Every finding on record at Cerritos Vista Healthcare Center

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) who had behaviors of getting up unassisted, was not restrained in a Trendelenburg (a specific body position where the patient lies flat on their back with their feet elevated higher than their head) like position, while seated in a Geri-chair. This deficient practice resulted in Resident 6's inability to get out of the Geri-chair unassisted and frustration when he wanted to get up but could not do so himself. This deficient practice had the potential for Resident 6 to act out and move in ways that could cause him injury. Findings: During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 had diagnoses including encephalopathy (a condition in which there is disturbance in brain function that causes confusion, memory loss and coma), dementia (a progressive state of decline in mental abilities) and depression (a mood that causes ongoing sadness and loss of interest in normal daily activities of life). During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool) dated 6/29/2026, the MDS indicated Resident 6 was forgetful and unable to make decisions. Resident 6 required a one person assist to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 6's Medical Record, the Medical Record indicated there was no written documentation of Resident 6's need or evaluation for a restraint, no physician's order for a restraint, and no alternative measures used before restraining Resident 6 in a Geri-chair. During an observation on 7/29/2026 at 10:14 a.m., Resident 6 was seen sitting in a Geri-chair, in a Trendelenburg like position. The Activity Director (AD) pushed Resident 6 in the Geri-chair to the facility's patio. Resident 6's jaw was tightened and her was frowning and attempted to turn from side to side while in the Geri-chair. Resident 6 was heard telling the AD that he did not want to go outside, and he wanted to get out of the Geri-chair. Resident 6 continued to frown and glare while talking loudly to the AD. During an interview on 7/29/2026 at 10:18 a.m., the Social Services Director (SSD) stated she was on the patio with Resident 6 when Resident 6 verbalized he was unhappy and wanted to get out of the Geri-chair but could not get up on his own. The SSD stated Resident 6 was confused and the Geri-chair had been recommended for use by the rehabilitation department for Resident 6's safety. During an interview on 7/29/2026 at 12:35 p.m., the Director of Rehabilitation (DOR) Services stated Resident 6 had good trunk control while sitting in a wheelchair and only needed assistance when moving from place to place in the wheelchair. The DOR stated a Geri-chair was not recommended for use by Resident 6 because Resident 6 could sit well in a regular wheelchair. During an interview on 7/29/2026 at 1:03 p.m., Certified Nursing Assistant (CNA) 1 stated she positioned Resident 6 with his head lower than his legs while sitting in a Geri-chair so Resident 6 would not try to get up and fall. During an interview on 7/29/2026 at 1:14 p.m., the AD stated Resident 6 should be positioned with his head lower than his legs and his legs elevated over his head for his safety because he was a fall risk. During an interview on 7/29/2026 at 1:35 p.m., Resident 6's Responsible Party (RP) stated the nursing staff told her they place Resident 6 in a Geri-chair because he tries to get up unassisted. During an interview on 7/29/2026 at 1:56 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 6 had a behavior of getting up unassisted and to prevent him from falling, the CNAs would position him in a Geri-chair with his feet elevated over his head for his safety. During an interview on 7/29/2026 at 2:36 p.m., the Director of Nursing (DON) stated the nursing staff should not have placed Resident 6 in a Geri-chair to prevent him from getting up even if he was a fall risk. The DON stated positioning Resident 6 in the Geri-chair with his head lower than his lower extremities restricted his movements and they should have monitored and redirected him when he attempted to get up unassisted. During a review of the facility's P/P titled, Use of Restraints revised 4/2017, the P/P indicated the facility shall only use restraints such as a Geri-chair, to: a. Ensure the safety and well-being of the resident and only after alternatives have been tried unsuccessfully, b. Implement and perform a pre-restraining assessment and review to determine the need for restraints and to determine if there are least restrictive interventions., c. Use the restraints only upon the written order of the physician and after obtaining consent from the resident and/or responsible party d. Inform the residents and their responsible parties about the potential risks and benefits of all options under in consideration, including the use of restraints, not using restraints, and the alternatives to restraint use; and e. Use the restraints to treat the residents' medical symptoms and never for discipline or staff convenience, of the prevention of falls.

Based on interview and record review the facility failed to ensure one of one resident's (Resident 1) Minimum data Set ([MDS] resident assessment tool), dated 5/8/2026, was coded correctly. This failure resulted in an inaccurate assessment of Resident 1's current health status and Resident 1's inaccurate MDS indicated that Resident 1 did not have broken teeth and abnormal gum tissue in the mouth. Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was recently re-admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), gastroesophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into the esophagus) and a gastrostomy ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) on staff with activities of daily living (ADLs- activities such as bathing, dressing oral hygiene, and toileting a person performs daily). The MDS Section L indicated Resident 1 did not have abnormal mouth tissue, did not have broken natural teeth, and did not have inflamed or bleeding gums.During a review of Resident 1's COC/Interact Assessment Form (SBAR), 4/25/2026 at 3:30 p.m., the form indicated Resident 1 had a broken incisor tooth (front tooth).During a review of Resident 1's Dental Notes dated 4/30/2026, the dental note indicated that Resident 1 had localized moderate gingival (gum) inflammation involving three of the resident's incisor teeth.During a concurrent interview and record review on 5/28/2026 at 10:17 a.m. with the MDS Coordinator (MDSC), Resident 1's medical records were reviewed. The MDSC stated Resident 1 had a broken tooth documented on 4/25/2026 and Resident 1 had moderate inflammation in the gums documented on 4/30/2026. The MDSC stated Resident 1's MDS dated [DATE] was inaccurately coded that Resident 1 did not have teeth and gum issues and should have been coded correctly so the facility could provide the proper care Resident 1 needed.During an interview on 5/28/2026 at 11:36 a.m. with the Director of Nursing (DON), the DON stated MDS assessments should be accurate to ensure the resident has appropriate interventions and be provided with the needed ancillary services (supplementary, specialized medical and diagnostic services provided beyond basic nursing care).During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 9/2019, the P&P indicated any person completing a portion of the MDS must attest to the accuracy of the assessments.During a review of Long-Term Care Facility Resident Assessment Instrument (RAI - a standardized evaluation that helps healthcare providers assess a resident's needs, strengths, and preferences) 3.0 User's Manual, revised 10/2025, the Manual indicated the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to ensure one of one resident's (Resident 1) Enteric coated ([EC] a pill with a protective layer that won't dissolve in the stomach but will be released once in the small intestines) Aspirin ([ASA] nonsteroidal anti-inflammatory drug) was not crushed and administered through the gastrostomy ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).This failure had the potential to result in severe stomach irritation or reduced medication effectiveness.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was recently re-admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), gastroesophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into the esophagus) and a G-tube.During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) on staff with activities of daily living (ADLs- activities such as bathing, dressing oral hygiene, and toileting a person performs daily).During a concurrent interview and record review on 5/28/2026 at 10:17 a.m., with the MDSC, Resident 1's Order history for EC ASA was reviewed. The order history indicated that Resident 1's had EC ASA ordered from 7/26/2024 until 5/272026. The MDSC stated Resident 1 had been receiving EC ASA while she was in the facility and the order should have been a chewable tablet not EC formulation.During a concurrent interview and record review on 5/28/2026 at 10:17 a.m., with the MDS Coordinator (MDSC), Resident 1's Medication Administration Record (MAR) for 5/2026 was reviewed. The MAR indicated EC ASA was administered via G-tube one time a day from 5/1/2026 to 5/27/2026. The MDSC stated Resident 1 had a G-tube inserted last year on 5/2025. The MDSC stated EC ASA should not be crushed and administered through the G-tube.During an interview on 5/28/2026 at 11:36 a.m. with the Director of Nursing (DON), the DON stated EC ASA must only be administered orally, not crushed and then administered through the G-tube. The DON stated medication orders need to be administered in the correct form, for resident safety to prevent medication error. During a review of the facility's P&P titled, Crushing Medications, revised 4/2018, the P&P indicated medications shall be crushed when appropriate and the nursing staff will notify the physician who gives an order to crush a drug that the manufacturer states should not be crushed for example enteric coated medications.

Based on interview and record review, the facility failed to ensure physician's orders for an orthopedic surgeon (specialist in bones, joints, and muscles) and vascular specialist (specialist in blood vessels and circulation) was carried out and/or follow-up was made for one of four sampled residents (Resident 1) who had dry gangrene (tissue death caused by loss of blood supply) of the left finger. These failures resulted in a two-week delay in obtaining Resident 1's ordered consultations and placed Resident 1 at risk for worsening gangrene, auto-amputation (dead portion may fall of on its own due to lack of blood supply) of the left finger, and infection. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 was admitted with diagnoses including open wound of the left index finger without damage to nail, type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and epilepsy (a brain disorder that causes repeated seizures [uncontrolled movement]).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/21/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and Resident 1 required moderate assistance (helper does less than half the effort) from staff for eating and was dependent (helper does all the effort) on staff for toileting and bathing. The MDS further indicated Resident 1 had a total of four venous (related to veins) and arterial (related to arteries) ulcers (a small open sore or wound generally found in the stomach or on the skin).During a review of Resident 1's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 1 was not able to make medical decisions. The H&P indicated Resident 1 was readmitted to the facility from a General Acute Care Hospital (GACH) with gangrene of the left finger and required an outpatient follow-up with an orthopedic specialist to determine the need for amputation (the surgical removal of f body part, such as a finger, toe, hand, foot, or limb). During a review of Resident 1's Order Summary Report (Physician's Orders) dated 4/1/2026, the Physician's Orders indicated the facility was to obtain an authorization for Resident 1 to be seen by an orthopedic surgeon, ordered on 3/13/2026 and by a vascular specialist, ordered on 3/16/2026.During an observation on 4/2/2026 at 8:30 a.m., in Resident 1's room, the Treatment Nurse (TXN) 1 was observed performing wound care and a dressing change to Resident 1's left index finger. Resident 1's left index finger appeared darkened with blackened areas at the tip with discoloration extending along the finger. Resident 1's fingertip appeared larger compared to the adjacent fingers. During a review of the Social Service Note dated 3/17/2026, the Social Service Note indicated the Case Manager (CM) notified the Power of Attorney ([POA] the person who is legally allowed to receive information about the resident, make care decisions, and handle insurance or financial matters on the resident's behalf) to make her aware that the orthopedic surgeon did not accept Resident 1's secondary insurance and would refer Resident 1 to another orthopedic provider that accepted his secondary insurance. During a review of [NAME] Healthcare's Prior Authorization ([PA] insurance approval before certain medical services can be provided or paid for) determination, dated 3/18/2026, the insurance determination indicated the PA request for outpatient consultation services for Resident 1's gangrene left index finger was returned. The insurance determination indicated Resident 1's primary insurance was Medicare, and that Resident 1 had secondary insurance. The insurance determination instructed the facility to contact the Resident 1's primary insurance for coverage of the outpatient consultation services.During an interview on 4/2/2026 at 2:48 p.m. with the SSD, the SSD stated when nurses authorize a specialist referral, they write a physician's order then give it to Social Services. Social Services then faxes the authorization request form to the resident's insurance. If the authorization is denied, then they (nursing staff) need to find other options. The SSD stated she was not aware of Resident 1's referral because she believed the CM was handling the authorization.During a review of Resident 1's Medical Records dated 3/13/2026 through 4/2/2026, there was no documentation indicating the SSD coordinated, scheduled, or followed up on these referrals after the authorization issue was identified.During an interview on 4/2/2026 at 2:58 p.m., with the CM, the CM stated Resident 1 required vascular and orthopedic referrals and stated the resident's insurance did not cover the referrals. The CM stated she submitted an authorization request to Resident 1's secondary insurance on 3/18/2026 and stated the authorization response indicated the resident's primary insurance was Medicare. The CM stated the authorization for Medicare was not the facility's responsibility and stated the secondary insurance was responsible for obtaining Medicare authorization and did not follow up after the insurance denial. During an interview on 4/2/2026 at 3:19 p.m., with Registered Nurse (RN 1), RN 1 stated she attempted to make an appointment for Resident 1, but the surgeon's office informed her they did not accept the resident's insurance. RN 1 stated the facility attempted to offer private pay, but the surgeon's office stated the resident could not be seen as a private pay because the resident had active insurance coverage. RN 1 stated she requested assistance from the SSD and informed the CM of the insurance issue. RN 1 stated she was responsible for scheduling the specialist appointments, but when the insurance authorization was denied, she referred the issue to the CM. RN 1 stated she made several attempts to locate a specialist who accepted Resident 1's insurance and notified the CM; however, did not document those attempts. During an interview on 4/6/2026 at 11:10 a.m., with the Director of Nursing (DON), the DON stated when a resident required a referral, nursing receives the physician's order, carries out the order, and notifies the SSD and CM. The DON stated nursing located the specialists listed in the order and initiated calls. If a specialist required insurance information or did not accept the resident's insurance, nursing would notify CM. The DON stated CM was responsible for obtaining insurance authorizations and communicating ongoing issues to SSD and the BO. The DON stated the SSD was responsible for tracking referrals, coordinating outside appointments, handling insurance appeals, and monitoring CM activity related to the resident's care. The DON stated the SSD should have coordinated referrals under Medicare once Resident 1's secondary insurance indicated Medicare was the primary payer. The DON stated the CM and SSD should have worked together and the SSD should have overseen CM's activity when referrals impacted the resident's care. The DON stated missed communication and missed coordination in the referral process resulted in a delay of resident care. During a review of the facility's Job Description titled Social Services Designee, dated 1/27/2022, the job description indicated the Social Service Designee responsibilities include: 1. Assisting in the provision of medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.2. Assisting residents or responsible parties in processing forms or applications in the effort to obtain outside services, including but not limited to Social Security, Medicaid, SSI or any other service to which the resident may be entitled; and3. Implements social service interventions that achieve treatment goals, address resident needs, and link social supports, physical care and physical environment to enhance quality of life.During a review of the facility's policy and procedure (P&P) titled Social Services, revised September 2021, the P&P indicated:1. Social services staff are responsible for making referrals and obtaining needed services from outside entities.2. The facility is responsible for ensuring that all residents are provided with medically related social services whether by a staff member or through referrals to an outside agency.3. Obtaining or attempting to obtain medically related social services on behalf of a resident are not contingent upon Medicaid coverage of needed services.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when:There was trash of paper, plastic and soiled gloves left in the bottom of the dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts)One trash can was not covered and has no lid near the residents' refrigerator in Hall 1 when actively not used. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 129 of 129 facility residents.Findings: a. During a concurrent observation and interview on 2/24/2026 at 11:03 a.m., of the dumpster area, with the Dietary Supervisor (DS), trash was observed (plastic, gloves on the ground, and paper trash) in the bottom of the dumpster. The DS stated there was plastic trash on the ground of the dumpster surroundings and it should be cleaned. The DS stated trash attracts pests (destructive animals that spread diseases), cockroaches, rodents which could potentially go to the kitchen and make the residents sick. b. During a concurrent observation and interview on 2/24/2026 at 11:27 a.m. of the residents' refrigerator in Hall 1 with the DS, a trach can was observed without a lid. The DS stated the trash was not covered and it should not be near the residents' refrigerator. The DS stated the trash should be covered to prevent cross-contamination (transfer of harmful bacteria from one place to another). The DS stated trash could attract flies and cockroaches if not covered and infection could spread as a potential outcome. During a review of the facility's policies and procedures (P&P) titled Waste Control and Disposal, dated 3/15/2025, the P&P indicated, All waste will be disposed of daily and as needed throughout the day.2) Trash bin should be covered at all times.6) Outside garbage bin should be kept closed at all times and surrounding area must be kept clean. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 116 of 129 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 2/24/2026 at 2:00 p.m. of the dishwashing area, Dietary Aide 2 (DA 2) was observed throwing meal tickets in a grey trash can.During a concurrent observation and interview on 2/24/2026 at 2:05 a.m. of the dishwashing process with the Dietary Supervisor (DS), DA 2 was observed throwing meal tickets in the trash. The DS stated she saw DA 2 throw the meal tickets in the trash and the trash will go to the dumpster. The DS stated DA 2 should have separated the meal tickets and placed it in the corodata (secure onsite destruction services for confidential documents) to shred. The DS stated the meal ticket contained residents' name, diet, room number, food preferences and identification number (ID, residents' number in the chart). The DS stated the meal ticket needed to be shredded for privacy as somebody could access the residents' chart because of their ID number. The DS stated the residents' identity could be stolen as a potential outcome of throwing the menu tickets in the trash. The DS stated they were not protecting residents' information because anyone can access the meal tickets in the trash.During a review of the facility's policies and procedures (P&P) titled Confidentiality of Information and Personal Privacy, dated 10/2017, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and ImplementationThe facility will safeguard and personal privacy and confidentiality of all resident personal and medical records.The facility will strive to protect the resident's privacy regarding his or her:Accommodations;Medical treatment;Written and telephone communications;Personal care;Visits; andFamily and resident group meetingsProviding a private room for each resident is not required to maintain or protect resident privacy.Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed chili was too sticky and left a thick film during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) and pureed tossed salad was too watery. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 13 of 129 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).Findings:During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus, dated 2/23/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 (foods that are soft and pudding like consistency) would include the following foods on the tray:Pureed three (3) bean chili one (1) cup (c, household measurement)Pureed tossed green salad 1/3 cPureed corn bread with green chilis 1/4 cMargarine (pureed with bread)Pudding 1/3 cMilk four (4) ounces (oz, a unit of measurement)During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 2/23/2026 at 1:15 p.m. of the puree diet with the Dietary Supervisor (DS) and the Registered Dietitian (RD),it was observed that the puree Jello had lumps in it. The DS stated puree foods should be an applesauce-like consistency and smooth to swallow. The DS stated they would know the puree food was in the right consistency by seeing and tasting the food. The DS stated she could not think of any other test they performed to identify the food was in proper texture and consistency. The DS stated she was the one providing in-services to the staff with the RD.During an interview on 2/23/2026 at 1:19 p.m. with the RD, the RD stated they used spoon tilt test to check puree food consistency and puree foods should have no clumps, grains with little to no residue on the spoon. The DS stated the puree food should retain its shape. The RD performed a spoon tilt test for the puree chili and stated there was a lot of puree chili sticking on the spoon. The RD stated the puree salad was a bit runny and it should not look like it was lying flat on the plate. The DS stated the Jello looked like it was regular Jello because it was lumpy. The DS stated residents on puree diets could have aspirated (accidental breathing in of food and liquid into the airway and lungs) and choked on the food if the puree food was not on the right texture and consistency. The DS stated they performed a spoon tilt test during the food preparation and corrected the food texture and consistency if there were issues, however, they do not do the spoon tilt test after food preparation.During a review of the facility's policies and procedures (P&P) titled Menus, dated 3/15/2025, the P&P indicated, Twenty-eight-day cycle menus are prepared by the dietitian and modifications of individual resident menus are made as necessary to comply with physician orders and or resident preferences.The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and a standardized food production. The menus will be prepared as written using standardized recipes.During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled IDDSI Level 4: Regular Pureed Diet, dated 3/15/2025, the diet manual indicated, The pureed diet is a regular diet that has been designed for resident who have difficulty chewing and/or swallowing. The texture of the prepared food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in Book #1, under the Food Safety/Miscellaneous Section. All foods are to be prepared in a blender. This diet has texture specifications that must pass IDDSI Level #4 testing requirements. IDDSI Testing Requirements: The finished puree food item must pass IDDSI Level #4 testing requirements (i.e. appearance, fork drip, and spoon tilt tests).During a review of the facility's standardized recipe titled Recipe: 3 Bean Chili dated 2025, the recipe indicated, IDDSI #4 Puree 1 cup. Puree following recipes in the Food Safety/Misc. section of Book 1. Utilize the critical test and IDDSI audit to confirm texture meets level #4 specification.During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Salad, the recipe indicated, (3) the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests).During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

Based on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity and respect by failing to ensure residents were served in China wares during lunch time.This deficient practice had the potential to affect 116 of 129 residents' self-esteem and self-worth. Findings:During an observation on 2/23/2026 at 12:06 p.m., observed [NAME] 2 using paper bowls for the chili.During an observation on 2/23/2026 at 12:20 p.m., observed dietary staff using paper plates for fruit salad and sandwiches sides for lunch.During a concurrent observation and interview on 2/23/2026 at 1:06 a.m. with a test tray (a process of tasting, temping, and evaluating the quality of food) of the regular diet meal with the Dietary Supervisor (DS) and the Registered Dietitian (RD), observed chili was served on paperware. The DS stated the presentation of the food tray was okay, but the chili should be in a bowl. The DS stated they had insulated bowls, but she was unsure why the cooks did not use them. The DS stated serving in insulated bowls would keep the food hot and the presentation would be better. The RD stated the presentation of the food could improve by using a regular bowl instead of disposable bowl. The RD stated they might have run out of bowls during lunch time, but it affected the attractiveness of the food presentation, and it did not make it look like a home environment. The RD stated residents could potentially question why their food was in paperware and could complain about it. During a review of the facility's policies and procedures (P&P) titled Dignity, dated 2/2021, the P&P 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, and feelings of self-worth and self-esteem. (1) Residents are treated with dignity and respect at all times.During a review of the facility's P&P titled Food Preparation, dated 3/15/2026, the P&P indicated, Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: 1. All food will be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Tray set up must be: (a) neat (b) dishes, utensils, glasses, cups, and flatware free of rust, chips, cracks.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:One (1) of four (4) racks in the walk-in refrigerator had rust and amber discoloration.Kitchen equipment and utensils were not free from dirt, dust and food debris.Vent in the walk-in refrigerator had dust buildup.Walk-in refrigerator wall had dressing spillsWalk-in freezer wall had a black dirt spill coming from the ceiling and the racks had dirt, dust, and food particles in the walk-in freezer.Corn starch spilled into the lentil's container.Pans had burnt plastic debris and sticker residue.Two (2) of three (3) food warmers had food and dirt debris.Six (6) of 6 dented cans were stored with non-dented cans.Pots and pans were stacked wet in the storage area.Staff were thawing fish under water temperature of 77 degrees Fahrenheit ( F, a scale of temperature) and fish was at 67 F. There was no temperature and time monitoring during thawing. Staff did not use the proper Quaternary Ammonium Compounds (QUAT, a chemical used a disinfectant, sanitizer to kill bacteria and viruses) sanitizer dilution.These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 116 of 126 medically compromised residents who received food and ice from the kitchen. Findings: 1.During an observation on 2/23/2026 at 8:52 a.m. of the walk-in refrigerator, 1 of 4 racks was observed with amber discoloration. During an interview on 2/23/202026 at 9:06 a.m. with the Dietary Supervisor (DS), the DS stated the rack has rust. During an interview on 2/23/2026 at 9:19 a.m. with the DS, the DS stated the rust from the rack could go to the food and could cause cross-contamination. During a review of the facility's policies and procedures (P&P) titled Sanitizing Equipment and Surfaces, dated 3/15/2025, the P&P indicated, (6) Dietary staff should ensure that all equipment, shelves, serving utensils, utility carts, cutting boards, vents, and surface areas are clean and in good condition. (7) Dietary staff should notify maintenance of any issues using the maintenance log sheet. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 2.a. During an observation on 2/23/2026 at 8:52 a.m. of the walk-in refrigerator, observed the vent had dirt buildup. During an interview on 2/23/2026 at 9:14 a.m. with the DS, the DS stated the refrigerator vents are cleaned by maintenance once a week. During an interview on 2/23/2026 at 9:16 a.m. with the Registered Dietitian (RD), the RD stated the last time the maintenance staff cleaned the vent was two weeks ago however, there were still dark spots, dirt, dust buildup and mold. During an interview on 2/23/2026 at 9:19 a.m. with the DS, the DS stated they needed to clean the vent because they store food in the refrigerator. The DS stated the vent is blowing air and it could blow dust the food causing cross-contamination. The DS stated residents could get sick of nausea, vomiting and diarrhea as a potential outcome. b. During an observation on 2/23/2026 at 8:52 a.m. of the walk-in refrigerator, the refrigerator wall was observed with food spills on it. During an interview on 2/23/2026 at 9:04 a.m. with the DS, the DS stated there was a dressing spill and it should be cleaned. The DS stated dietary staff clean two times a week and they wipe spills as soon as they drop something. c. During an observation on 2/23/2026 at 8:57 a.m. of the walk-in freezer, the freezer wall was observed with dried up black liquid spills and the racks have dirt, dust and food particles. During an interview on 2/23/2026 at 9:12 a.m. with the DS, the DS stated freezer racks had food debris, and the wall had a black water residue coming from the ceiling. The DS stated the liquid was dripping from the top and it's black and it was dirt. d. During a concurrent observation and interview on 2/23/2026 at 9:48 a.m. of the lentil storage container with the DS, the container was observed with white powder looking spill. The DS stated the corn starch spilled in the lentil container and it could cause cross-contamination. The DS stated the dietary staff should have cleaned right away when they spilled it. The DS stated residents allergic to corn starch who ate lentil could get anaphylactic reaction (allergic reaction causing breathing difficulties, low blood pressure, and shock) as a potential outcome. The DS stated the spilled corn starch could attract pests and can nibble on the corn starch. The DS stated the pest could cause infection to the residents. e. During an observation on 2/24/2026 at 10:27 a.m. of the pots and pans storage rack, the pans were observed with dirt debris. During an observation on 2/24/2026 at 10:28 a.m. of the food container stored in the clean area, the food container was observed with sticky residue. During a concurrent observation and interview on 2/24/2026 at 10:42 a.m. of the storage area for clean pans with DS, pans were observed wet. The DS stated the pans had dried up plastic and it should have been scrubbed and cleaned before storing to prevent cross-contamination. The DS stated the food container had sticker and the dietary staff forgot to remove it during dishwashing. f. During an observation on 2/24/2026 at 10:31 a.m. of the plate warmer, observed the plate warmer have dirt debris. During a concurrent observation and interview on 2/24/2026 at 10:53 a.m. of the plate warmer, 2 of 3 plate warmers used for plate storage were observed with dirt debris on them. The DS stated there was dirt and food debris in the plate warmer and it should have been clean after every use and it should be free from debris. The DS stated dirt debris in the plate warmer could cause cross contamination and residents could get sick of nausea, vomiting and diarrhea as a potential outcome. During a review of the facility's P&P titled Refrigerator and Freezer, dated 3/15/2026, the P&P indicated, The refrigerator and freezer area will be clean, dry, well-ventilated at all times. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, dated 3/15/2025, the P&P indicated, Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. During a review of the facility's P&P titled Storage of Canned and Dry Goods, dated 3/15/2025, the P&P indicated, Food and supplies will be stored properly and in a safe manner. (1) The storage area will be clean, dry, well ventilated at all times. (8) Storage area will be cleaned regularly and checked for any evidence of pests. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 3. During a concurrent observation and interview on 2/23/2026 at 9:27 a.m. of the dry storage area with the DS, a dented can was observed stored with non-dented cans. The DS stated dented cans are separated in the dented cans area by the entrance door. The DS stated they should not have found dented cans with the non-dented can because if the can is dented it could cause botulism (food poisoning caused by bacteria growing in dented cans). The DS stated botulism is when the can is dented it could be open and bacteria could come in and grow. The DS stated if residents consumed foods from the dented cans, the residents could get hospitalized and get sick. During an interview on 2/23/2026 at 9:30 a.m. with the RD, the RD stated when a can is dented there is a chemical reaction that could cause botulism causing double vision, paralysis and if not treated it could lead to death. During a concurrent observation and interview on 2/23/2026 at 9:38 a.m. of the dry storage area, observed 6 dented cans stored with non- dented cans. The DS stated the dented cans should not be stored with non-dented cans and dented cans include dents on the rim of the cans. During a review of the facility's P&P titled, Storage of Canned and Dry Goods, dated 3/15/2026, the P&P indicated, Canned items should be inspected for damage such as dented, leaking or bulging cans. These items will be stored separately in the designated area-DENTED CANS for return to the vendor or disposed of properly. During a review of the facility's P&P titled, Safe Food Transfer and Cross-Contamination Prevention Policy, dated 3/15/2025, the P&P indicated, All canned food products must be transferred to clean, sanitized containers in a way that prevents any risk of cross-contamination to ensure the health and safety of residents. (2). Inspecting the can: all cans must be checked for swelling, dents, rust, or signs of contamination. Damaged or expired cans must be discarded per facility policy. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. During an observation on 2/24/2026 at 10:32 a.m. of the pots and pans storage area, pans were observed stacked wet. During an interview on 2/24/2026 at 10:46 a.m. with the DS, the DS stated the dishes needed to be air dried before storing. The DS stated the pans could not be stacked wet because the chemicals could still be in there and it would not be safe to use due contamination. During an interview on 2/24/2026 at 10:50 a.m. with the RD, the RD stated if the pots and pans were not properly air dried, water could pull out in the dish and bacteria could build up. The DS stated there were still water particles on the pans and they were stacked wet and not properly air dried. The DS stated resident could get sick as a potential outcome. During review of the facility's P&P titled Dishwashing Procedures-Dish machine, dated 3/15/2026, the P&P indicated, Dishes will be properly sanitized through the dish machine. The dish machine will be kept clean and in good condition. (5). Dishes, utensils, pots and pans will be air dried before storage. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 5. During an observation on 2/24/2026 at 10:34 a.m. of the preparation sink, dietary staff was observed thawing chicken in the kitchen sink. During an interview on 2/25/2026 at 10:25 a.m. with [NAME] 1, [NAME] 1 stated she was the one thawing the chicken in the sink yesterday and it came from the refrigerator then she thawed it in the sink with running water. [NAME] 1 stated they pull the chicken out from freezer to the refrigerator two (2) days before use which was 2 days ago then thawed it in the preparation sink from 10:00-11:00 am. [NAME] stated she cooked the chicken around 1:00 p.m. to 1:30 p.m. [NAME] 1 stated she did not take the temperature of the chicken during thawing and before cooking and there was no log for it., [NAME] 1 stated she has not attended in-services for thawing of food. During a concurrent observation and interview on 2/25/2026 at 10:34 a.m. of the preparation sink with [NAME] 2, observed turkey and tilapia thawing under a running water. [NAME] 2 stated the tilapia, and turkey came from the freezer, and it has been out for 45 minutes, and these foods are for today's use. During an interview on 2/25/2026 at 10:35 a.m. with the DS, the DS stated their process of thawing is pulling the food from the freezer and it stayed in the refrigerator for a maximum of three (3) days and thawing in the sink under a room temperature running water. The DS stated the dietary staff feel the meat from the refrigerator if it's thawed all the way and if it's not, they could thaw it in the sink. During an interview on 2/25/2026 at 10:41 a.m. with the RD, the RD stated the dietary staff thaw food the night before from the freezer to the refrigerator then transfer it to the sink with cold water for 1-2 hours before cooking. The RD stated she did not train the dietary staff to log time and temperature during thawing process in the sink. During an interview on 2/25/2026 at 10:43 a.m. with the DS, the DS stated the dietary staff should thaw food in a manner that is safe and the temperature of the food should not go above 40 F as the bacteria could start growing and multiply causing foodborne illnesses. During an interview on 2/25/2026 at 10:52 a.m. with the RD, the RD stated the safest way to thaw is under the refrigerator with a food temperature under 41 F and below. The RD stated the dietary staff should be thawing in the sink under cold running water with a temperature of 70 F or below for a maximum of 2 hours. During a concurrent observation and interview on 2/25/2026 at 11:12 a.m. of the preparation sink with the RD, the DS and [NAME] 2, observed the RD took the temperature of the running water used to thaw the fish. The RD stated the water temperature was at 77 F and it should be below 70 F. [NAME] 2 stated she took the fish out from the refrigerator at 10:00 a.m. and she did not take the temperature because it was still frozen. Observed the temperature of the fish at 69 F. The RD stated the fish was not safe to cook because the water temperature was above 70 F. The RD stated the hot water knob was turned on during the thawing process, that was why the water used for thawing was hot. During a review of the facility's P&P titled, Thawing Food, dated 3/15/2025, the P&P indicated, All food will be thawed in a safe and sanitary manner. (2) Under potable, running water at a temperature 70 F or lower, with sufficient velocity to agitate and float off loose food particles into the overflow. During a review of Food Code 22, dated 1/18/2023, the Food Code 2022 indicated, 3-501.13 Except specified in (D) of this section, Time/Temperature control for safety food shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below. (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (4) For a period of time does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11 (A) or (B) to be above 41 for more than 4 hours including (a) the time the food is exposed to the running water and the time needed for preparation for cooking or (b) the time it takes under refrigeration to lower the food temperature to 5 C (41 F). 6. During a concurrent observation and interview on 2/24/2026 at 2:35 a.m. with Dietary Aide 1 (DA 1), DA 1 stated the red bucket contained QUAT sanitizer for sanitizing the cart. DA 1 stated he pours the QUAT sanitizer to cold water in the red bucket with a ratio of 5 liters of water is to 75 ml of QUAT sanitizer During an interview on 2/24/2026 at 2:50 a.m. with the DS, the DS stated the ratio of QUAT sanitizer to water is 4 quarts of water is to 7.5 ml based on manufacturer's guidelines. The DS stated using 5 quarts of water is to 7.5 ml ratio would be diluted and the solution would not be effective to get 200-400 parts per million (ppm, a unit of concentration) concentration of the sanitizer. The DS stated the sanitizer concentration would be below 200 ppm, and it would not sanitize the surface right causing foodborne illnesses and viruses to the residents. During a review of the facility's P&P titled Red Bucket (Quarternary Ammonium Sanitizer) Policy, dated 3/15/2025, the P&P indicated, To ensure proper preparation, use, monitoring, and disposal of quarternary ammonium (QUAT) sanitizer used in red sanitizer buckets for food contact surfaces in the kitchen. Red sanitizer buckets containing QUAT solution will be used for wiping cloth storage and sanitizing food contact surfaces during food preparation and service. The solution will be prepared according to manufacturer instructions and maintained at safe and effective concentration (200-400 ppm). Preparation: Red buckets must be clearly labeled SANITIZER. Fill bucket with 1 gallon of water. Add 1/2 -1 tablespoon of Sani-Tech QUAT sanitizer per gallon (per manufacturer instructions. Mix thoroughly. During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24 C (75 F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.

Based on interview and record review, the facility failed to formulate Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) correctly in the medical records for three of 14 sampled residents (Resident 7, 15 and 126) by not:Completing the AD form for Resident 7Completing the AD form for Resident 15Providing written information to Resident 126 and/or responsible parties and had a completed AD Acknowledgement/Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency)These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergencies, end of life, and changes in condition.Findings: a. During a review of Resident 7's admission Record, the admission Record indicated, Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (a language disorder caused by brain damage that impairs speaking, writing, reading, and understanding, without affecting intelligence) and cardiac arrhythmia ( an abnormal heart rhythm where the heart beats too fast, too slow, or irregularly). During a review of Resident 7's History and Physical (H&P), dated [DATE], the H&P indicated, Resident had fluctuating capacity (ability) to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 7's cognition (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated the resident required moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, showering, personal hygiene, supervision assistance (helper provides verbal cues and/ or touching/ steading and/or contact guard assistance as resident completes activity) with eating, oral hygiene, dressings. During a concurrent interview and record review on [DATE], at 9:50 a.m., with the Social Services Director (SSD), Resident 7's Advance Healthcare Directive Acknowledgement (AHDA), dated [DATE] was reviewed. The SSD stated the AHDA form, dated [DATE] was left blank except for the physician's signature, the form was not discussed and completed by the resident or the resident's representative, and this was not compliant practice. The SSD stated an AD is a legal document that expresses a resident or resident representative's wishes regarding end-of-life or emergency care, it allows the resident to appoint a health care agent to make decisions if the resident becomes unable to do so, health care providers must respect and follow the resident's expressed wishes. The SSD stated an AD ensures care aligns with the resident's preferences, reduces family burden, and provides clear guidance to medical professions and should be completed. During an interview on [DATE], 9:28 a.m., with the Director of Nursing (DON), the DON stated, the facility failed to formulate the resident's AHDA accordingly, the ADHA form should be completed upon a resident's admission as soon as possible at least within 72 hours. The DON stated if the AHDA form indicated the resident executed an AD, the copy of AD should be obtained and maintained in the chart. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, undated, the P&P indicated, the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. b. During a review of Resident 15 's admission Record, the admission Record indicated Resident 15 was initially admitted to facility on [DATE] and readmitted on [DATE] with diagnosis including but not limited to: perforation of intestines (a small hole or tear in the wall of the intestine), muscle weakness, chronic pain, and hypertension (high blood pressure). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 15 cognitively intact, can make decision for himself. During a concurrent interview and record review on [DATE] at 12:20 p.m. with Registered Nursing Supervisor (RNS) 1, Advance Healthcare Directive Acknowledgement (AHDA), dated [DATE], was reviewed. The AHDA form did not indicate whether Resident 15 had an advance directive executed or not. RNS 1 stated the Resident 15's AHDA form was incomplete. The advance directive is a legal document; it expresses the residents' wishes regarding end-of-life care and if they appoint someone to make decision for them if residents become unable to do so. RNS 1 also stated Resident 15's AHDA form should be completed, in case of emergency, facility would follow Resident 15's advance directive. Failing to complete the AHDA form had potential to affect Resident 15's care. c. During a review of Resident 126's admission Record, the admission Record indicated, Resident 126 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). During a review of Resident 126's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 126 did not have the capacity (ability) to understand and make decisions. During a review of Resident 126's MDS, dated [DATE], the MDS indicated Resident 126 required dependent assistance (Helper does all of the effort) from two or more staff for eating, hygiene, shower/bath, dressing, bed mobility, and transfer. During a concurrent interview and record review on [DATE], at 10:53 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 126's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE] was reviewed. The POLST indicated, Resident 126 had an order for Do Not Attempt Resuscitation (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). The POLST indicated, Section D for AD was left blank and it was not completed. RNS 1 stated, the POLST was not completed because there was missing information. RNS 1 stated, if the POLST was not completed, the resident would be treated as a full code and all life sustaining measures would be done during the emergency per policy. RNS 1 stated, the resident would be treated against his/her wishes. During a review of Resident 126's Order Summary Report (OSR), dated [DATE], the OSR indicated, Do Not Attempt Resuscitation/DNR, comfort focused treatment, no hospitalization, and no artificial means of nutrition including feeding tube was ordered on [DATE]. During an interview on [DATE], at 10:56 a.m., with the SSD, the SSD stated, there was no AD Acknowledgement done. The SSD stated, she did not provide written materials regarding AD to Resident 126's Responsible Party (RP- a family member or agent assisting with admission, often asked to manage the resident's funds to pay for care). The SSD stated, she did not complete and update the POLST after the code status changed from full code to DNR. The SSD stated, it was her responsibility to ensure documenting the availability of AD and educating regarding AD with the resident or RP on POLST to honor the resident's wishes regarding care and treatment. During an interview on [DATE], 10:44 a.m., with the Director of Nursing (DON), the DON stated, AD and POLST should be available for all residents regardless. The DON stated, the SSD and staff should have ensured the completion of POLST and provided written information regarding AD to the residents and RP. The DON stated, AD and POLST were important to honor residents' wishes and the guideline for how to treat residents in emergency situation. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, undated, the P&P indicated, Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3.Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative . 5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents' legal representative.

Based on interview and record review, the facility failed to ensure three of six sampled residents (Resident 9, Resident 46 and Resident 56)'s Preadmission Screening and Resident Review (PASARR, a screening that helps decide whether a person moving into a nursing home has a serious mental illness, an intellectual disability, or another condition that needs special care.) was complete correctly.This failure had the potential to affect Resident 9, 46 and 56's care and treatment.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to facility on 3/16/2023 and readmitted on [DATE] with the diagnosis that included but not limit to: diabetes (a condition where a person's body has trouble controlling the amount of sugar in their blood), anemia (a condition where a person does not have enough healthy red blood cells), chronic kidney disease, and schizoaffective disorder (a mental health conditions, schizophrenia can cause someone to have trouble knowing what is real).During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 12/4/2025, the MDS indicated an active diagnosis of schizoaffective disorder.During a review of Resident 9's care plan revision date 6/20/2025, the care plan indicated Resident 9 had schizophrenia.During a review of Resident 9's PASARR, dated 1/31/2026, the PASSAR did not indicate the resident was diagnosed for serious mental illness therefore it also did not indicate a referral for a Level II PASSAR.During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was initially admitted to facility on 12/30/2024 and readmitted on [DATE] with the diagnosis that included but not limit to: end stage renal disease (a condition a person's kidney is not working well), dialysis (a medical treatment that helps clean a person's blood when their kidneys are not working well), hypertension (high blood pressure), and depression (a mental health condition that makes a person feel very sad, empty, or hopeless for a long time).During a review of Resident 46's MDS dated [DATE], the MDS indicated an active diagnosis of depression.During a review of Resident 46's care plan revision date 1/14/2026, the care plan indicated Resident 46 had depression.During a review of Resident 46's PASARR, dated 1/31/2026, the PASSAR did not indicate the resident was diagnosed for serious mental illness therefore it also did not indicate a referral for a Level II PASSAR.During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to facility on 2/24/2018 and readmitted on [DATE] with the diagnosis included but not limit to: type 2 diabetes mellitus (a condition where a person's body has trouble controlling the amount of sugar in their blood), seizures (a condition a person to lose control of their body for a short period of time), depression (a mental health condition that makes a person feel very sad, empty, or hopeless for a long time), anxiety disorder (a condition where a person feels very worried, nervous, or scared much more often than most people).During a review of Resident 56's MDS dated [DATE], the MDS indicated an active diagnosis of depression and anxiety disorder.During a review of Resident 56's PASARR, dated 1/31/2026, the PASSAR did not indicate the resident was diagnosed for serious mental illness therefore it also did not indicate a referral for a Level II PASSAR.During an interview on 2/24/2026 at 10:19 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated she completed the PASARR screen for Resident 9, 46 and 56. RNS 1 also stated she did not review residents' MDS and care plan when she did PASARR screening for them, so the PASARR screening was done incorrectly. RNS 1 stated inaccurate assessment have negative affect on Resident 9, 46 and 56's care and treatment.During an interview on 2/26/2026 at 8:37 a.m. with MDS supervisor (MDS RN), MDS RN stated Resident 9, 46 and 56 the PASARR screening had discrepancies, the nurse should review the MDS and care plan to ensure accurate assessment on the screening. Inaccurate PASARR screenings could negatively affect Resident 9, 46, and 56's care and treatment.During a review of facility policy and procedure (P&P) Resident Assessment dated 03/2022, the P&P indicated, MDS should be used to conduct resident assessment.

Based on interview and record review the facility failed to to ensure:a. Residents' care plans were implemented for two of four sample residents (Resident 9 and 46).b. Ensure resident's request for hospice (end of life care ensuring the person feels comfortable and supported) care for one of four sampled residents (Resident 89).These deficient practices resulted in Resident's 9 and 46 not receiving person centered care and Resident 89 not receiving necessary comfort-focused interventions, pain management supports, and coordinated end of life services. Findings: A. During a review of Resident 9's admission record, the admission record indicated Resident 9 was initially admitted to facility on 3/16/2023 and readmitted on [DATE] with the diagnoses but not limited to diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). anemia (a condition where a person doesn't have enough healthy red blood cells), chronic kidney disease, and schizoaffective disorder (a mental health conditions, schizophrenia can cause someone to have trouble knowing what is real). During a review of Resident 9's Minimum Data Set (MDS – a comprehensive resident assessment tool), dated 12/4/2025, the MDS indicated an active diagnosis of diabetes. During a review of Resident 9's care plan, dated 12/8/2025, the care plan indicated, Resident is at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. During a review of Resident 9's physician's orders, dated 11/4/2025, the orders indicated Resident 9 should get 6 units of lispro (a fast-acting insulin medication used to treat diabetes by controlling blood sugar) before meals and at the bedtime for diabetes if Resident 9's blood sugar is between 200-249 mg/dL (milligrams per deciliter, a unit of measurement). During a review of Resident 9's medication administration record (MAR), dated February 2026, the MAR indicated on 2/16/2026 at 6:30 a.m. Resident 9's blood sugar was 243 mg/dL and lispro was not given to the Resident 9. During a review of Resident 46's admission record, the admission record indicated Resident 46 was initially admitted to facility on 12/30/2024 and readmitted on [DATE] with the diagnoses but not limited to hypertension (high blood pressure), hypertensive heart failure (when long-term high blood pressure forces the heart to work too hard), end stage renal disease (a condition a person's kidney is not working well), and dialysis (a medical treatment that helps clean a person's blood when their kidneys are not working well) During a review of Resident 46's MDS, dated [DATE], the MDS indicated an active diagnosis of hypertension. During a review of Resident 46's physician's orders, dated 11/19/2025, the orders indicated clonidine (a medication to help lower blood pressure) 0.2 mg (milligrams, unit of measurement) tablet to be given every 6 hours as needed for high blood pressure, if systolic (the top number in a blood pressure reading) is greater than 160 mmHg (millimeters of mercury, a unit of measurement). During a review of Resident 46's care plan, dated 1/12/2026, the care plan intervention indicated the Resident will be administered prn (given as needed) clonidine 0.2 mg for elevated (high) blood pressure. During a review of Resident 46's MAR, dated February 2026, the MAR indicated: On 2/2/2026 at 6:00 a.m. Resident 46's blood pressure was 197/112 mmHg and clonidine was not given to the resident. On 2/21/2026 at 6:00 a.m. Resident 46's blood pressure was 168/88 mmHg and clonidine was not given to the resident. During a review of Resident 56's admission record, the admission record indicated Resident 56 was initially admitted to facility on 2/24/2018 and readmitted on [DATE] with the diagnoses but not limited to diabetes mellitus (a condition where a person's body has trouble controlling the amount of sugar in their blood), seizures (a condition a person to lose control of their body for a short period of time), depression (a mental health condition that makes a person feel very sad, empty, or hopeless for a long time), anxiety disorder (a condition where a person feels very worried, nervous, or scared much more often than most people). During a review of Resident 56's MDS, dated [DATE], the MDS indicated an active diagnosis of diabetes. During a review of Resident 56's physician order, dated 7/29/2025, the order indicated Resident 56 should get 20 units of Lantus (a long-acting insulin medication used to treat diabetes by controlling blood sugar) two times a day for diabetes, hold it if blood sugar less than 120 mg/dL. During a review of Resident 56's physician order, dated 7/29/2025, the order indicated Resident 56 should not get any HumaLOG (a rapid acting insulin medication used to treat diabetes by controlling blood sugar) injection before meals if Resident 56's blood sugar is between 50 -149 mg/dL. During a review of Resident 56's MAR, dated Feburary 2026, the MAR indicated: On 2/7/2026 at 6:00 a.m. Resident 56's blood sugar was 110 mg/dL and 20 units of Lantus was given. On 2/7/2026 at 6:30 a.m. Resident 56's blood sugar was 110 mg/dL, and 2 units of HumaLOG was given. On 2/13/2026 at 6:00 a.m. Resident 56's blood sugar was 114 mg/dL and 20 units of Lantus was given. On 2/23/2026 at 6:00 a.m. Resident 56's blood sugar was 118 mg/dL and 20 units of Lantus was given. During an interview on 2/24/2026 at 8:35 a.m. with RNS (Registered Nurse Supervisor) 1, RNS 1 stated: For Resident 9: the nurse did not follow physician's order on date 2/16/2026. Resident 9's blood sugar level indicated insulin injection needed, nurse failed to give medication, it could cause harm to Resident 9. For Resident 46: the nurse did not follow physician's order on date 2/2/2026 and 2/21/2026. Resident 46's blood pressure level indicated medication should be given, nurse failed to give medication, it could cause stroke to Resident 46. For Resident 56: the nurse did not follow physician's order on date 2/7/2026, 2/13/2026 and 2/23/2026. Resident 56's blood sugar level did not indicated any insulin injection, nurse given insulin to Resident 56 will further lower the Resident 56's blood sugar and cause hypoglycemia (low blood sugar) to Resident 56. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 03/2023, the P&P indicated medications are to be administered in accordance with prescriber orders. B. During a review of Resident 89's admission Record, the admission Record indicated the facility admitted Resident 89 on 1/18/2017, and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any disease, damage, or malfunction of the brain that alters its structure or function) and Alzheimer's disease (a progressive, irreversible brain disorder that destroys memory and thinking skills over time). The admission Record indicated Resident 89's Family Member (FM)1 was considered an authorized responsible party and a Power of Attorney ([POA]- a legal document that lets you appoint a trusted person to manage your finances, property, or medical care if you become unable to do so) for Resident 89. During a review of Resident 89's Physician Orders for Life-Sustaining Treatment (POLST-a medical form that tells doctors and nurses what kind of treatment a patient wants or does not want, especially in a serious illness or emergency), dated 2/12/2026, the POLST indicated FM 1 signed consent for do not attempt resuscitation (DNR) if patient has no pulse and is not breathing. During a review of Resident 89's admission History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 89 was forgetful and confused. During a review of Resident 89's MDS, dated [DATE], the MDS indicated Resident 89's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making were severely impaired. The MDS indicated Resident 89 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering dressings, and personal hygiene. During a telephone interview on 2/24/2026 at 9:05 a.m., with FM 1, FM 1 stated Resident 1 had been declining over the past 10 years, and FM 1 did not want to see Resident 89 suffer. FM 1 stated the family had asked the facility about the possibility of hospice care, the facility has not followed up on the request. During a telephone interview on 02/24/2026 at 9:46 a.m. with FM 2 stated FM 1 had asked the facility about hospice care for Resident 89 on multiple occasions. FM 2 stated the most recent request was on 2/19/2026 while FM 1 and FM 2 were visiting Resident 89. FM 2 stated the facility had not followed up on the request. During a concurrent interview and record review on 2/24/2026 at 9:50 a.m., with the Social Services Director (SSD), Resident 89's Progress Notes, for the month of February 2026, were reviewed. The SSD stated FM 1 expressed their wish for hospice care for Resident 89 on 2/12/2026 and updated the POLST on the same day. The SSD stated nursing staff were expected to notify the physician to obtain an order for hospice care. The SSD stated 12 days had passed since the request and there was no documentation regarding hospice care in the resident's medical record. The DSD stated the resident and family have the right to request hospice care and their wishes should be respected. During an interview on 2/26/2026 at 9:28 a.m., with the Director of Nursing (DON), the DON stated the facility should follow up on a resident's or resident representative's request for hospice services, as it is the resident's right. The DON stated the facility failed to follow up on the request in this case. During a review of the facility's policy and procedure (P&P) titled, Resident rights, revised February 2021, the P&P indicated resident's rights include communication with and access to people and services, both inside and outside the facility; be informed of, and participate in, his or her care planning and treatment. During a review of the facility's policy and procedure (P&P) titled Hospice Program, revised March 2023, the P&P indicated Upon admission and periodically during their stay, residents are informed of the availability of hospice services coordinated through the facility.

Based on observation, interview, and record review, the facility failed to implement infection control measures by failing to:A. Ensure a visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for Resident 35 who was on Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism(MDRO) spread where direct contact is likely].B. Ensure padded side rails that were wrapped with porous (having minute spaces or holes through which liquid or air may pass) foams were disinfected properly for Resident 59.C. Prevent spread of infection for Resident 37 when yankauer (a rigid, commonly disposable oral suctioning instrument) was observed on the floor. ([NAME])D. Ensure one Certified Nurse Assistant (CNA) performs hand hygiene when she goes from one resident's room to another resident's room. ([NAME])This failure had the potential to result in compromised infection control measures to prevent the spread of infection among residents, staff, and visitors.Findings: A. During a review of Resident 35's admission record, the admission record indicated Resident 35 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with sepsis (a life-threatening blood infection), Extended Spectrum Beta Lactamase infection (infection that caused by bacteria resistant to many common antibiotics), and cellulitis (a skin infection that causes swelling and redness)of left lower extremities. During a review of Resident 35's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 35 was able to make needs known and Resident 35's family member was the power of Attorney (POA- a legally appointed agent who has authority to act on behalf of the resident ) to make medical decisions. During a review of Resident 35's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 35 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, bed mobility, maximal assistance (Helper does more than half the effort) from one staff for dressing, shower, toilet hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from one staff for eating. During a review of Resident 35's Order Summary Report (OSR), dated [DATE], the OSR indicated, place Enhanced Barrier Precaution Colonized ESBL was ordered on [DATE]. During a review of Resident 35's Care Plan Report (CPR) titled, Enhanced Barrier Precaution: High risk for infection and history of colonization with ESBL, revised [DATE], the CPR Goal indicated, reduce risk for active infection daily for three months. The CPR Interventions indicated, post signage for EBP and provide gloves, gowns, and masks. During a concurrent observation and interview on [DATE], at 10:14 a.m., with Resident 35's Family Member (FM) 1 in Resident 35's room, FM 1 was at the bedside and did not wear any PPE such as gloves, mask, and gowns. FM 1 was holding Resident 35's hands and stroking Resident 35's hair. FM 1 stated, he did not see EBP signage (signage informing persons entering the room to wear PPE to prevent exposure to an infection) at the entrance and did not realize the EBP signage was on the wall. FM 1 stated, the facility staff did not inform him of the importance of wearing PPE. During an interview on [DATE], at 10:20 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 35's room, LVN 2 stated, she should have educated FM 1 regarding wearing PPE in EBP room. LVN 2 stated, there was EBP signage in the room on the wall above the head of Resident 35's bed, but there was no signage outside of the room. LVN 2 stated, the staff forgot to wear PPE. LVN 2 stated, all visitors and the staff should wear PPE to prevent infection from spreading. During an interview on [DATE], at 10:18 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated, the staff and visitors should wear mask, gown, and gloves before performing high contact activities such as bathing, hygiene care, changing, transferring, and touching to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) when they were caring for the residents who were on EBP. The IPN stated, the staff should have provided education to visitors and asked them to wear PPE as well. During an interview on [DATE], at 10:44 a.m., with the Director of Nursing (DON), the DON stated, PPE should be worn correctly according to different types of isolation. The DON stated, Resident 35 met the criteria for EBP due to history of colonization (the presence, growth, and multiplication of microorganisms [bacteria, fungi, viruses] on or in a host) of high risk infection such as ESBL and sepsis which was invasive line and EBP required to wear mask, gown, and gloves before performing high contact cares that required touching the residents. The DON stated, the staff and visitors must wear proper PPE to protect themselves and vulnerable residents. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated [DATE], the P&P indicated, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity . 12. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. During a review of the facility's P&P titled, Personal Protective Equipment, revised 10/2018, the P&P indicated, Policy Interpretation and Implementation: 4. PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed . 7. Visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge. B. During a review of Resident 59's admission record, the admission record indicated Resident 59 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and urinary tract infection (UTI- an infection in the bladder/urinary tract) During a review of Resident 59's H&P, dated [DATE], the H&P indicated, Resident 59 was able to make decisions for activities of daily living. During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, dressing, and maximal assistance (Helper does more than half the effort) from one staff for shower, bed mobility, eating. During a review of Resident 59's OSR, dated [DATE], the OSR indicated, padded siderails while in bed for safety secondary to seizure disorder was ordered on [DATE]. During a review of Resident 59's CPR titled, Seizure Disorder: at risk for injury secondary to seizure activity, revised [DATE], the CPR Goal indicated, Resident 59 will have no injury until target date of [DATE]. The CPR Interventions indicated, provide padded siderails. During an observation on [DATE], at 11:36 a.m., in Resident 59's room, Resident 59's side rails were wrapped with porous foam and electrical tape (a pressure-sensitive and non-conductive tape). During a concurrent observation and interview on [DATE], at 10:11 a.m., with Housekeeping Staff (HKS) 1, HKS 1 was cleaning Resident 59's side rails with a sanitizer. HKS 1 stated, she cleaned all resident's equipment including the side rail foam with the sanitizer. HKS 1 stated, she did not realize that the sanitizer manufacturer's guidelines indicated that it could not be used to clean porous surfaces. During an interview on [DATE], at 10:14 a.m., with the IPN, the IPN stated, that the manufacturer's instructions on the sanitizer indicated it was to be used on hard, nonporous surfaces. The IPN stated using the sanitizer on the porous foam wrapped on the bed side rails was not appropriate because they were porous and could cause the surface to not be cleaned properly and also break down the foam. IPN stated, this practice would place vulnerable residents at risk for infection. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised 6/2011, the P&P indicated, General Guidelines: 5. Manufacturers' instructions will be followed for proper use of disinfecting. During a review of the Manufacturer's Guidelines for the sanitizer, undated, the Manufacturer's Guideline indicated, the sanitizer should be used for disinfection of hard and non-porous surfaces. During a review of Resident 37's admission Record (face sheet), the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of gastrostomy tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and hypertension ([HTN], high blood pressure). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 37 was rarely/never understood so the brief interview for mental status cannot be conducted. The MDS indicated Resident 37 was dependent (helper does all the effort to complete the activity) on self-care abilities such as hygiene, showers, and dressing. The MDS indicated Resident 37 was dependent on mobility such as turns and transfers. During an observation on [DATE] at 11:16 a.m. in Resident 37's room, Resident 37 was resting in bed with eyes closed. The bedside dresser near Resident 37's bed had a suctioning machine (a medical device that uses negative pressure to remove fluids, mucus, or obstruction from a patient's airway or surgical site), the canister (a medical receptacle used with suction devices to collect bodily fluids and waste during procedures, facilitating safe disposal and infection control), and the tubing with the yankauer device attached to the canister. The yankauer device was on the floor. During a concurrent observation and interview on [DATE] at 12:47 p.m., with Certified Nursing Assistant (CNA) 2 in Resident 37's room, the suctioning machine, the canister and the tubing with the yankauer device were at the bedside on top of the bedside dresser. CNA 2 was presented with a photograph showing the suctioning yankauer device lying on the floor. CNA 2 stated yankauer device should be in a bag and dated with the date of when the yankauer device was placed at the bedside or opened to use on the resident. CNA 2 stated if the staff used the yankauer device that was on the floor, on the resident, that resident can get an infection. CNA 2 stated if staff see the yankauer device not in a bag and not dated, the Licensed Vocational Nurse (LVN) should be notified. CNA 2 stated the yankauer device should be in a bag like any other oxygen related supplies such as nasal cannulas (a lightweight, flexible tube with two prongs inserted into the nose to deliver oxygen for breathing difficulties), or breathing mask (also known as a nebulizer mask designed to deliver medication directly to the lungs through the nose and mouth). During an interview on [DATE] at 2:36 p.m., with LVN 3, LVN 3 stated the yankauer device, nasal cannula tubing, or any breathing treatment supplies are to be placed in a plastic bag with the date it was opened or replaced. LVN 3 was presented with a photograph showing the yankauer device lying on the floor. LVN 3 stated the yankauer device lying on the floor was an infection control issue, it should be changed out and put into the bag. LVN 3 stated the yankauer device was supposed to be dated as well with the date opened or used on the resident. LVN 3 stated the resident was at high risk of infection if the yankauer device was used on him after it had been lying on the floor. During an interview on [DATE] at 11:44 a.m., with the DON, the DON stated yankauer device should have been in a bag and placed on top of the bedside dresser. The DON stated the yankauer device should be changed out if found on the ground. The DON stated the risk for residents using a yankauer device that was lying on the floor was the potential for infection. The DON stated residents can get an infection if using a dirty yankauer device to suction the resident's mouth. During a review of the facility's P&Ptitled Policies and Procedures - Infection Prevention and Control, revised 12/2023, indicated adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. D. During a concurrent observation and interview on [DATE] at 11:38 a.m., in the hallway, CNA 1 exited room [ROOM NUMBER], entered and exited room [ROOM NUMBER] without performing hand hygiene. CNA 1 stated she did not wash her hands after leaving room [ROOM NUMBER]. She stated she should perform hand hygiene after leaving room [ROOM NUMBER] and before entering and exiting room [ROOM NUMBER]. During an interview on [DATE] at 9:59 a.m. with Assistant Director of Nursing (ADON), the ADON stated any staff entering and exiting patient's room, they should perform hand hygiene. ADON stated that if a CNA fails to perform hand hygiene, it increases the risk of spreading infection among residents. During a review facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene dated 10/2023, the P&P indicated hand hygiene should be perform before and after touching a resident.

Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 9, 6, and 136) received appropriate services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) and mobility by failing to:1a. For Resident 9, put on right and left ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) during Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for no more than three hours, as ordered by a physician.1b. Indicate objective ROM measurements for impaired joints on Resident 9's Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 11/4/2025.1c. Complete an annual Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) joint mobility screen for Resident 9 in 6/2025.2a. Indicate objective ROM measurements for impaired joints on Resident 6's OT Evaluation dated 2/20/2026.2b. Complete an admission OT joint mobility screen for Resident 6 in 7/2025.3. Complete an admission OT joint mobility screen for Resident 136 in 7/2025.These deficient practices had the potential to cause injury and pain due to prolonged wearing of AFOs for Resident 9, and prevent accurate monitoring and provision of appropriate care for decline in range of motion and mobility for Residents 9, 6, and 136.Findings:1. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly) with diabetic chronic kidney disease (loss of ability to remove waste and balance fluids) and contracture (loss of motion of a joint) of left elbow and right elbow. During a review of Resident 9's Minimum Data Set (MDS, resident assessment tool) dated 12/4/2025, the MDS indicated Resident 9 was severely impaired for cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 9 had functional limitations in ROM impairments on both sides of the upper extremities (BUE, shoulder, elbow, wrist/hand) and both sides of the lower extremities (BLE, hip, knee, ankle/foot). The MDS indicated Resident 9 required dependent assistance with eating, dressing, hygiene, bathing, and chair to bed transfers. During a review of Resident 9's Care Plan Report (CP) initiated 7/25/2024 and revised on 2/13/2025, the CP indicated Resident 9 was at risk for decrease in ROM and strength to BLE due to immobility. The CP goal indicated RNA will provide splints and perform passive range of motion (PROM, movement at a given joint with full assistance from another person) to BLE without adverse effects and communicate new findings or need for reassessment/modification to rehab team if necessary. The CP intervention indicated to refer to RNA program from rehab services. During a review of Resident 9's CP initiated on 6/6/2024 and revised on 2/13/2025, the CP indicated Resident 9 had alteration in joint mobility as evidenced by limitations in both arms and both feet. The CP goal indicated Resident 9 will minimize the risk for further loss of ROM daily. The CP interventions indicated initial, quarterly, annual assessment of joint mobility or as needed, monitor for pain or stiffness, and provide ROM exercises if ordered. During a review of Resident 9's Order Summary Report dated 2/25/2026, the Order Summary Report indicated the following orders:-dated 1/23/2026 for RNA for PROM of BUE followed by both elbow splints and both resting hand splints for three to four hours or as tolerated five times a week or as tolerated.-dated 1/23/2026 for RNA to apply both AFO for three hours a day, five times a week or as tolerated.-dated 1/23/2026 for RNA to apply both knee splints for fours a day, five times a week or as tolerated.-dated 1/23/2026 for RNA to perform PROM exercises to both lower extremities five times a week or as tolerated. During an observation on 2/23/2026 at 9:39 a.m., Resident 9 was lying in bed and could not speak. Resident 9's elbows were bent more than halfway, both wrists were straight, and both hands were in a fisted position, and both ankles were pointed away from Resident 9's body. 1a. During a review of Resident 9's January 2026 RNA Documentation Survey Report, the RNA DSR indicated RNA put on left and/or right AFO for more than three hours a day on the following days: 1/26/2026, 1/29/2026, 1/30/2026. During a review of Resident 9's February 2026 RNA Documentation Survey Report, the RNA DSR indicated RNA put on left and/or right AFO for more than three hours a day on the following days: 2/3/2026, 2/4/2026, 2/5/2026, 2/9/2026, 2/10/2026, 2/11/2026, 2/16/2026, 2/17/2026, and 2/19/2026. During an interview and record review on 2/26/2026 at 8:48 a.m., Restorative Nursing Aide (RNA 1) stated Resident 9's RNA treatment orders were for PROM exercises on both UE and both LE and splinting on both elbows, both wrist/hands, both knees, and both ankle/feet. RNA 1 reviewed 1/2026 and 2/2026 RNA Documentation Survey Report and confirmed RNAs put on left and/or right AFOs for longer than three hours during RNA treatment. RNA 1 stated if the RNA order was to put on left and right AFOs for three hours, then RNA should take off the splints at three hours, because RNA need to follow the RNA orders. During an interview and record review on 2/26/2026 at 8:58 a.m., Physical Therapist (PT 1) stated PTs use splints to help prevent further contractures from developing. PT 1 stated during PT treatment, PT assessed how long a resident could tolerate a splint safely and slowly increase the wear time for a splint. PT 1 stated Resident 9's RNA order was to put on left and right ankle AFOs for three hours and three hours should be the maximum time Resident 9 should wear the AFOs. PT 1 stated if Resident 9 was wearing the AFOs for longer than three hours, then the AFOs could cause Resident 9 pain or cause skin integrity issues. During an interview on 2/26/2026 at 11:24 a.m., the Director of Nursing (DON) stated the RNA program helped to maintain a resident's joint mobility and current functional status. DON stated an RNA program was created by therapists for each resident and RNAs were to follow the RNA orders. DON stated RNAs could not change anything from the RNA order and if the RNA could not complete the RNA order for any reason, then RNAs should report it to the charge nurse and inform therapy. During a review of the facility's undated policies and procedures (P&P), titled, Joint Mobility Contracture Management Program, the P&P indicated RNA responsibilities included apply splint daily according to instructions. 1b. During a review of Resident 9's OT Evaluation and Plan of Treatment dated 11/4/2025, the OT Evaluation indicated Resident 9 had impaired ROM in both shoulders, elbows, wrists, hands, thumbs, index fingers, middle fingers, ring fingers, and little fingers. The OT Evaluation did not indicate an objective measurement of the ROM in both elbows, wrists, thumbs, index fingers, middle fingers, ring fingers, or little fingers. During an interview and record review on 2/26/2026 at 9:11 a.m., Occupational Therapist (OT 1) stated OTs evaluate and assess ROM during every OT evaluation and if the ROM at a certain joint was impaired, the OT should indicate the remaining objective ROM measurements in that specific impaired joint. OT 1 stated OTs needed to document and evaluate the impaired ROM, because it was the objective measurement and how OTs would know if the ROM at the joint improved or worsened. OT 1 stated the goal was to improve, maintain ROM. OT 1 reviewed Resident 9's OT Evaluation dated 11/4/2025 and stated the objective ROM measurements were not documented for Resident 9's elbows, wrists, thumbs, index fingers, middle fingers, ring fingers, or little fingers. OT 1 stated based on the OT Evaluation, OT 1 could not know what Resident 9's ROM was in the impaired joints. OT 1 stated it was important to capture the objective data of ROM measurements, because therapists were the only profession that was able to measure ROM. OT 1 stated it was important to measure ROM to keep track of a resident's ROM and to help create goals in therapy. During a review of the facility's undated Occupational Therapist Job Description, the OT Job Description indicated job responsibilities included provide comprehensive evaluations using standardized or non-standardized tests, document results, and interpret findings. During a review of the facility P&P revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. 1c. During a review of Resident 9's Annual Joint Mobility Screen (JMS) - Upper Extremities dated 6/5/2025, the JMS indicated Resident 9 had minimal ROM loss in both wrists, right hand/fingers, and both elbows. The JMS indicated Resident 9 had moderate ROM loss in left hand/fingers and severe ROM loss in both shoulders. During a review of Resident 9's admission JMS - Upper Extremities (JMS) dated 11/4/2025, the JMS indicated Resident 9 had minimal ROM loss in both wrists, right hand/fingers, and both elbows. The JMS indicated Resident 9 had moderate ROM loss in left hand/fingers and severe ROM loss in both shoulders. During a review of Resident 9's readmission JMS - Lower Extremities dated 11/4/2025, the JMS indicated Resident 9 had severe ROM loss in both knees, both knees, and both ankles. During a review of Resident 9's JMS, there was no Annual JMS - Lower Extremities completed in 6/2025. During a concurrent interview and record review on 2/25/2026 at 2:44 p.m. with the Director of Rehabilitation (DOR), Resident 9's JMS were reviewed. DOR stated PT and OT completed JMS on admission, annually, and as needed such as a change in condition. DOR reviewed Resident 9's JMS and stated an annual JMS for lower extremities was not completed in June 2025. DOR stated it was important for PT and OT to complete JMS because the JMS provided a baseline for ROM for residents when they were admitted to the facility and on an annual basis. DOR stated the JMS helped to monitor residents for ROM and if there was any decline, it would be an indication to provide PT and OT if needed. DOR stated if a resident declined in ROM, it could affect the resident's ability to perform ADLs and ambulation. During an interview on 2/26/2026 at 8:58 a.m., the Physical Therapist (PT 1) stated JMS were completed on admission and annually. PT 1 stated therapists checked the integrity of the joints and to monitor if there were any decreases in ROM. PT 1 stated it was important to check and monitor joint ROM, because if the joints were getting tighter and contractures were developing, therapy could address it as soon as possible. PT 1 stated if therapists missed a JMS, then a resident's joints and ROM get tighter and stiffer. During an interview on 2/26/2026 at 9:11 a.m., the Occupational Therapist (OT 1) stated therapists completed JMS on admission and annually. OT 1 stated therapists completed JMS to get a baseline for ROM on admission or readmission and annually to see if there were any changes. OT 1 stated ROM affected residents functionally so it was important to keep track of a resident's ROM, for example a resident could lose their ability to use their hand if their joints were stiffer and stuck in a fist and a resident's skin integrity could also get worse. During a review of the facility's undated policies and procedures (P&P) titled, Joint Mobility Contracture Management Program, the P&P indicated new admissions are to be screened by the therapy staff for appropriateness for intervention including contracture management. During a review of the facility's Memorandum dated 11/3/2025, titled Rehab Screening and Joint Mobility Update, the Memorandum indicated the following guidelines reflect the most current rehab screening and joint mobility forms and policy: rehab will complete the joint mobility screening on admission, annually and with change of condition. 2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 6 had functional limitations in ROM impairments on one side of the upper extremity and no impairment on the lower extremities. The MDS indicated Resident 6 required dependent assistance with dressing, hygiene, bathing, and chair to bed transfers. During a review of Resident 6's Care Plan (CP) dated 7/9/2025, the CP indicated Resident 6 was at risk of decreased strength and ROM due to cognition. The CP goal indicated Resident 6 will maintain current level of ROM and strength. During a review of Resident 6's CP initiated 7/3/2024 and revised on 8/6/2025, the CP indicated Resident 6 had self-care deficits. The CP interventions indicated a rehab screen on admission, quarterly and as needed. During an observation on 2/23/2026 at 1:19 p.m., Resident 6 was lying on a geriatric chair (a large, padded chair designed to help persons with limited mobility). Resident 6's left elbow was bent about halfway, the left wrist was straight and fingers were slightly bent. Resident 6's right hand was behind Resident 6's head and Resident 6 was able to move the right arm. 2a. During a review of Resident 6's Occupational Therapy Evaluation and Plan of Treatment dated 2/20/2026, the OT Evaluation indicated Resident 6 had impaired ROM in the left shoulder, elbow, wrist, and hand. The OT Evaluation did not indicate an objective measurement of the ROM in left wrist or left hand. During an interview and record review on 2/26/2026 at 9:11 a.m., Occupational Therapist (OT 1) stated OTs evaluate and assess ROM during every OT evaluation and if the ROM at a certain joint was impaired, the OT should indicate the remaining objective ROM measurements in that specific impaired joint. OT 1 stated OTs needed to document and evaluate the impaired ROM, because it was the objective measurement and how OTs would know if the ROM at the joint improved or worsened. OT 1 stated the goal was to improve, maintain ROM. OT 1 reviewed Resident 6's OT Evaluation dated 2/20/2026 and stated the objective ROM measurements were not documented for Resident 6's left wrist and hand. OT 1 stated based on the OT Evaluation, OT 1 could not know for certain what Resident 6's ROM was in the impaired joints but had to assume what the ROM could be. OT 1 stated it was important to capture the objective data of ROM measurements, because therapists were the only profession that was able to measure ROM. OT 1 stated it was important to measure ROM to keep track of a resident's ROM and to help create goals in therapy. During a review of the facility's undated Occupational Therapist Job Description, the OT Job Description indicated job responsibilities included provide comprehensive evaluations using standardized or non-standardized tests, document results, and interpret findings. During a review of the facility P&P revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. 2b. During a review of Resident 6's readmission JMS - Lower Extremities dated 7/31/2025, the JMS indicated Resident 6 had full range of motion on both hips, knees, and ankles. During a review of Resident 6's JMS, there was no readmission JMS - Upper Extremities completed in 7/2025. During a concurrent interview and record review on 2/25/2026 at 2:44 p.m. with the Director of Rehabilitation (DOR), Resident 6's JMS were reviewed. DOR stated PT and OT completed JMS on admission, annually, and as needed such as a change in condition. DOR stated Resident 6 readmitted to the facility on [DATE] and PT/OT should complete a JMS due to the readmission. DOR reviewed Resident 6's JMS and stated a readmission JMS for upper extremities was not completed. DOR stated it was important for PT and OT to complete JMS because the JMS provided a baseline for ROM for residents when they were admitted to the facility and on an annual basis. DOR stated the JMS helped to monitor residents for ROM and if there was any decline, it would be an indication to provide PT and OT if needed. If residents decline with ROM, it could affect the resident's ability to perform ADLs and ambulation. During an interview on 2/26/2026 at 8:58 a.m., the Physical Therapist (PT 1) stated JMS were completed on admission and annually. PT 1 stated therapists checked the integrity of the joints and to monitor if there were any decreases in ROM. PT 1 stated it was important to check and monitor joint ROM, because if the joints were getting tighter and contractures were developing, therapy could address it as soon as possible. PT 1 stated if therapists missed a JMS, then a resident's joints and ROM get tighter and stiffer. During an interview on 2/26/2026 at 9:11 a.m., the Occupational Therapist (OT 1) stated therapists completed JMS on admission and annually. OT 1 stated therapists completed JMS to get a baseline for ROM on admission or readmission and annually to see if there were any changes. OT 1 stated ROM affected residents functionally so it was important to keep track of a resident's ROM, for example a resident could lose their ability to use their hand if their joints were stiffer and stuck in a fist and a resident's skin integrity could also get worse. During a review of the facility's undated policies and procedures (P&P) titled, Joint Mobility Contracture Management Program, the P&P indicated new admissions are to be screened by the therapy staff for appropriateness for intervention including contracture management. During a review of the facility's Memorandum dated 11/3/2025, titled Rehab Screening and Joint Mobility Update, the Memorandum indicated the following guidelines reflect the most current rehab screening and joint mobility forms and policy: rehab will complete the joint mobility screening on admission, annually and with change of condition. 3. During a review of Resident 136's admission Record, the admission Record indicated Resident 136 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to encephalopathy (any damage or disease that affects the brain), (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side, and contracture (loss of motion of a joint) left elbow, left hand, and left knee. During a review of Resident 136's MDS dated [DATE], the MDS indicated Resident 136 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 136 had functional limitations in ROM impairments on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 136 required moderate assistance with eating and dependent assistance with dressing, hygiene, bathing, and chair to bed transfers. During a review of Resident 136's Care Plan Report (CP), the CP initiated 10/16/2025 indicated Resident 136 was at risk for decline in ROM status of both lower extremities and left upper extremities. The CP goal indicated to minimize complications related to decreased mobility or contractures through appropriate through the next assessment. The CP intervention indicated restorative nursing referral by rehab, RNA to perform PROM exercises to both lower extremities once a day, five times a week or as tolerated. During a review of Resident 136's readmission JMS - Lower Extremities dated 7/25/2025, the JMS indicated Resident 136 had minimal ROM loss in right hip, moderate ROM loss in right knee, left ankle, and severe ROM loss in left hip, left knee, and right ankle. During a review of Resident 136's Annual JMS - Lower Extremities dated 12/2/2025, the JMS indicated Resident 136 had minimal ROM loss in right hip, moderate ROM loss in right knee, left ankle, and severe ROM loss in left hip, left knee, and right ankle. During a review of Resident 136's Annual JMS - Upper Extremities (JMS) dated 12/2/2025, the JMS indicated Resident 136 had full range of motion in right wrist, hand/fingers, elbow, and shoulder. The JMS indicated Resident 136 had full severe ROM loss in left wrist, hand/fingers, elbow, and shoulder. During a review of Resident 136's JMS, there was no readmission JMS - Upper Extremities completed in July 2025. During an observation and interview on 2/23/2026 at 1:53 p.m., Resident 136 was lying in bed and stated she had a stroke and could not move her left arm or leg. Resident 136's left arm was bent, the left wrist was straight, and the left hand was in a fisted position. During a concurrent interview and record review on 2/25/2026 at 2:44 p.m. with the Director of Rehabilitation (DOR), Resident 136's JMS were reviewed. DOR stated PT and OT completed JMS on admission, annually, and as needed such as a change in condition. DOR stated Resident 136 readmitted to the facility on [DATE] and PT/OT should complete a JMS due to the readmission. DOR reviewed Resident 136's JMS and stated a readmission JMS for upper extremities was not completed. DOR stated it was important for PT and OT to complete JMS because the JMS provided a baseline for ROM for residents when they admitted to the facility and on an annual basis. DOR stated the JMS helped to monitor residents for ROM and if there was any decline, it would be an indication to provide PT and OT if needed. If residents decline with ROM, it could affect the resident's ability to perform ADLs and ambulation. During an interview on 2/26/2026 at 8:58 a.m., the Physical Therapist (PT 1) stated JMS were completed on admission and annually. PT 1 stated therapists checked the integrity of the joints and to monitor if there were any decreases in ROM. PT 1 stated it was important to check and monitor joint ROM, because if the joints were getting tighter and contractures were developing, therapy could address it as soon as possible. PT 1 stated if therapists missed a JMS, then a resident's joints and ROM get tighter and stiffer. During an interview on 2/26/2026 at 9:11 a.m., the Occupational Therapist (OT 1) stated therapists completed JMS on admission and annually. OT 1 stated therapists completed JMS to get a baseline for ROM on admission or readmission and annually to see if there were any changes. OT 1 stated ROM affected residents functionally so it was important to keep track of a resident's ROM, such as a resident could lose their ability to use their hand if their joints were stiffer and stuck in a fist, the skin integrity could also get worse. During a review of the facility's undated policies and procedures (P&P) titled, Joint Mobility Contracture Management Program, the P&P indicated new admissions are to be screened by the therapy staff for appropriateness for intervention including contracture management. During a review of the facility's Memorandum dated 11/3/2025, titled Rehab Screening and Joint Mobility Update, the Memorandum indicated the following guidelines reflect the most current rehab screening and joint mobility forms and policy: rehab will complete the joint mobility screening on admission, annually and with change of condition.

Based on observation, interview, and record review, the facility failed to ensure safe and appropriate management of enteral tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) and hydration bag for two of five sampled residents (Resident 11 and 129) by failing to:Ensure Resident 11's hydration bag did not run for more than 24 hours against the physician's order.Ensure Resident 129's tube feeding was labeled including date and time the formula was hung/administered.These deficient practices had the potential to increase the risk of infection prevention and compromised resident health.a. During a review of Resident 11's admission Record, the admission Record indicated the facility admitted Resident 11 on 7/25/2024, and readmitted on [DATE] with diagnoses including attention to gastrostomy (a small, safe surgical opening made through the belly skin directly into the stomach) and dysphagia (having trouble swallowing food or liquids, making them pass slowly or painfully from the mouth to the stomach). During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 11's cognition (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 11 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering, and personal hygiene. During a review of Resident 11's Order Summary Report, orders as of 2/24/2026, the Order Summary Report indicated the following enteral tube feeding orders: Starting 5/2/2025, change open bag system and Gastrostomy Tube Feeding (GTF-administration of nutrition, fluids, or medication directly into the stomach through a surgically placed feeding tube) every night shift.Starting 5/2/2025, change hydration bag (a container, similar to a plastic pouch or infusion bags, used to deliver water or fluids into the stomach through a feeding tube) every 24 hours.Starting 7/14/2025, feeding Jevity 1.5 (calorically dense, fiber-fortified therapeutic nutrition) at 55 milliliter (ml- a unit of measure for volume) per hour for 20 hours via (through) pump to provide 1100 cubic centimeter (cc- a unit of measure for volume)/1650 kilocalorie (kcal-a unit of measure for energy) per day.During a review of Resident 11's care plan titled 'Resident is on Gastrostomy Tube Feeding', revised 1/21/2026, the care plan interventions included to administer enteral feedings as ordered, and change tubing's per policy or as ordered.During an observation on 2/23/2026 at 10:15 a.m., in Resident 11's room, observed a hydration bag connected to the resident without a label indicating the date and time of initiation. There was also a tube feeding bag labeled with the date 2/22/2026 and time 2:30 a.m. The hydration bag and tube feeding were connected to the resident.During a concurrent interview and record review on 2/24/2026 at 2:04 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 11's Order Summary Report as of 2/24/2026, were reviewed. LVN 1 stated staff should change Resident 11's tube feeding daily according to the physician's order. LVN 1 confirmed staff (unknown) initiated Resident 11's feeding on 2/22/2026 at 2:30 a.m., and the tube feeding bag remained running for more than 24 hours at the time of her (LVN 1) rounding on 2/23/2026 at 8 a.m. LVN 1 confirmed staff (unknown) had not labeled the hydration bag.b. During a review of Resident 129's admission Record, the admission Record indicated the facility admitted Resident 129 on 10/5/2023, and readmitted on [DATE] with diagnoses including attention to gastrostomy and dysphagia. During a review of Resident 129's Minimum Data Set (MDS- a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 129 Cognitive (functions your brain uses to think, pay attention, process information, and remember things) Skills for Daily Decision Making were severely impaired. The MDS indicated Resident 129 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, showering, dressings, putting and taking off/taking off, and personal hygiene. During a review of Resident 129's Order Summary Report, orders as of 2/24/2026, the Order Summary Report indicated the following enteral feeding order:Starting 10/25/2024, change hydration bag every 24 hours.Starting 4/22/2025, feed Jevity 1.5 at 60cc per hour for 20 hours via pump to provide 1200ml/1800kcal per day.During a review of Resident 129's care plan titled, 'Resident is on Gastrostomy Tube feeding with adequate water flushing, revised 12/16/2025, the care plan's intervention included to change tubing per policy or as ordered, and administer enteral feedings as ordered.During an observation on 2/23/2026 at 10:49 a.m., in Resident 129's room, observed a tube feeding and an empty hydration bag connected to the resident. Both bags lacked labels indicating the resident's name, the date and time the formula was hung/administered, and staff initials.During a concurrent interview and record review on 2/24/2026 at 2:04 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 129's Order Summary Report, orders as of 2/24/2026, were reviewed. LVN 1 stated Resident 129's Order Summary Report indicated staff should change Resident 129's hydration bag daily per the physician's order. LVN 1 stated the tube feeding and hydration bag connected to Resident 129, which was observed on 2/23/2026 at 10:49 a.m., were not labeled. LVN 1 stated, without labels, LVN 1 could not determine when the tube feeding, or hydration bag was initiated. LVN 2 stated staff should administer tube feeding and hydration according to the physician's order and label the tube feeding and hydration bag with the resident's name, feeding rate, and the date and time of initiation. LVN 1 explained proper labeling ensures the feeding is administered as prescribed, prevents infection, maintains formular freshness, and ensures the feeding has not expired for the resident's safety.During an interview on 2/26/2026 at 9:28 a.m., with the Director of Nursing (DON), the DON stated staff must follow the physician's order and the resident's care plan when providing tube feeding care and must verify the order with the physician if any concerns arise, in accordance with the standard of care. The DON stated staff must label and date on the tube feeding and hydration bag when initiating a new bag.During a review of the facility's policy and procedure (P&P) titled Enteral Tube Feeding via Continuous Pump, revied November 2018, the P&P indicated, staff should label on the formula: document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.

Based on interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of five sampled residents (Resident 2 and Resident 8) as evidence by:A. Failing to initiate conservatorship [ a court-ordered arrangement where a judge appoints a responsible person or organization (conservator) to manage the financial affairs and/or daily care of an adult (conservatee) who is unable to do so themselves due to physical or mental limitations] or public guardian (a court-appointed official or agency that acts as a conservator for individuals unable to care for themselves or manage their finances due to age, illness, or incapacity) to protect Resident 2 who had no mental capacity (ability) to make decisions.B. Failing to intervene and ensure Resident 8 received social security checks when public guardian was unable to provide it since 10/2025.This failure had the potential to result in delay in the delivery of care and services.Findings:A. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities), aphasia (a disorder that makes it difficult to speak) followed by cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 2 had no capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 2 required dependent assistance (Helper does all of the effort) from two or more staff for toilet hygiene, dressing, transfer, maximal assistance (Helper does more than half the effort) from one staff for shower, personal hygiene, and moderate assistance (Helper does less than half the effort) from one staff for bed mobility, eating.During a review of Resident 2's Care Plan Report (CPR) titled, Resident 2 has cognitive deficit and moderately impaired decision making related to dementia, revised on [DATE], the CPR Goal indicated, Resident 2 will be able to maximize decision making capabilities daily by target date of [DATE]. The CPR Interventions indicated, use yes/no questions and encourage choices of care.During a review of Resident 2's Consent for Medical Treatment, dated [DATE], the Consent for Medical Treatment indicated, it was signed by Resident 2.During a review of Resident 2's Physical Restraint Informed Consent, dated [DATE], the Physical Restraint Informed Consent indicated, FM 3 verbally consented via telephone regarding using side rails for safety purposes.During a review of Resident 2's admission Record (Face Sheet), dated [DATE], the admission Record indicated, Resident 2 was the primary decision maker and FM 3 was the emergency contact.During a concurrent interview and record review on [DATE], at 10:40 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 2's Psychotherapeutic Drug (medications designed to treat mental health disorders to improve mood, behavior, and thought patterns) Informed Consent Form, dated [DATE] was reviewed. The Psychotherapeutic Drug Informed Consent Form indicated, it was verbally consented via telephone by Resident 2's Family Member (FM) 3 with two witnesses on [DATE] for Aripiprazole (a medication to treat mental disorder such as schizoaffective disorder) 5 milligram (mg) one tablet two times a day by mouth for schizoaffective disorder manifested by anger outburst. RNS 1 stated Resident 2 was to be self-responsible, but the staff noticed Resident 2's mental capacity had declined. RNS 1 stated, the staff contacted FM 3 for the consent because she was listed as emergency contact. RNS 1 stated, the staff should have identified Resident 2's Responsible Party (RP- the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) before obtaining the consent from FM 3.During an interview on [DATE], at 4:15 p.m., with the Social Service Director (SSD), the SSD stated she was not aware of the situation. The SSD stated there was no discussion during the Interdisciplinary Team (IDT- a regular, structured collaboration among healthcare professionals) meeting. The SSD stated, she would initiate public guardianship or conservatorship to protect Resident 2 if the staff notified her regarding lack of RP. The SSD stated, initiating and applying public guardianship/conservatorship was important to protect Resident 2's rights and interests when Resident 2 lost her capacity to make decisions.During an interview on [DATE], at 10:44 a.m., with the Director of Nursing (DON), the DON stated, the staff and the SSD should have identified FM 3 as her authorized representative prior to having her sign the informed consent for medications and treatment. The DON stated having someone who is not an authorized representative of the resident sign for informed consent increases the risk that Resident 2 may not be able to exercise her right to opt out of treatment.B. During a review of Resident 8's admission record, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities), respiratory failure (not enough oxygen passes from your lungs to the blood), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 8's H&P, dated [DATE], the H&P indicated, Resident 8 was able to make her own medical decisions.During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 required dependent assistance (Helper does all the effort) from two or more staff for bed mobility, transfer, dressing, shower, hygiene, and moderate assistance (Helper does less than half the effort) from one staff for eating.During an interview on [DATE], at 11:46 a.m., with Resident 8 in her room, Resident 8 stated, she had not received her social security check since 11/2025 and she was worried about her bills not getting paid on time.During a concurrent interview and record review on [DATE], at 9:27 a.m., with the Business Office Manager (BOM), Resident 8's Statement for Share of Cost (the amount of money the residents must pay each month towards medical related services, supplies, or equipment), dated from 11/2025 to [DATE] was reviewed. The Statement for Share of Cost indicated Resident 8's total balance due was $3,618 as of [DATE]. The BOM stated, Resident 8 was under Public Guardian (PG) 1 and the facility did not receive Social Security benefit money from PG 1 since 11/2025. The BOM stated, she contacted PG 1 many times, but PG 1 kept telling her that this matter was handled by another department investigating this matter.During an interview on [DATE], at 10:56 a.m., with the SSD, the SSD stated, she was not aware of this issue, and no one informed her regarding not receiving payments since 11/2025. The SSD stated, she would have helped Resident 8 out of Public Guardianship since recent H&P indicated that Resident 8 could make her decisions. The SSD stated, she would have taken her to Social Security Office to correct the problems. The SSD stated, Resident 8 should not go through issues such as this.During a telephone interview on [DATE], at 8:39 a.m., with PG1, PG 1 stated, there were discrepancies regarding mailing address and other personal information. PG 1 stated, Social Security Office was holding Resident 8's benefit checks until the information discrepancies cleared out.During an interview on [DATE], at 10:54 a.m., with the DON, the DON stated, the SSD should be proactive with assisting the residents. The DON stated it was SSD's responsibility to assist the residents with all aspects of their lives. The DON stated, PG 1 was difficult to contact and could not solve this Social Security Benefit issues. The DON stated, the SSD should help Resident 8 to regain her decision-making right and resolve this issue.During a review of the facility's Policy and Procedure (P&P) titled, Job Description: Social Service Designee, dated [DATE], the P&P indicated, ESSENTIAL DUTIES AND RESPONSIBILITIES: Assists in the provision of the medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . Assists residents with financial needs . Conducts in-service programs to educate staff regarding psychosocial issues and patient rights . Must be aware of and understand the needs of the residents.During a review of the facility's Policy and Procedure (P&P) titled, Social Services, revised 9/2021, the P&P indicated, Policy Statement: Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Policy Interpretation and Implementation: The director of social services is a qualified social worker and is responsible for meeting or assisting with the medically related social service needs of residents . 3.The facility staff is able to identify and address factors that have a potentially negative effect on psychosocial functioning of a resident, for example: financial needs or problems.During a review of the facility's Policy and Procedure (P&P) titled, GUARDIANSHIP: REFERRAL, undated, the P&P indicated, PROCEDURE: 1. If a resident does not have capacity and there is no responsible party, family member or interested party with legal authority to make decisions, the Social Worker/Social Service Designee will make a referral to the Public Guardian. 2. The Social Worker/Social Services Designee will document referrals to the Public Guardian.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when:The Dietary Supervisor (DS) was unable to verbalize the International Dysphagia Initiative/Level 4 ([IDDSI] level 4 testing process-cohesive, pudding-like foods and liquids that hold their shape on a spoon, require no chewing, and do not flow easily) diet.Cooks (Cook 1 and [NAME] 2) were unable to verbalize proper thawing of food in the sink.Dietary Aide (DA) 1 unable to verbalize Quaternary Ammonium Compounds (QUAT, a chemical used a disinfectant, sanitizer to kill bacteria and viruses) sanitizer ratio with water. These failures had potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food and drinks that are contaminated with germs or chemicals) for 116 of 129 medically compromised residents who received food from the kitchen.Findings:1.During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus, dated 2/23/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative/Level 4 would include the following foods on the tray:Pureed three (3) bean chili one (1) cup (c, household measurement)Pureed tossed green salad 1/3 cPureed corn bread with green chilis 1/4 cMargarine (pureed with bread)Pudding 1/3 cMilk four (4) ounces (oz, a unit of measurement)During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 2/23/2026 at 1:15 p.m. of the puree diet with the DS and Registered Dietitian (RD), it was observed that the puree Jello had lumps. The DS stated puree foods should be an applesauce-like consistency and smooth to swallow. The DS stated they would know the puree food was in the right consistency by seeing and tasting the food. The DS stated she could not think of any other test they performed to identify the food was in proper texture and consistency. The DS stated she was the one providing in-services to the staff with the RD.During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled IDDSI Level 4: Regular Pureed Diet, dated 3/15/2025, the diet manual indicated, The pureed diet is a regular diet that has been designed for resident who have difficulty chewing and/or swallowing. The texture of the prepared food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in Book #1, under the Food Safety/Miscellaneous Section. All foods are to be prepared in a blender. This diet has texture specifications that must pass IDDSI Level #4 testing requirements. IDDSI Testing Requirements: The finished puree food item must pass IDDSI Level #4 testing requirements (i.e. appearance, fork drip, and spoon tilt tests).During a review of the facility's job description (JD) titled, Job Description: Dietary Supervisor, dated 2019, the JD indicated, Qualifications: Have a thorough knowledge of food service supervision, therapeutic diets, and leadership skills. Responsibilities: Directs the food service operation following the facility and Dietary Policy and Procedure Manuals. (10) Ensures residents receive the proper food items to meet their dietary needs and that food is served at the appropriate temperature for safety and palatability.During a review of the facility's checklist titled, Competency Checklist, dated 2/16/2026, the checklist indicated, DS was able to demonstrate how prepare or assist in meal preparation according to menus and recipes provided. The checklist did not specifically indicate competencies for IDDSI testing methods.2. During an observation on 2/24/2026 at 10:34 a.m. of the preparation sink, it was observed that the dietary staff thawed chicken in the kitchen sink.During an interview on 2/25/2026 at 10:25 a.m. with [NAME] 1, [NAME] 1 stated she was the one thawing the chicken in the sink yesterday and it came from the refrigerator then she thawed it in the sink with running water. [NAME] 1 stated they pull the chicken out from freezer to the refrigerator two (2) days before use which was 2 days ago then thawed it in the preparation sink from 10:00-11:00 am. [NAME] 1 stated she cooked the chicken around 1:00 p.m. to 1:30 p.m. [NAME] 1 stated she did not check the temperature of the chicken during thawing and before cooking and there was no log for it., [NAME] 1 stated she has not attended in-services for thawing of food. During a concurrent observation and interview on 2/25/2026 at 10:34 a.m. of the preparation sink with [NAME] 2, turkey and tilapia was observed thawing under a running water. [NAME] 2 stated the tilapia, and turkey came from the freezer, and it has been out for 45 minutes, and these foods are for today's use.During an interview on 2/25/2026 at 10:35 a.m. with the DS, the DS stated their process of thawing is pulling the food from the freezer and it stayed in the refrigerator for a maximum of three (3) days and thawing in the sink under a room temperature running water. The DS stated the dietary staff feel the meat from the refrigerator if it's thawed all the way and if it's not, they could thaw it in the sink.During an interview on 2/25/2026 at 10:41 a.m. with the RD, the RD stated the dietary staff thaw food the night before from the freezer to the refrigerator then transfer it to the sink with cold water for 1-2 hours before cooking. The RD stated she did not train the dietary staff to log time and temperature during thawing process in the sink.During an interview on 2/25/2026 at 10:43 a.m. with the DS, the DS stated the dietary staff should thaw food in a manner that is safe and the temperature of the food should not go above 40 F as the bacteria could start growing and multiply causing foodborne illnesses.During an interview on 2/25/2026 at 10:52 a.m. with the RD, the RD stated the safest way to thaw is under the refrigerator with a food temperature under 41 F and below. The RD stated the dietary staff should be thawing in the sink under cold running water with a temperature of 70 F or below for a maximum of 2 hours.During a concurrent observation and interview on 2/25/2026 at 11:12 a.m., of the preparation sink with the RD, the DS and [NAME] 2, observed the RD took the temperature of the running water used to thaw the fish. The RD stated the water temperature was at 77 F and it should be below 70 F. [NAME] 2 stated she took the fish out from the refrigerator at 10:00 a.m. and she did not take the temperature because it was still frozen. The temperature of the fish was observed at 69 F. The RD stated the fish was not safe to cook because the water temperature was above 70 F. The RD stated the hot water knob was turned on during the thawing process, that was why the water used for thawing was hot. During a review of the facility's P&P titled, Thawing Food, dated 3/15/2025, the P&P indicated, All food will be thawed in a safe and sanitary manner. (2) Under potable, running water at a temperature 70 F or lower, with sufficient velocity to agitate and float off loose food particles into the overflow. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.13 Except specified in (D) of this section, Time/Temperature control for safety food shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below. (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (4) For a period of time does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11 (A) or (B) to be above 41 for more than 4 hours including (a) the time the food is exposed to the running water and the time needed for preparation for cooking or (b) the time it takes under refrigeration to lower the food temperature to 5 C (41 F).During a review of the facility's JD, titled Dietary [NAME] Job Description, dated and signed by [NAME] 2 on 10/1/2017, the JD indicated, Essential Duties and Responsibilities: Prepares all foods according to the menu and standardized recipes in a safe and sanitary manner.During a review of the facility's checklist titled, titled Dietary Competency Checklist, dated 10/20/2025 and 2/16/2026, the checklist indicated [NAME] 2 was able to demonstrate proper thawing of food.During a review of facility's records titled Record of Inservice Training dated 3/2025 to 1/5/2026, the records indicated there was no training about thawing process.3.During a concurrent observation and interview on 2/24/2026 at 2:35 a.m. with DA 1, DA 1 stated the red bucket contained QUAT sanitizer for sanitizing the cart. DA 1 stated he pours the QUAT sanitizer to cold water in the red bucket with a ratio of five (5) liters of water is to 75 milliliters (ml, a unit of measurement) of QUAT sanitizer.During an interview on 2/24/2026 at 2:50 a.m. with the DS, the DS stated the ratio of QUAT sanitizer to water is four (4) quarts of water is to 7.5 ml based on manufacturer's guidelines. The DS stated using 5 quarts of water to 7.5 ml ratio would be diluted and the solution would not be effective to get 200-400 parts per million (ppm, a unit of concentration) concentration of the sanitizer. The DS stated the sanitizer concentration would be below 200 ppm, and it would not sanitize the surface right, causing foodborne illnesses and viruses to the residents.During a review of the facility's P&P titled Red Bucket (Quaternary Ammonium Sanitizer) Policy, dated 3/15/2025, the P&P indicated, To ensure proper preparation, use, monitoring, and disposal of quaternary ammonium (QUAT) sanitizer used in red sanitizer buckets for food contact surfaces in the kitchen. Red sanitizer buckets containing QUAT solution will be used for wiping cloth storage and sanitizing food contact surfaces during food preparation and service. The solution will be prepared according to manufacturer instructions and maintained at safe and effective concentration (200-400 ppm). Preparation: Red buckets must be clearly labeled SANITIZER. Fill bucket with 1 gallon of water. Add 1/2 -1 tablespoon of Sani-Tech QUAT sanitizer per gallon (per manufacturer instructions. Mix thoroughly.During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24 C (75 F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.During a review of the facility's JD titled Dietary Aide/Dishwasher Job Description, dated and signed by DA 1, the JD indicated Essential Duties and Responsibilities: Follows all policies and procedures regarding sanitation, safety, and fire prevention.During a review of the facility's checklist titled Dietary Infection Prevention Competency Checklist, dated 2/16/2026, the checklist indicated DA 1 was able to demonstrate the ability to identify appropriate ppm and/or bleach but there was no competency on how to mix QUAT sanitizer to water.During a review of facility's records titled Record of Inservice Training dated 3/2025 to 1/5/2026, the records indicated there was no training about mixing QUAT sanitizer ratio to water.

Based on observation, interview, and record review the facility failed to follow the methods that conserved appearance and temperature for lunch when hot food (chili) served on paperwares was not hot, cold foods were not served cold, and tossed green salad was watery.This failure had the potential to result in decrease in food intake to 116 of 129 residents on regular and therapeutic diets, resulting in unplanned weight loss.Findings:During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus dated 2/23/2026, the spreadsheet indicated residents on regular and therapeutic diets would include the following foods on the tray:Three bean chili one (1) cup (c, a household measurement)Tossed green salad 1/2 cSalad dressing 1/2 ounces (oz, a unit of measurement)Cornbread with green chilis 1 pieceCitrus chiffon delight 2x2 1/2 inch 1 pieceMilk 4 ozDuring a test tray process (a process of tasting, temping, and evaluating the quality of food) observation on 2/23/2026 at 12:58 p.m. of the regular diet with the Dietary Supervisor (DS), observed the DS took the temperature of the foods, using the facility thermometer, with temperatures as follows:Chili 120 degrees Fahrenheit ( F, a scale of temperature)Corn bread 84 F.Citrus chiffon delight 60 F.Tossed green salad 64 F.During a test tray process observation on 2/23/20206 at 1:02 p.m. of the puree diet with the DS, observed the DS took the temperature of the foods, using a facility thermometer with temperature as follows:Puree chili 94 FPuree salad 56 FPuree citrus chiffon delight 52 F.During an interview on 2/23/2026 at 12:53 p.m. with the DS and the Registered Dietitian (RD), the DS stated the chili was served on paperware and it did not hold heat. The DS stated the food temperatures were affected because the food was not hot and residents could lose their appetite and weight loss in the long run as a potential outcome. During a concurrent observation and interview on 2/23/2026 at 1:30 p.m. with the DS, it was observed that the tossed green salad was drenched (wet thoroughly) with liquid. The DS stated the recipe for the tossed green salad to mix with the salad dressing during preparation. The DS stated the tossed salad was watery and it should not be watery. The DS stated the lettuce was soggy and the liquid in the salad came from the lettuce. The DS stated the salad should have dressings, but it should not be soggy (wet and soft). The DS stated salad would have less nutrition because it was watery and residents would eat less or would not eat it as a potential outcome.During a review of the facility's policies and procedures (P&P) titled Food Preparation Policy dated 3/15/2025, the P&P indicated, Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. All meals must comply with the physician-ordered diet, approved menu, and portion control standards to ensure consistency, adequate nutrition, and regulatory compliance. (1) All food will be prepared by methods that preserve nutritional value, flavor, and appearance, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident.During a review of the facility's P&P titled Menu, dated 3/15/2025, the P&P indicated, (5) Menus will be prepared as written using standardized recipes. The dietary service supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed.

Based on interview and record review, the facility failed to:Obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their authorized responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with Abilify (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 2.)Obtain a new informed consent pursuant to a dosage increase for Cymbalta (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 111.)These deficient practices of failing to obtain informed consent prior to initiating treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Residents 2 and 111 from exercising their right to decline treatment with Abilify and Cymbalta, respectively and had the potential for increased risk that Residents 2 and 111 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Abilify or Cymbalta leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:A. During a review of Resident 2's admission Record (a record containing diagnostic and demographic resident information), dated 2/25/26, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness characterized by hearing or seeing things that are not there, mood swings, and paranoia.) The admission Record further indicated that Resident 2 was considered self-responsible and did not have an authorized RP.During a review of Resident 2's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 10/17/25, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Order Summary Report (a summary of all current physician orders), dated 2/25/26, the order summary report indicated, on 10/16/25, Resident 2's attending physician prescribed Abilify 5 milligrams (mg - a unit of measure for mass) by mouth twice daily for delusions interfering with daily care causing fear, anger, or stress.During a review of Resident 2's available informed consent documentation for Abilify, dated 1/30/26, the informed consent indicated the facility obtained the informed consent to use Abilify from Resident 2's daughter despite not having her daughter listed as a responsible party.During an interview on 2/25/26 at 10:44 a.m. with the Director of Nursing (DON), the DON stated Resident 2 has been self-responsible, however, recently her physician determined that she did not have the capacity to make or understand decisions. The DON stated the facility failed to properly identify Resident 2's daughter as her authorized representative prior to having her sign the informed consent for the use of Abilify. The DON stated the facility had no record of a conference with Resident 2's daughter to identify her as a responsible party prior to asking for her authorization to use Abilify. The DON stated having someone who is not an authorized representative of the resident sign for informed consent increases the risk that Resident 2 may not be able to exercise her right to opt out of treatment with Abilify. The DON stated this could cause Resident 2 to experience side effects related to Abilify use which could possibly lead to a decline in her quality of life.B. During a review of Resident 111's admission Record), dated 2/25/26, the admission Record indicated Resident 111 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus due to underlying condition with diabetic neuropathy (a medical condition characterized by impaired control of blood sugar levels with nerve pain.)During a review of Resident 111's History and Physical dated 10/23/25, the H&P indicated Resident 111 had the capacity to make healthcare decisions.During a review of Resident 111's Order Summary Report, dated 2/25/26, the order summary report indicated, on 2/24/26, Resident 111's attending physician prescribed Cymbalta 30 mg to give three capsules by mouth (90 mg) once daily for neuropathic pain. During a review of Resident 111's most recent informed consent documentation for Cymbalta, dated 5/14/25, the informed consent indicated the facility obtained the informed consent to use Cymbalta from Resident 111 for a dose of 30 mg by mouth twice daily (60 mg total.)During an interview on 2/25/2026 at 10:48 a.m. with the DON, the DON stated the facility failed to obtain a new informed consent when the dosage of Cymbalta was increased in August of 2025. The DON stated this is required because Resident 111 may experience an increase of adverse effects as well which could cause a decline in his quality of life. The DON stated failing to obtain a new informed consent also increased the risk that Resident 111 may not have been able to exercise his right to opt out of the dosage increase. A review of the facility's policy Informed Consent, revised December 2024, indicated .Informed consent for psychotherapeutic drugs. must be renewed. whenever there is an increase in dosage.A review of the facility's policy Psychotropic Medication Use, revised March 2023, indicated Residents (and/or representatives) have the right to decline treatment with psychotropic medications.

Based on interview and record review, the facility failed to monitor for adverse effects (unwanted or dangerous medication-related side effects) related to the use of Cymbalta (a medication used to treat mental illness) between 11/2/25 and 2/24/26 in one of five residents sampled for unnecessary medications (Resident 111.)The deficient practices of failing to monitor adverse effects related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 111 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 111's admission Record (a record containing diagnostic and demographic resident information), dated 2/25/26, the admission record indicated he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus due to underlying condition with diabetic neuropathy (a medical condition characterized by impaired control of blood sugar levels with nerve pain.)During a review of Resident 111's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 10/23/25, the H&P indicated Resident 111 had the capacity to make healthcare decisions.During a review of Resident 111's physician orders, dated 8/1/25, the physician orders indicated his attending physician prescribed Cymbalta 30 milligrams (mg - a unit of measure for mass) and Cymbalta 60 mg (90 mg daily total) to be taken together once daily for neuropathic pain.During a review of Resident 111's Medication Administration Record (MAR - a record of medication administration and monitoring), indicated the facility did not monitor for adverse effects related to the use of Cymbalta between 11/2/25 and 2/24/26.During an interview on 2/25/26 at 10:48 a.m. with the Director of Nursing (DON), the DON stated the facility failed to monitor the adverse effects of Cymbalta for Resident 111 between 11/2/25 and 2/24/26. The DON stated even when an antidepressant is being used to manage nerve pain, it must be monitored for adverse effects to ensure that the medication is safe and effective. The DON stated failing to monitor for adverse effects increased the risk that Resident 111 may have experienced adverse effects related to Cymbalta possibly leading to a decline in his quality of life. A review of the facility's policy Psychotropic Medication Use, revised March 2023, indicated Psychotropic medication management includes: . adequate monitoring for efficacy and adverse consequences. Residents receiving psychotropic medications are monitored for adverse consequences.

Based on interview and record review, the facility failed to ensure the resident, who was confused with poor safety awareness and history of falls, was provided with supervision to prevent from fall and injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was supervised after the fall on 9/17/2022, and again less than a month later, on 10/13/2022 and sustained a fracture (broken bone). 2. Ensure Resident 1's plan of care was revised after the fall on 9/17/2022 to incorporate assistive devices and close supervision, as per the director of rehabilitation (DOR) assessment to assist Resident 1 from having a second fall and prevent further falls. 3. Ensure the staff adhere to the facility's policy and procedures titled Promoting Safety, Reducing Falls, to promote Resident 1's safety and prevent falls. These failures resulted in Resident 1 having two unwitnessed falls on 9/17/2022 and 10/13/2022. The second fall on 10/13/2022 resulted in Resident 1 sustaining a right intertrochanteric femur (proximal femur [thigh bone] that occur between the greater and lesser trochanter [a large prominence on the side of the bone] fracture causing pain. Resident 1 required a transfer to a general acute care hospital (GACH) and was admitted for five days after undergoing an open reduction internal fixation ([ORIF] a type of surgery used to stabilize and heal a broken bone) surgery of the right hip. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including anxiety disorder (persistent feeling, feelings of nervousness, panic and fear which can interfere with daily life), unspecified dementia (loss of the ability to remember, and reason to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and a history of falls. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/5/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. According to the MDS, Resident 1 required an extensive assistance (resident involved in activity, staff provide weight bearing [body weight] support) with two-persons physical assistance during transfers (moving from between surfaces including to and from: bed, chair, wheelchair, standing position). During a review of Resident 1's history and physical (H/P), dated 9/8/2022, the H/P indicated it was unclear if Resident 1 had the ability to make her own medical decisions. During a review of Resident 1's Fall Risk Assessment (FRA), dated 8/30/2022, the FRA indicated Resident 1 had a high risk for falls. The FRA indicated the facility must develop and implement a care plan to reduce falls and injuries for Resident 1 and to complete the following assessments and interventions: Fall Interdisciplinary Team meeting ([IDT]-a group of health care professionals with various areas of expertise who work together toward the resident's goals), initiate a Falling Star/Super star care plan, and complete a Rehabilitation (Rehab-assessment conducted by the therapy department) Fall Risk Assessment. During a review of Resident 1's care plan (C/P), initiated on 9/1/2022, the C/P indicated the resident was at risk for fall/injury due to dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), general weakness, history of falls, impaired cognition (thought process), and cerebral infarction ([stroke] disrupted blood flow to the brain due to problems with the blood vessels that supply it) when blood does not get to the brain). The C/P goal was to reduce risk of falls and injury daily. The staff's interventions included the following: 1. Resident 1's fall risk assessment upon admission, quarterly and as needed (PRN). 2. Place Resident 1 on a falling star program (facility's program for staff awareness which identifies residents who are on a high risk for falls [a yellow star placed by resident's name on their doors]). 3. Nursing staff to visibly observe Resident 1 frequently. 4. Provide Resident 1 proper fitting shoes. 5. Physical Therapy (PT) to assess Resident 1 quarterly and PRN for safety of gait (the way one walks), transfer, sitting balance, and need for safety devices, assess resident medication for possible adverse side effects. 6. Provide Resident 1 with safe and clutter-free environment. 7. Keep Resident 1's call light within easy reach and courage resident to use it to get assistance. 8. Keep Resident 1's frequently used personal items within easy reach. 9. Inform responsible party/resident quarterly during IDT meetings regarding fall risk, notify Medical Doctor (MD) if needed, encourage the resident to attend, and participate in activity programs. During a review of Resident 1's Change of Condition (COC) and a Situational Background Assessment Recommendation (SBAR) assessment form, dated 9/17/2022, the COC/SBAR (an internal communication document) indicated Resident 1 was alert with confusion with no behavioral outburst. The COC/SBAR indicated the resident was intermittently in and out of her room, using a wheelchair chair and had attempted to self-transfer multiple times with an unsteady gait and needed constant redirection. According to the COC/SBAR, on 9/17/2022, at approximately 8:30 p.m., Resident 1 was found by Certified Nurse Assistant 1 (CNA 1) sitting on the floor beside the wheelchair in her room. Resident 1 complained of hip pain 4 out of 10 on a pain scale (0 for no pain and 10 for being the worse pain). The COC/SBAR indicated Resident 1 was non-redirectable. During a review of Resident 1's FRA, dated 9/17/2022, the FRA indicated Resident 1 remained at high risk for falls. The FRA indicated the facility must develop and implement a care plan to reduce falls and injuries, complete a Fall IDT meeting, initiate a Falling Star/Super star care plan, complete a Rehabilitation Fall Risk Assessment, an assessment environmental hazards, and implement useful interventions to prevent further falls. During a review of Resident 1's IDT conference record, dated 9/18/2022, the IDT record indicated Resident 1 had an unwitnessed fall on 9/17/2022. The IDT record indicated Resident 1 was admitted to the facility with a history of falls, muscle weakness and an unsteady gait. The IDT record indicated Resident 1 had multiple episodes of attempting to self-transfer without calling for assistance and refusal to be assisted to bed from wheelchair and vice versa and was very forgetful in using her wheelchair and calling for assistance. The IDT record did not indicate recommendations from the therapy department. During a review of Resident 1's care plans, there was no documented evidence the staff revised the resident's plan of care after the fall on 9/17/2022 to protect the resident and prevent further falls. During a review of Resident 1's Rehab's FRA dated 9/19/2022, the assessment indicated the following: Resident 1 had an unwitnessed fall on 9/17/2022, Resident 1 does not use the call light properly, cannot recall and demonstrate proper use of a call light after one hour, does not demonstrate proper safety while using an assistive device, does not demonstrate proper safe sitting and standing balance, does not show sufficient strength and correct posture in sitting and standing. The Rehabilitation assessment recommended for the resident to have skilled occupational and physical therapy ([OT/PT] help residents improve in movement and manage pain; focus on helping residents develop or regain the skills needed for daily tasks so they can function independently]), to continue to reinforce safety education during mobility training. During a review of Resident 1's COC/SBAR dated 10/13/2022, the COC/SBAR indicated on 10/13/2022 at 4:30 p.m., the charge nurse saw Resident 1 laying on the floor mat on her right side next to her wheelchair in her room. The COC/SBAR indicated Resident 1 was noted with facial grimacing (distort one's face in an expression usually of pain, disgust, or disapproval) and complaining of pain in her leg. According to COC/SBAR on 10/14/2022 at 2:41 a.m., the X-ray (a photographic or digital image of the internal composition of something, especially a part of the body) report indicated the resident had an acute intertrochanteric right femoral neck fracture (broken right hip). On 10/14/2022 at 4:31 a.m. Resident 1 was transferred by paramedics to a GACH. During a review of Resident 1's GACH's H/P dated 10/14/2022, the H/P indicated Resident 1 was admitted to the GACH from the facility for complaints of hip and neck pain. The H/P indicated the resident's X-ray showed an acute right intertrochanteric right femoral neck fracture. During a review of Resident 1's GACH Discharge summary dated 10/19/2022, the summary indicated Resident 1 was discharged from the GACH back to the facility on [DATE] (five days after admission) after undergoing surgical procedure of an intermedullary nailing (used to align and stabilize fractures) of the right hip fracture. During a review of Resident 1's IDT re-admission document, dated 10/19/2022, the document indicated Resident 1 was readmitted from the GACH after sustaining an intertrochanteric femur fracture. The document indicated Resident 1 had two surgical sites on the right outer thigh. During a concurrent interview and review of the facility's policy and procedure (P/P) on 2/7/2023 at 3:30 p.m. with the Director of Nursing (DON), the undated P/P titled, Initial Fall Risk Assessment, the DON stated according to the P/P, an FRA would be completed within 72 hours of admission for all new admissions to attempt reduction of episodes of falls. According to the P/P PT services and nursing would review each new admission for the plan of care including interventions for fall preventions for the next three months and the care plan would be reviewed by the IDT quarterly and as needed for updates for the resident's current needs. The DON stated when Resident 1 was initially admitted to the facility on [DATE], a fall risk IDT meeting (involving nursing and therapy services) and the rehabilitation fall assessment were not conducted as indicated on Resident 1's care plan and per facility's P/P. The DON stated by not conducting the IDT meeting and rehabilitation fall assessment, Resident 1 was at higher risk for falls by not having appropriate and specific interventions in place to prevent falls. The DON stated the facility's records indicated Resident 1 had a fall on 9/17/2022 and a second fall on 10/13/2022. During a concurrent interview and review of Resident 1's Rehab FRA on 2/10/2023 at 3:30 p.m. with the Director of Rehabilitation ([DOR] supervises all the OT, PT and Speech rehabilitation therapy staff). The DOR reviewed Resident 1's Rehab FRA, dated 9/19/2022 and stated due to Resident 1's cognitive status and confusion, recommendations should have been incorporated on the assessment conducted after the fall on 9/17/2022. The DOR stated the staff's interventions should have been focused on supervision to include placing Resident 1 in a wheelchair in the dining room or out in the hall close to the nursing station where she could be directly supervised. The DOR stated Resident 1 should have not been left alone in her room unattended while in a wheelchair. The DOR stated the staff should have line of sight (a straight line along which an observer has unobstructed vision) on Resident 1, who was known to have confusion and poor safety awareness. The DOR stated future fall assessments should have included more specific, detailed, and individual interventions. The DOR stated Resident 1 had a second fall on 10/13/2022. During a review of the facility's undated P/P titled, Rehabilitation-Fall Assessment/Risk Assessment, the P/P indicated during initial admissions each resident will be screened by the Therapy department per the facility's policy. An FRA will be completed by nursing with input from the therapy department. The P/P further indicated when a fall occurs the therapist will re-screen the resident using the fall assessment form. According to the P/P, an investigation and IDT meeting should address all the residents' safety issues and a care plan developed to prevent recurrence. During a review of the facility's undated P/P titled, Promoting Safety, Reducing Falls, the P/P indicated if caregivers are to prevent falls, they must first have a working knowledge of the key factors that determine which residents are at most risk. The P/P indicated the following are major risk factors for falls: history of falls, gait and balance disturbances and elimination patterns. The P/P further indicated caregivers must be alert to residents who have a history of falls and make conscious effort to eyeball them more frequently. Caregivers should observe resident's elimination patterns and develop regularly scheduled trips to the bathroom for residents who need assistance. This prevents residents from trying to go unassisted, causing falls.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to a resident with dementia (decline in mental ability severe enough to interfere with daily life) for one of two sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Supervise Resident 1 while he moved to and from different locations on the unit. Resident 1 should not be wheeling his wheelchair independently in accordance with his comprehensive assessment (Minimum Data Set) and the Rehabilitation Screening (assessment). 2. Supervise Resident 1 while he was inside the bathroom in accordance with the comprehensive assessment. Resident 1 had an unwitnessed fall from the wheelchair while in the bathroom on [DATE]. A certified nursing assistant had to go the bathroom to respond to the wheelchair alarm after the fall. 3. Complete and/or conduct neurological checks (an assessment of brain functions and level of consciousness) after each fall incident. 4. Monitor Resident 1's behavior and safety when in the wheelchair with a physical restraint. The resident exhibited a behavior of removing the soft non-release belt by wiggling his body and lifting the seat belt over his head. 5. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) process after each fall incident to assess the Resident 1's behavior, to determine appropriate interventions to manage the restlessness and anxiety behavior of Resident 1, and to determine the appropriateness and effectiveness of the use of a physical restraint on Resident 1 to prevent further falls. 6. Review and revise the care plan for falls, and evaluate the effectiveness of the current interventions after each fall incident to resolve the identified problem. 7. Implement the physician order [REDACTED]. 8. Provide training to the facility staffs regarding monitoring the behaviors of residents with dementia and how to manage their behaviors to prevent falls. Resident 1, who was blind, had dementia, and was on medications to thin the blood, had five falls in the facility, which involved hitting his head during the falls. The facility identified restlessness and anxiousness as possible contributing factors to his falls. The resident was given a non-self-release seat belt instead of the ordered self-release belt while in the wheelchair. There were no IDT care conferences that were conducted to manage the resident's agitated behavior, to reassess Resident 1's use of restraints or the use of a self-release belt, and to review and revise the care plan. The direct care staff (LVN 2, LVN 3, and LVN 6) were not in-serviced on how to provide appropriate care to a resident with dementia. On the resident's fifth fall on [DATE], the resident sustained [REDACTED]. These deficient practices resulted in Resident 1's having a brain surgery to evacuate the hemorrhage (an escape of blood from a ruptured blood vessel, especially when excessive) over the surface of his brain and placement of percutaneous endoscopic gastrostomy (PEG, an endoscopic medical procedure in which a tube passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). The resident was transferred to another skilled nursing facility for hospice care (a type and philosophy of care for terminally ill or seriously ill patients that focuses on pain and symptoms, and attending to their emotional and spiritual needs) on [DATE] and he died on [DATE]. Findings: On [DATE] at 10:53 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1 sustaining several falls at the facility. A review of Resident 1's Admission Record indicated that resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Assessment, dated [DATE], indicated the resident was a high risk for falls. The resident's fall risk assessment score indicated that the resident was given a score of 18 on [DATE], 20 on [DATE] and [DATE], and 22 on [DATE] (a total score of 10 or above represented high risk for falling). A review of Resident 1's Physician's [MEDICAL CONDITION] Order, dated [DATE], indicated to give the resident [MEDICATION NAME] (an antianxiety medication) 0.5 milligrams sublingual (apply under the tongue) every six (6) hours as needed (prn) for anxiety as manifested by agitation/restlessness, and to monitor the behavior of restlessness and tally by hash mark every shift. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated Resident 1's vision and cognition (the ability to think and reason) were severely impaired; had minimal difficulty hearing; was able to understand others and make himself understood sometimes; and required extensive assistance (resident involved in activity, staff provided support in bearing weight) with two person physical assist with transfers (the moving of a patient from one surface to another) and toileting. The MDS indicated Resident 1 required extensive assistance with the assistance of one person while Resident 1 moved from one place to another (locomotion) inside his room and adjacent corridor on the same floor; he needed supervision while he moved to and returned from off-unit locations (areas set aside for dining, activities, or patio); and he used a wheelchair as a mobility (to move around) device. The MDS indicated Resident 1's balance during transitions (transfer) and walking was not steady and he was only able to stabilize with staff assistance. During an interview, on [DATE] at 10:52 a.m., the MDS coordinator stated that Resident 1 requiring extensive assistance in locomotion on the unit meant someone had to push the resident's wheelchair and that the resident should not be left alone while in the wheelchair. direct care staff know this? A review of Resident 1's care plan titled Resident Care Plan Potential for Fall, dated [DATE], indicated Resident 1 was at risk for falls related to his unsteady gait, poor safety awareness, behavior problems, behavioral problems (physical restlessness), and use of [MEDICATION NAME]. The staff's interventions included but not limited to observing Resident 1 for unsteady gait and poor balance, anticipating and meeting all his needs timely, and providing a low bed and personal alarm in bed. A review of the facility's policy and procedure titled Resident Fall, with an effective date [DATE], indicated that facility required staff to provide the necessary care and treatment to medically stabilize, and to initiate prompt interventions to prevent or reduce further falls with or without injury. The facility's policy and procedure indicated the IDT will create or revise the care plan, assess if resident is in appropriate level of care, ensure adequate resources to implement plan of care as written, and inform direct care staff. A review of Resident 1's care plan titled Anxiety Care Plan, dated [DATE], indicated the resident had generalized anxiety and dementia manifested by restless fidgeting (to behave or move nervously or restlessly). The staff intervention included but not limited to monitoring the resident for signs of disturbance, providing reassurance, providing redirection or diversion, and monitoring the significant side effects of the anti-anxiety medication, [MEDICATION NAME], such as drowsiness, sedation, dizziness, headache, nausea, and low blood pressure. A review of Resident 1's record titled Rehabilitation Screening, dated [DATE], indicated Resident 1 was not able to ambulate and needed assistance with wheelchair mobility. During an interview, on [DATE] at 11:11 a.m., the physical therapist (PT 1) stated that needing assistance with wheelchair meant Resident 1 should not be left alone when he was sitting on the wheelchair because resident was screened as high risk for falls. PT 1 stated that Resident 1 should not be wheeling himself in the wheelchair and that a staff or a family member should push the wheelchair for him at all times. PT 1 stated he communicated verbally with the nurses that Resident 1 could not be left alone while in wheelchair and that he was not sure if the nurses created a new care plan. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's report titled Report of Incident SBAR (Situation, Background, Assessment, Request/Responsible Party Notification/Response) -Actual or Suspected Fall, dated [DATE] and timed at 1:16 p.m., indicated Resident 1 had an unwitnessed fall in the bathroom and was found on the floor. Resident was found by a certified nursing assistant (CNA) when the CNA responded to answer the alarm. A possible contributing factor for the fall was the resident's restlessness or anxiousness. The resident was unable to communicate what happened. The falls episodic care plan indicated to conduct neurological checks. A review of Resident 1's record titled Incident Accident Report, dated [DATE], indicated that at 1:16 p.m., a loud thump and the sound of an alarm were heard. Resident 1 was on the floor holding his head. A registered nurse (RN) assessed the resident for injuries. Resident 1 did not have bruises or lacerations and he was assisted to the wheelchair. A review of Resident 1's plan of care, dated [DATE], indicated the resident had an actual fall. The staff interventions included but not limited to placing a sensor alarm in the wheelchair. A review of Resident 1's physician orders, dated [DATE] and timed at 9:17 p.m., indicated that staff may apply a self-release belt when Resident 1 was on the wheelchair to prevent Resident 1 from getting up unassisted. A review of Resident 1's care plan titled Physical Restraint, dated [DATE], indicated the resident was provided with a self-release belt and the goal was to alert staff when the resident attempted to get up unassisted from the wheelchair. A review of Resident 1's fall incident report, dated [DATE] and timed at 11p.m., indicated a CNA called the charge nurse because Resident 1 fell on the left side of his head and had a red spot only on his head. The resident was found sitting at the end of his low bed. A review of Resident 1's report titled Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], and timed at 11p.m., indicated Resident 1 had an unwitnessed fall from a low bed, which occurred during self-ambulation. A possible contributing factor to the fall was the resident's restlessness or anxiousness. Resident 1 was unable to communicate what occurred. The falls episodic care plan indicated to conduct neurological checks. A review of Resident 1's care plan, dated [DATE], indicated the resident had an actual fall without injury. The staff interventions included but not limited to assessing causative factor and intervene accordingly, encouraging to call for assistance as needed, applying a sensor alarm in bed/wheelchair, applying a landing mat. A review of Resident 1's fall incident report, dated [DATE] and timed at 9:30 a.m., indicated that while passing medications, a licensed vocational nurse (LVN 2) heard the sound of the (wheelchair) alarm on the hallway and saw Resident 1walking, losing his balance, and falling. LVN 2 saw Resident 1 landing on his bottom (buttocks) and then hitting his head on the floor. After LVN 2 assessed Resident 1, the resident was transferred to his wheelchair and placed back to bed. There was bruising on Resident 1's occipital area (the back of the head) and cold compress was applied. Neurological checks were initiated. A review of Resident 1's report titled Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], and timed at 10 a.m., indicated a registered nurse and an LVN witnessed Resident 1 fall to the floor at the hallway. The SBAR report indicated the wheelchair alarm sounded and a possible contributing factor for the resident's fall was his restlessness and anxiousness. The falls episodic care plan indicated to conduct neurological checks. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's physician orders [REDACTED]. Resident 1 received the following anticoagulants: [MEDICATION NAME] ([MEDICATION NAME]) 40 milligrams (mg) injection from [DATE] to [DATE], [MEDICATION NAME] 3 mg tablet from [DATE] to [DATE], and [MEDICATION NAME] 4 mg tablet from [DATE] to [DATE] and from [DATE] to [DATE]. A review of Resident 1's report titled Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], and timed at 7:30 p.m., indicated a CNA called the charge nurse to Resident 1's room. Resident 1 was found on the floor from the wheelchair. Resident 1 stated that he slid from the wheelchair while attempting to open the sliding door. The resident's wheelchair alarm sounded. A possible contribution factors were that Resident 1 was restless and anxious. The falls episodic care plan indicated to conduct neurological checks. A review of Resident 1's record titled Laboratory Report, dated [DATE], indicated Resident 1's [MEDICATION NAME] time (PT) result was 21.2 seconds and was high (it meant it would take longer for the blood to clot). The PT reference range is less than 14.5 seconds. It is a test that measure the time it takes for the blood to clot. A review of Resident 1's record titled Licensed Personnel Progress Notes, dated [DATE] and timed at 1:45 a.m., indicated Resident 1 was screaming and wanted to sit on his wheelchair. The licensed progress notes indicated that staff sat him in a wheelchair and then applied a soft belt waist restraint. At 2 a.m., Resident 1 was wheeling himself in front of nurses' station and that Resident kept trying to stand up and that Resident 1 kept trying to take off the soft belt waist restraint. A review of Resident 1's record titled Licensed Personnel Progress Notes, dated [DATE] and timed at 3:30 a.m., indicated Resident 1 was lying on the floor (at the hallway) and was bleeding from his left forehead and had a laceration (a deep cut or tear in skin or flesh). The notes indicated Resident 1 was nonverbal but responded to painful stimuli and that a facility staff called 911. A review of Resident 1's report titled Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], and timed at 4 a.m., indicated Resident 1 was noted on the floor face down and sustained a laceration on top of his forehead and was bleeding. The report indicated that a facility staff was not able to stop the bleeding and a facility staff called 911. A review of Resident 1's GACH record titled Pertinent Report, dated [DATE] and timed 4:10 a.m., indicated Resident 1 was admitted to the GACH with [DIAGNOSES REDACTED]. effect (the growing mass is pushing the surrounding tissue) subdural hematoma (SDH, a collection of blood in the brain's surface), acute on chronic left frontoparietal (the top and sides of the skull) subdural hematoma with maximum thickness of one (1) centimeter (SDHs greater than 1 centimeter at the thickest point generally require rapid surgical treatment), high blood pressure, and dementia. (http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.348.5434) (http://emedicine.medscape.com/article/ 2-overview) A review of Resident 1's GACH records titled ED Notes, dated [DATE] and timed 4:46 a.m., indicated the resident's international normalized ratio (INR) results were 2.49 (high) and [MEDICATION NAME] time (PT) results were 26.8 seconds (high). PT/INR are tests that measure the time it takes for the blood to clot. These tests are used to monitor the effectiveness of the anticoagulant therapy/treatment. The higher the PT/INR number, the thinner your blood, which means it takes longer for the blood to clot. With an INR of 2, your blood takes twice as long as normal unthinned blood. The normal range for a healthy person not using [MEDICATION NAME] is 0XXX,[DATE].2, and for people on anticoagulant therapy an INR of 2XXX,[DATE].0 is usually targeted. (http://www.webmd.com/a-to-z-guides/[MEDICATION NAME]-time#1) A review of Resident 1's GACH records titled Preoperative or Procedure Report, dated [DATE], and timed 6:56 p.m., indicated Resident 1 underwent an urgent surgery under general anesthesia (a medically induced coma) for a craniectomy (a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed, it is performed on victims of [MEDICAL CONDITION] and stroke) for evacuation of right subdural hematoma with harvesting of fascial graft (implant of fibrous tissue (consisting of or characterized by fibers: a group or layer of similarly specialized cells that together perform certain special functions)), repair of dural (dura mater, outermost membrane surrounding the brain) defect with cranial reconstruction (a surgical procedures used to repair or reshape the face and skull), insertion of subdural shunt (a surgical procedure creating a passage by which blood is diverted from one area to another), and microdissection (a microscope is used for dissection (to cut apart or separate)). A review of Resident 1's GACH records titled Discharge Summary, dated [DATE], and timed at 4:19 p.m., indicated Resident 1 had to be fed through an nasogastric (NG, a medical process involving the insertion of a plastic tube through the nose, past the throat, and down into the stomach). Resident 1did not tolerate the NG tube feedings and required a PEG tube. Resident 1's family members opted for comfort measures and was Resident 1 was transferred to a hospice environment on [DATE]. A Review of Resident 1's death certificate indicated Resident 1 died on [DATE] and the immediate cause of death was an acute (of sudden onset) and chronic (continuing or occurring again and again for a long time) subdural hemorrhage and fall. On [DATE] at 8:58 a.m., during an interview, Family member (FAM 1) stated that Resident 1 needed to be supervised due to his [MEDICAL CONDITION] and he required assistance from staff. On [DATE] at 2:23 p.m., during a review of Resident 1's medical record with the facility's administrator (ADM), the ADM stated that Resident 1 was taking [MEDICATION NAME] and was at higher risk for bleeding (internally and or externally) and or bruising. The ADM stated that Resident 1 had abnormal coagulation laboratory results [MEDICATION NAME] time (PT) results of 21.2 (seconds) on [DATE] (1 day prior to Resident 1's fall), and that the nursing staff did not inform the physician. The ADM stated that it was imperative for the nurses to notify the doctor of any abnormal coagulation laboratory results due to the high risk for bleeding for Resident 1. During the interview and record review of Resident 1's medical record, the ADM stated that the neurological (neuro) checks conducted after the resident's fall incidents on [DATE], [DATE], [DATE] were incomplete and the neuro checks were not done after the resident fell on [DATE]. ADM stated that neuro checks should have been done for 72 hours after each of Resident 1's falls to detect any neurological abnormality (abnormal changes in relation to the brain's function) in accordance with the resident's fall care plan and the facility's policy and procedures On [DATE] at 3:19 p.m., while reviewing Resident 1's medical record, LVN 1 stated that Resident 1 needed a different facility such as a psych facility due to his behavior issues and that the facility's staffs were not properly trained to care for residents, who had behavior issues. LVN 1 stated that Resident 1 did not belong in the facility and that the facility's admission staff did not screen Resident 1 well to be admitted to the facility. LVN 1 stated that Resident 1's falls should have been prevented. LVN 1 stated she was assigned to Resident 1 on [DATE] (the fourth fall incident) and that usually she had up to 40 or more residents to pass medications and that it was hard to keep Resident 1 supervised. On [DATE] at 3:39 p.m., during an interview and concurrent review of Resident 1's record titled, Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], at 10 a.m., LVN 2 stated she was assigned to care for Resident 1 on [DATE] (the third fall incident). LVN 2 stated that Resident 1 was blind, hard of hearing, and needed supervision. LVN 2 stated that on the [DATE] fall incident, Resident 1 was walking by himself and that he lost his balance and fell and hit his head on the floor. On [DATE] at 6:23 a.m., during an interview and concurrent review of Resident 1's record titled, Report of Incident SBAR-Actual or Suspected Fall, dated [DATE], at 4a.m., LVN 3 stated that she was assigned to Resident 1 on [DATE] (the fifth fall incident) and that Resident 1 was restless and wanted to be sitting on his wheelchair. LVN 3 stated that Resident 1 was then placed on his wheelchair and a non-self-release soft restraint was placed on Resident 1's waist level and tied at the back of Resident 1's wheelchair. LVN 3 stated that she gave Resident 1 [MEDICATION NAME] 0.5 mg at 2:15 a.m. LVN 3 stated that Resident 1's room was not close to the nurses' station. LVN 3 stated Resident 1 wheeled himself while using his wheelchair but the resident needed to be supervised while in wheelchair because the resident was confused and had visual impairment and was at high risk for falls. LVN 3 stated she did not supervise Resident 1 at the time he fell because she was on her break and that LVN 4 was supposed to supervise Resident 1 while she was out. During the interview, LVN 3 stated that LVN 4 took over Resident 1's care while she was on break. LVN 3 stated that LVN 4 told her that he noticed that Resident 1 was trying to remove the non-self-release restraint, that LVN 4 later heard a sound and noticed that Resident 1 fell to the floor with his face down, that the resident was bleeding profusely, and that a facility staff called 911. On [DATE] at 6:52 p.m., during an interview, CNA 1 stated she was not assigned to Resident 1 on [DATE] (the fifth fall incident) and that she saw Resident 1 prior to his fall. CNA 1 stated that Resident 1 was sitting in his wheelchair and was wheeling himself using the handrails. CNA 1 stated that Resident 1 was wearing a blue soft non-self-release restraint that went around Resident 1's waist area and was tied at the back of Resident 1's wheelchair. During a concurrent observation, CNA 1 demonstrated a restraint as to the one Resident 1 was wearing on [DATE]. CNA 1 stated that Resident 1 was wearing a blue, soft, non-self-release restraint. During the interview, CNA 1 stated that there was only one type of restraint that she was familiar with and the only kind of restraint used throughout the facility. CNA 1 stated that she saw Resident 1 struggling to remove the restraint and was moving (wiggling) his body while sitting on the wheelchair from side to side. CNA 1 stated that Resident 1 was trying to lift the restraint over his head to free himself from it and that he was able to finally tear it apart. CNA1 stated that the nurses in charge were aware that the Resident was agitated and trying to get the restraint out. On [DATE] at 9:20 a.m., during a telephone interview, LVN 4 stated that Resident 1 was agitated on [DATE] and wanted to be placed in a wheelchair. LVN 4 stated that LVN 3 gave Resident 1 [MEDICATION NAME] prior to LVN 3 going on a break and that Resident 1 needed to be supervised closely because he was at risk for falls. LVN 4 stated that Resident 1 was wearing a non-self-release soft waist restraint and that he wheeled himself throughout the facility. LVN 4 stated that Resident 1 was blind and was non-compliant. LVN 4 stated that the side effects of the [MEDICATION NAME] medications were dizziness, and sleepiness. LVN 4 stated that Resident 1 was trying to get up from the wheelchair and was agitated. LVN 4 stated that he did not have full vision of resident and that he saw Resident wheeling himself near the nurses station and that there no were no CNAs assigned to watch resident on one to one. During the interview, LVN 4 stated that he heard a loud noise and he noticed Resident 1 was on the floor by hallway. LVN 4 stated Resident 1 was bleeding profusely from his forehead and that he (LVN 4) could not stop the bleeding. LVN 4 stated that other facility staff member called 911. LVN 4 stated Resident 1 needed to be supervised but no facility staff member was assigned to supervise him on a one-to-one basis. On [DATE] at 1:36 p.m., during an interview, the social services designee (SSD) stated that Resident 1 did not see a psychiatrist as ordered by the physician (on [DATE]). The SSD stated that Resident 1's insurance did not cover the consultation. The SSD stated that Resident 1 should have seen a psychiatrist. On [DATE] at 4:02 p.m., during an interview and concurrent review of Resident 1's record titled, Licensed Personnel Progress Notes, dated [DATE], at 2 a.m., LVN 7 stated that there was no documentation to indicate whether the resident's attending physician was notified regarding agitation and that the resident was trying to remove the restraint. On [DATE] at 11:50 a.m., during an interview, RN 1 stated that the Resident 1's care plans (restraint care plan dated [DATE], anxiety care plan dated [DATE], and falls care plan dated [DATE]) should have been revised, discussed during IDT because if the previous plan was not working, the physician should have been notified and then the IDT would discuss what other interventions should have been implemented. Resident 1's care plans for anxiety, restraint, and falls were reviewed with RN 1. RN 1 stated that the care plan for anxiety should have been revised by the IDT and an assessment should have been conducted to determine if a physical restraint was appropriate for the resident. RN 1 compared the falls care plans for [DATE] (the second fall incident) and [DATE] (the third fall incident), that there were no new interventions developed for the fall on [DATE]. On [DATE] at 2:20 p.m., during an interview, RN 2 stated that Resident 1 needed someone to push his wheelchair at all times and that someone should have stayed with him. On [DATE] at 3:48 p.m., during an interview and concurrent review of Resident 1's record titled, IDT Post-Occurrence Assessment and Plan Review, dated [DATE], [DATE], and [DATE], the director of nursing (DON) stated that after reviewing Resident 1's medical record, that she, the previous MDS nurse coordinator, and a facility staff (the DON could not remember who) had three meetings regarding the Resident 1's falls but none of the three meetings were specific to discuss interventions to prevent the resident from falling and to monitor his behaviors, including the use of either self-release belt or physical restraint. On [DATE] at 4:42 p.m., during an interview, the administrator stated that he used to be the previous MDS nurse coordinator and that he, the DON, and a facility staff (the administrator was not able to remember who) conducted three IDT meetings on [DATE], [DATE], and [DATE], and that according to Resident 1's record titled, IDT Post-Occurrence Assessment and Plan Review, dated [DATE], [DATE], and [DATE], there were no interventions discussed regarding Resident 1's behaviors and use of a physical restraint. A review of the facility's policy titled Care Plan Conference, dated [DATE] indicated that the interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative would develop the plan of care based on the comprehensive assessment, and that the care plan conference was to identify resident needs and establish obtainable goals and that care plans were reviewed to include at a minimum; completed MDS, problem list, long-term goals, short-term goals, approaches and interventions, barriers, rehabilitation potential, and discharge plan. A review of the facility's policy titled Behavior Assessment and Management, dated [DATE], indicated that the facility required staff to observe, document and use behavior intervention appropriately and that the administrator, DON and social services designee would develop and implement a monitoring period and program for the individual resident based on the particular behavior.

Based on observation, interview, and record review, the facility failed to conduct a pain assessment, and provide effective pain relief after a resident was exhibiting signs and symptoms of pain for 1 of 4 sampled residents (Resident 4). As a result, Resident 4 experienced severe pain and discomfort. Cross refer to F425. Findings: A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's admission Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/2/16, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 was completely dependent for assistance with personal hygiene, required extensive assistance (resident involved in the activity; staff provide weight-bearing support) for bed mobility, had a functional limitation with range of motion (the full movement potential of each joint) due to impairment on both sides of the upper and lower extremities, and was always incontinent (insufficient voluntary control of defecation or urination) of bowel and had an indwelling urinary catheter (a flexible plastic tube used to drain urine from the bladder into a collection bag). The MDS, dated [DATE], indicated Resident 4 had a Stage 4 pressure ulcer upon admission to the facility that measured two (2) centimeters (cm) in length, one (1) cm in width, and one (1) cm in depth. A review of Resident 4's Nurses Admission Record, dated 8/27/16, indicated the resident was admitted to the facility with a Stage 4 pressure ulcer in the coccyx (tailbone) area. A review of Resident 4's care plan, initiated on 8/27/16, titled, Alteration in Comfort from Back Pain and Arthritic Pain, indicated a goal for the resident's pain to be relieved within one hour after pain medication was given. The approach included to assess Resident 4 for signs and symptoms of pain, to call the physician for any significant changes in the resident's medical condition, and provide measures to comfort and lessen the intensity of the pain. A review of Resident 4's Physician Orders, dated 8/27/16, indicated to rate the resident's pain level every shift, according to the pain scale from zero to 10 (zero indicated no pain, 10 out of 10 indicated severe pain) as follows: 1-2 equals mild pain 3-6 equals moderate pain 7-10 equals severe pain A review of Resident 4's physician orders, dated 8/27/16, indicated to administer to the resident [MEDICATION NAME]-[MEDICATION NAME] (a combination of a controlled-substance medication that relieves pain) tablet 5/325 milligrams (mg), one tablet via gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly into the stomach), every 12 hours prn (as needed) for moderate pain. A review of Resident 4's Medication Administration Record (MAR), for the month of August 2016, indicated the licensed nurse did not document the rate of the resident's pain level as ordered by the physician, from 8/28/16 through 8/31/16 (for four days after the date of admission) during the day shift (7 a.m. to 3 p.m. shift), and on 8/30/16, during the evening shift (3 p.m. to 11 p.m. shift). The August 2016 MAR indicated Resident 4 had a pain level of four out of 10 (moderate pain), on 8/27/16 and 8/28/16 during the night shift (11 p.m. to 7 a.m. shift), but there was no documented evidence the resident received medication for pain relief as prescribed. A review of Resident 4's September 2016 MAR indicated the following: 1. The resident had severe pain (pain level 7/10) on 9/5/16 during the day shift and on 9/10/16 during the night shift but the resident was given one (1) tablet of narcotic pain medication ([MEDICATION NAME]-[MEDICATION NAME]), which was ordered to relieve moderate pain. 2. The resident's pain assessment was not documented for 18 days out of 30 days, during the day shift, and for two days during the evening shift (on 9/22/16 and 9/26/16). 3. The resident received one (1) tablet of the [MEDICATION NAME]-[MEDICATION NAME] for moderate pain (pain level 5/10) on 9/22/16 during the day shift but the Individual Resident's Narcotic Record (a disposition record of the narcotic medication) indicated the resident received the narcotic pain medication two (2) times (the documented time was not legible) on 9/22/16. There was no documented evidence the resident's pain level was assessed prior to the administration of the narcotic pain medication for the second time on 9/22/16. 4. The resident had severe pain (pain level 8/10) on 9/27/16 (the shift was not indicated) but the resident was given one (1) tablet of the narcotic pain medication ([MEDICATION NAME]-[MEDICATION NAME]), which was ordered to relieve moderate pain. The Individual Resident's Narcotic Record indicated the narcotic pain medication was disposed at 1:30 am. during the night shift. On 10/12/16, at 9:15 a.m., during an observation of morning care with the certified nursing assistant (CNA 1), Resident 4 was observed screaming and moaning, with facial grimacing (facial expression suggesting pain). The resident was observed with both arms flexed on top of her chest. On 10/12/16, at 9:30 a.m., during an interview and a concurrent review of Resident 4's MAR for the month of October 2016, a licensed vocational nurse (LVN 2) stated Resident 4 did not receive pain medications during her shift. LVN 2 stated Resident 4's pain medication of [MEDICATION NAME] (the brand name for the narcotic pain medication, [MEDICATION NAME]-[MEDICATION NAME]), one tablet, was last administered to the resident on 10/12/16, at 1 a.m., and was not due to be administered because it was ordered for as needed every 12 hours. LVN 2 stated she did not know what else she could do if the resident was in pain and the pain medication was not yet due to be administered. On 10/12/16, at 11 a.m., during an observation and tour of the facility, Resident 4 was observed moaning with facial grimacing, while LVN 1 was observed repositioning Resident 4 in the bed. On 10/12/16, at 11:15 a.m., during an interview, LVN 1 stated Resident 4 would be given pain medication when it was due at 1 p.m., and 30 minutes prior to performing wound care treatment. On 10/12/16, at 1:15 p.m., during an interview and concurrent observation of Resident 4's wound care treatment, Resident 4 was observed screaming with facial grimacing, while being repositioned by LVN 1. LVN 1 attempted to reposition the resident once again but the resident was observed still screaming. LVN 1 stated, I can't go on with the treatment, I'll ask my supervisor. LVN 1 stated Resident 4 was in more pain than usual. During a concurrent observation, LVN 2 spoke with LVN 1 and informed LVN 1 that Resident 4 received one tablet of [MEDICATION NAME] at 12:30 p.m., for a four out of 10 pain level (moderate pain). On 10/12/16, at 1:20 p.m., during an interview and a concurrent record review of Resident 4's clinical record, LVN 1 stated Resident 4's family requested for the resident not to receive too much pain medication but LVN 1 was not able to find the family's request documented on Resident 4's clinical record. On 12/14/16, at 4 p.m., during an interview, the director of nursing (DON), stated if Resident 4's physician ordered to check the resident's pain level every shift, the pain scale should be documented in the MAR. On 12/15/16, at 10:45 a.m., during an interview, the DON stated the pain level of Resident 4 was not documented in the MAR on 9/22/16, and 9/26/16 during the evening shift, and for several days during the day shift (for the month of September). On 12/15/16, at 10:45 a.m., during an interview, the DON stated a pain level of 7 and above out of 10, is considered severe pain. The DON stated Resident 4 only received pain relief medication adequate for moderate pain, and should have been reassessed for possible dosage increase or change of pain relief medication. The DON stated on Resident 4's September MAR, Resident 4 was documented to have a 7/10 pain during the day shift (on 9/5/16), but was only given [MEDICATION NAME], during the night shift at 2 a.m. on 9/5/16 (prior to the start of the day shift at 7 a.m.). On 12/14/16, at 10:45 a.m., during an interview, the DON stated the Individual Resident's Narcotic Record (the documentation of the number of narcotic medication disposed) and the MAR (the documentation of the number of narcotic medication administered) should match and not have inconsistencies. The DON stated no one was assigned to routinely review the MAR and the Individual Resident's Narcotic Record to check for discrepancies of medication administration. The DON stated the narcotics were counted by two licensed nurses (the incoming nurse and the nurse leaving the shift), before the start of the next shift. A review of the facility's undated policy and procedure titled, Comprehensive Pain Assessment, indicated a registered nurse (RN) or licensed vocational nurse (LVN) reassesses pain as necessary for the effectiveness of the pain control method and should notify the physician if measures were unsuccessful. The policy indicated the resident's pain should be alleviated or reduced to a level of comfort that is acceptable to the resident. A review of the facility's undated policy and procedure titled, Medication and Treatment Administration, indicated the licensed nurse administering the medications or treatment should record the date, time, and dose of the medication in the individual MAR immediately after giving the medication. The policy indicated that when a prn medication is administered, the complaint or symptom for which the medication was given must be documented on the back of the MAR, and the results achieved from giving the dose and time results noted in the space provided in the back of the MAR.