1 cm into the nostrils) in place, and a low-air loss mattress on the bed with a fall mat alongside the floor of the bed. Upon introduction resident replied slowly with the voice tone of a weak whisper. During an interview with Certified Nurse Assistant 2 (CNA 2) on 6/20/16, at 11:15 a.m., CNA 2 stated Resident 5 sometimes gets out of bed and .he has trouble keeping himself up . The weight for Resident 5 recorded on 6/21/16, at 10:27 a.m., was 120 pounds, a weight loss of 42 pounds since admission six months earlier. During a telephone interview on 6/21/16, at 4:57 p.m., with the Medical Doctor (MD), the MD stated the facility was .unable to get an outpatient psychiatric evaluation and confirmed that the order was put in at the time of Resident 5's admission to the facility and that due to insurance issues .can't get psych eval .no acute indication for that . The MD confirmed that the family of Resident 5 had expressed concerns about possible depression and the family had reported to the MD that the resident was not talking much, not like himself. When questioned of the necessity of a psychiatry consult, the MD stated this resident is a unique situation . unable to get referral .maybe it (a psychiatric consult) would have helped at some point .I started an antidepressant to see if it helps .can't know if would have helped or not, he's had a steady decline. On 6/21/16, at 5:32 p.m., during an interview and concurrent record review of Resident 5's clinical record was conducted with the Director of Nursing (DON). The DON reviewed the clinical record for documentation that nursing or social services staff attempted to follow the MD order for a psychiatric evaluation, the DON stated there are no notes or documentation of social services efforts to obtain a psychiatry consult for Resident 5. The DON stated, .there's no psych doc here, (the MD) is managing his psych meds now . During an interview with Licensed Nurse 2 (LN 2) on 6/23/16, at 8:58 a.m., when asked about Resident 5's clinical condition, LN 2 stated (Resident 5)'s decided in his head he is not going to participate/live right now, until he decides, it will not change. He eats, I feed him, I look at his tray .we started [MEDICATION NAME] (a medication to stimulate the appetite), it didn't work .he is depressed. During a interview with a CNA and concurrent observation of Resident 5 while receiving assistance with eating lunch on 6/24/16, at 12:25 p.m., the CNA described the resident's ability to move about independently. She stated, he doesn't move much .legs do not extend .knees (are) bent always, he used to straighten his legs .he used to walk . A review of the clinical record for Resident 5's nutritional intake (snacks, meals, fluids) from 6/12/16 to 6/27/16 indicated Resident 5 consumed 76-100% for more than half of the three meals a day offered, and resident consumed 51-75 % for approximately a quarter of the meals offered. The weight for Resident 5 recorded on 6/21/16, at 10:27 a.m., was 120 pounds, a weight loss of 42 pounds since admission six months earlier. During an interview with the RD, on 6/28/16, at 9:42 a.m., the RD confirmed that the assessment on 2/2/16 was the first assessment for Resident 5 after the initial admission assessment in December and the RD recommendations were to increase the frequency of offering health shakes that nursing had already started providing the resident. The RD confirmed that her next encounter and review of the resident's nutritional status and weight was 4/1/16 and recommendations were made to fortify the diet for additional calories. The RD stated that .sometimes (I) recommend appetite stimulants for residents. During a telephone interview on 6/28/16, at 11:34 a.m., with the Corporate Executive Officer (CEO), when asked about psychiatric consultations ordered for residents of the facility, the CEO stated whatever the facility needs we will get that service, it's left up to the attending physician to make that call. The CEO was not aware of the facility's inability to provide psychiatric services as ordered for Resident 5, the CEO stated .access is an issue .that's still no excuse to not provide psychiatric services .if it's in the order then it should have been followed up.